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Licciardi F, Baldini L, Del Monte F, Geranzani A, Mulatero R, Covizzi C, Scaioli G, Mazza GA, Montin D. Persistent Valvular Regurgitation After Acute Rheumatic Fever: Early Predictors of Long Term Outcomes in a Pediatric Retrospective Cohort. Pediatr Cardiol 2024:10.1007/s00246-024-03547-0. [PMID: 38896284 DOI: 10.1007/s00246-024-03547-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 06/07/2024] [Indexed: 06/21/2024]
Abstract
Describe the echocardiographic evolution of valvular regurgitation in patients with rheumatic carditis (RC) and to establish which features may predict long-term outcome, in the absence of acute rheumatic fever (ARF) relapse. Retrospective cohort study. 123 patients with confirmed RC, diagnosed at Turin Children's Hospital between 2010 and 2019. We reviewed the echocardiographic images recorded at diagnosis, after 6-8 weeks, after 6 months, then yearly, to assess which predictors at diagnosis are associated with the degree of improvement at 6 months. Secondly, we tested which variables predict the regression of pathological regurgitation of mitral (MV) or aortic valve (AV) during follow-up. At onset, 90.2% patients had MV regurgitation while 42.3% had AV involvement. 115 (93.5%) patients were treated with steroids and 70.8% experienced a downgrading of RC after 6 months. Steroids were associated with better outcomes at six months (p = 0.01). During follow-up (median 56.1 months), MV improved in 58.6% patients, AV in 46.2%. At multivariate analysis, erythrocyte sedimentation rate (ESR) was positively associated with regression of MV regurgitation (OR 1.02, p = 0.02), while higher degree of carditis at onset was negatively associated (OR 0.04, p < 0.01). Conversely, regression of AV regurgitation was more frequent in patients with bi-valvular involvement (OR 20.5, p = 0.03) and in absence of murmur at onset (OR 0.04, p = 0.01). This study indicates that valvular regurgitation improves overtime if there are no ARF recurrences during follow-up, especially when the MV is involved and in patients treated with steroids.
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Affiliation(s)
- Francesco Licciardi
- Department of Public Health and Pediatrics, Università degli Studi di Torino, Piazza Polonia 94, 10126, Turin, Italy.
- Immunorheumatology Unit, Regina Margherita Children's Hospital, AOU Città della Salute e della Scienza di Torino, Turin, Italy.
| | | | | | - Alice Geranzani
- Department of Public Health and Pediatrics, Università degli Studi di Torino, Piazza Polonia 94, 10126, Turin, Italy
| | | | - Carlotta Covizzi
- Department of Public Health and Pediatrics, Università degli Studi di Torino, Piazza Polonia 94, 10126, Turin, Italy
- Immunorheumatology Unit, Regina Margherita Children's Hospital, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Giacomo Scaioli
- Department of Public Health and Pediatrics, Università degli Studi di Torino, Piazza Polonia 94, 10126, Turin, Italy
| | - Giuseppe Antonio Mazza
- Division of Pediatric Cardiology, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Davide Montin
- Department of Public Health and Pediatrics, Università degli Studi di Torino, Piazza Polonia 94, 10126, Turin, Italy
- Immunorheumatology Unit, Regina Margherita Children's Hospital, AOU Città della Salute e della Scienza di Torino, Turin, Italy
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Salam RA, Khan MH, Meerza SSA, Das JK, Lewis-Watts L, Bhutta ZA. An evidence gap map of interventions for noncommunicable diseases and risk factors among children and adolescents. Nat Med 2024; 30:290-301. [PMID: 38195753 DOI: 10.1038/s41591-023-02737-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 11/27/2023] [Indexed: 01/11/2024]
Abstract
Substance misuse, obesity, mental health conditions, type 1 diabetes, cancers, and cardiovascular and chronic respiratory diseases together account for 41% of disability-adjusted life years linked to noncommunicable diseases (NCDs) among children and adolescents worldwide. However, the evidence on risk factors and interventions for this age group is scarce. Here we searched four databases to generate an evidence gap map of existing interventions and research gaps for these risk factors and NCDs. We mapped 159 reviews with 2,611 primary studies; most (96.2%) were conducted in high-income countries, and only 100 studies (3.8%) were from low- and middle-income countries (LMICs). The efficacy of therapeutic interventions on biomarkers and adverse events for NCDs appears to be well evidenced. Interventions for mental health conditions appear to be moderately evidenced, while interventions for obesity and substance misuse appear to be moderate to very low evidenced. Priority areas for future research include evaluating digital health platforms to support primary NCD prevention and management, and evaluating the impact of policy changes on the prevalence of obesity and substance misuse. Our findings highlight the wide disparity of evidence between high-income countries and LMICs. There is an urgent need for increased, targeted financing to address the research gaps in LMICs.
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Affiliation(s)
- Rehana A Salam
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Maryam Hameed Khan
- Institute for Global Health and Development, Aga Khan University Hospital, Karachi, Pakistan
| | - Syed Saqlain Ali Meerza
- Institute for Global Health and Development, Aga Khan University Hospital, Karachi, Pakistan
| | - Jai K Das
- Institute for Global Health and Development, Aga Khan University Hospital, Karachi, Pakistan
| | - Laura Lewis-Watts
- Centre for Global Child Health, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada.
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Karthikeyan G, Watkins D, Bukhman G, Cunningham MW, Haller J, Masterson M, Mensah GA, Mocumbi A, Muhamed B, Okello E, Sotoodehnia N, Machipisa T, Ralph A, Wyber R, Beaton A. Research priorities for the secondary prevention and management of acute rheumatic fever and rheumatic heart disease: a National Heart, Lung, and Blood Institute workshop report. BMJ Glob Health 2023; 8:e012468. [PMID: 37914183 PMCID: PMC10618973 DOI: 10.1136/bmjgh-2023-012468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/14/2023] [Indexed: 11/03/2023] Open
Abstract
Secondary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) involves continuous antimicrobial prophylaxis among affected individuals and is recognised as a cornerstone of public health programmes that address these conditions. However, several important scientific issues around the secondary prevention paradigm remain unresolved. This report details research priorities for secondary prevention that were developed as part of a workshop convened by the US National Heart, Lung, and Blood Institute in November 2021. These span basic, translational, clinical and population science research disciplines and are built on four pillars. First, we need a better understanding of RHD epidemiology to guide programmes, policies, and clinical and public health practice. Second, we need better strategies to find and diagnose people affected by ARF and RHD. Third, we urgently need better tools to manage acute RF and slow the progression of RHD. Fourth, new and existing technologies for these conditions need to be better integrated into healthcare systems. We intend for this document to be a reference point for research organisations and research sponsors interested in contributing to the growing scientific community focused on RHD prevention and control.
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Affiliation(s)
| | - David Watkins
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Gene Bukhman
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Program in Global Noncommunicable Diseases and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | | | - John Haller
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Mary Masterson
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - George A Mensah
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Ana Mocumbi
- Non-Communicable Diseases Division, Instituto Nacional de Saúde, Marracuene, Mozambique
- Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Babu Muhamed
- The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Emmy Okello
- Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
| | - Nona Sotoodehnia
- Cardiovascular Health Research Unit, University of Washington, Seattle, Washington, USA
| | - Tafadzwa Machipisa
- Cape Heart Institute (CHI), Department of Medicine, University of Cape Town, Rondebosch, South Africa
- Clinical Research Laboratory & Biobank-Genetic & Molecular Epidemiology Laboratory (CRLB-GMEL), Population Health Research Institute, Hamilton, Ontario, Canada
| | - Anna Ralph
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Rosemary Wyber
- END RHD Program, Telethon Kids Institute, Perth, Western Australia, Australia
- National Centre for Aboriginal and Torres Strait Islander Wellbeing Research, Canberra, Australian Capital Territory, Australia
| | - Andrea Beaton
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Sejeeni NF, Alfahmi SS, Alzhrani RM, Almatrafi MK, Hussain AA. A Case Report: Acute Rheumatic Fever or Something More? Cureus 2023; 15:e36967. [PMID: 37139274 PMCID: PMC10151002 DOI: 10.7759/cureus.36967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2023] [Indexed: 04/03/2023] Open
Abstract
Acute rheumatic fever (ARF) is an autoimmune response that may occur after a group A Streptococcus (GAS) infection. Subcutaneous nodules are considered a rare manifestation of acute rheumatic fever with an incidence of 0%-10%. We present a case study of a 13-year-old girl who presented to us with subcutaneous nodules and articular involvement described as a non-migratory polyarticular joint pain involving the small joints of the hands, wrist, elbows, knees, and ankles for three months with poor response to the non-steroidal anti-inflammatory drug (NSAID) Ibuprofen. Accompanied with the presence of carditis, the patient fulfilled three major and two minor criteria of the revised Jones criteria 2015. Therefore, a diagnosis of acute rheumatic fever was made. The child was asymptomatic on subsequent visits, and although the subcutaneous nodules subsided, she will continue to receive penicillin every month for five years. We describe the successful diagnosis and management of a patient with ARF.
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Cytokine imbalance in acute rheumatic fever and rheumatic heart disease: Mechanisms and therapeutic implications. Autoimmun Rev 2022; 21:103209. [PMID: 36228998 DOI: 10.1016/j.autrev.2022.103209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/04/2022] [Indexed: 12/15/2022]
Abstract
Acute Rheumatic Fever (ARF) and Rheumatic Heart Disease (RHD) are autoimmune sequelae of Group A Streptococcus infection with significant global disease burden. The pathogenesis of these diseases is poorly understood, and no immune modulating therapies are available to stop progression from ARF to RHD. Cytokines and chemokines are immune signaling molecules critical to the development of autoimmune diseases. An increasing number of studies point to a central role for pro-inflammatory cytokines and chemokines in ARF and RHD pathogenesis, in particular IL-6, IL-8/CXCL8, and TNFα, which are elevated in circulation in both ARF and RHD patients. Histological studies of RHD valve tissue implicates Th1 and Th17 associated pro-inflammatory cytokines, chemokine CXCL9, and the fibrosis-associated cytokine TGF-β in progressive cycles of inflammatory damage and fibrotic repair. Taken together, this suggests immune molecules contribute to both the acute inflammatory disease stage of ARF, as well as cardiac remodeling and valve dysfunction in RHD. Monoclonal antibody blockade of pro-inflammatory cytokines IL-6 and TNFα are approved therapies for many autoimmune diseases and the most successful immunomodulating therapies for rheumatoid arthritis. Current evidence suggests possible benefit for ARF patients from IL-6 and TNFα blockade, in particular to interrupt progression to RHD, and warrants immediate investigation.
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Allen J, Munoz C, Byakova A, Pachulski R. Acute Fulminant Group A Beta-Hemolytic Streptococcus-Associated Carditis: A Case Report and Literature Review. Cureus 2022; 14:e27282. [PMID: 36039237 PMCID: PMC9405342 DOI: 10.7759/cureus.27282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2022] [Indexed: 11/25/2022] Open
Abstract
Group A beta-hemolytic streptococcus (GAS) is a gram-positive bacteria found in the upper respiratory tract that can cause disease with a wide gamut of symptoms ranging from pharyngitis to peritonsillar abscess, pneumonia, meningitis, and acute rheumatic fever (ARF). The primary goal of antibiotic therapy is to prevent complications of the primary infection such as ARF. ARF is defined by the revised Jones criteria. The Jones criteria have been modified to account for the moderate- to high-risk populations. The mechanism of the development of ARF from pharyngitis is not well understood, but the leading theory is molecular mimicry. The host’s own immune system that responds to bacterial virulence factors develops autoantibodies that attack the host tissue. ARF typically develops two to four weeks post pharyngitis. Markers such as antistreptolysin O rise by week 2-3. The rapid streptococcal antigen is often negative by the time ARF develops. We present a case of a 23-year-old male with no past medical history who presented with a chief complaint of fever and sore throat for one week associated with new-onset chest pain. The patient had a fever with normal blood pressure. Labs showed mild leukocytosis, elevated troponin I, and positive Group A strep polymerase chain reaction (PCR). He was initially treated with aspirin 81 mg, antibiotics, and non-steroidal anti-inflammatory drugs (NSAIDs) in the emergency room. The patient was subsequently started on prednisone 60 mg as he showed no clinical improvement. His initial echocardiography (ECHO) showed a left ventricular ejection fraction (LVEF) of 55%. Repeat ECHO showed LVEF of 45% with regional wall motion abnormalities (RWMA). His cardiac troponin continued to rise with EKG changes on day 7. With the addition of steroids, the patient’s clinical symptoms, as well as EKG and ECHO findings, improved. The patient was discharged with penicillin benzathine for 12 weeks. Case reports of acute carditis presenting concomitantly with pharyngitis are limited. The diagnosis of post-streptococcus complications relies on antistreptolysin O titer (ASOT) serology. With the increased availability of more acute diagnostic markers such as PCR, troponin, and ECHO, GAS confirmation can potentially be obtained within one hour and maybe in the future in the diagnosis of early-onset ARF.
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Acute rheumatic fever in the paediatric population: a descriptive study in the Malaysian state of Sabah. Cardiol Young 2022; 32:83-87. [PMID: 33941307 DOI: 10.1017/s1047951121001621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Rheumatic heart disease is among the leading causes of acquired valvular heart disease in the developing world. However, there is no data available for rheumatic heart disease in the paediatric population of Sabah. This study collected data for acute rheumatic fever admissions among the paediatric population in Sabah over a period of 3 years. METHODS This is a retrospective cohort study. All records for admissions to paediatric wards in Sabah for acute rheumatic fever from January 2016 to December 2018 were collected. The patient records were then traced and required information were collected. RESULTS A total of 52 cases of acute rheumatic fever were admitted. It was observed that the incidence of acute rheumatic fever was 74.4 per 100,000 paediatric admissions. Patients from the West Coast Division made up most of the admissions (n = 24, 46.2%). Male patients (n = 35, 67.3%) of the indigenous Kadazan-Dusun ethnicity (n = 21, 40.4%) were most commonly encountered. The mean age at time of presentation was 9.58 years. Most cases admitted (n = 38, 73.1%) were categorised as Priority 1 (severe rheumatic heart disease). CONCLUSION Most patients who were admitted had symptoms of heart failure and were diagnosed with severe rheumatic heart disease. Although this disease is preventable, the incidence in Sabah remains high. This study was limited as we only looked at patients who were admitted and we foresee the real incidence to be higher. Hence, there is an urgent need for a rheumatic heart disease registry in Malaysia to gather more data for prevention and early intervention.
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White M, Reginato AM, Cunha JS. Evolving Chest Pain in a Young Male. Arthritis Care Res (Hoboken) 2021; 74:867-878. [PMID: 34619016 DOI: 10.1002/acr.24802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 09/21/2021] [Accepted: 09/21/2021] [Indexed: 11/10/2022]
Abstract
A 33-year-old Hispanic male with a history of recent orchiectomy for suspected testicular cancer presented to the emergency department with worsening exertional chest pain and dyspnea in the setting of a 2-month history of diffuse myalgias and symmetric polyarthralgias.
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Affiliation(s)
- Matthew White
- Division of Rheumatology. Lifespan Physician Group, Pawtucket
| | - Anthony M Reginato
- Division of Rheumatology. The Warren Alpert Medical School of Brown University
| | - Joanne S Cunha
- Division of Rheumatology. The Warren Alpert Medical School of Brown University
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Ralph AP, Webb R, Moreland NJ, McGregor R, Bosco A, Broadhurst D, Lassmann T, Barnett TC, Benothman R, Yan J, Remenyi B, Bennett J, Wilson N, Mayo M, Pearson G, Kollmann T, Carapetis JR. Searching for a technology-driven acute rheumatic fever test: the START study protocol. BMJ Open 2021; 11:e053720. [PMID: 34526345 PMCID: PMC8444258 DOI: 10.1136/bmjopen-2021-053720] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION The absence of a diagnostic test for acute rheumatic fever (ARF) is a major impediment in managing this serious childhood condition. ARF is an autoimmune condition triggered by infection with group A Streptococcus. It is the precursor to rheumatic heart disease (RHD), a leading cause of health inequity and premature mortality for Indigenous peoples of Australia, New Zealand and internationally. METHODS AND ANALYSIS: 'Searching for a Technology-Driven Acute Rheumatic Fever Test' (START) is a biomarker discovery study that aims to detect and test a biomarker signature that distinguishes ARF cases from non-ARF, and use systems biology and serology to better understand ARF pathogenesis. Eligible participants with ARF diagnosed by an expert clinical panel according to the 2015 Revised Jones Criteria, aged 5-30 years, will be recruited from three hospitals in Australia and New Zealand. Age, sex and ethnicity-matched individuals who are healthy or have non-ARF acute diagnoses or RHD, will be recruited as controls. In the discovery cohort, blood samples collected at baseline, and during convalescence in a subset, will be interrogated by comprehensive profiling to generate possible diagnostic biomarker signatures. A biomarker validation cohort will subsequently be used to test promising combinations of biomarkers. By defining the first biomarker signatures able to discriminate between ARF and other clinical conditions, the START study has the potential to transform the approach to ARF diagnosis and RHD prevention. ETHICS AND DISSEMINATION The study has approval from the Northern Territory Department of Health and Menzies School of Health Research ethics committee and the New Zealand Health and Disability Ethics Committee. It will be conducted according to ethical standards for research involving Indigenous Australians and New Zealand Māori and Pacific Peoples. Indigenous investigators and governance groups will provide oversight of study processes and advise on cultural matters.
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Affiliation(s)
- Anna P Ralph
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Rachel Webb
- KidzFirst Hospital, Counties Manukau District Health Board, Auckland, New Zealand
- Starship Children's Hospital, Auckland, New Zealand
- Department of Paediatrics; Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Nicole J Moreland
- School of Medical Sciences and Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand
| | - Reuben McGregor
- School of Medical Sciences and Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand
| | - Anthony Bosco
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
| | - David Broadhurst
- Centre for Integrative Metabolomics and Computational Biology, Edith Cowan University, Perth, Western Australia, Australia
| | - Timo Lassmann
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
| | - Timothy C Barnett
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
| | - Rym Benothman
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
| | - Jennifer Yan
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Bo Remenyi
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Nigel Wilson
- Starship Children's Hospital, Auckland, New Zealand
| | - Mark Mayo
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Glenn Pearson
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
| | - Tobias Kollmann
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
| | - Jonathan R Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
- Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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Davis AG, Wilkinson RJ. Aspirin in tuberculous meningitis. EClinicalMedicine 2021; 35:100871. [PMID: 34027331 PMCID: PMC8129888 DOI: 10.1016/j.eclinm.2021.100871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/12/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Angharad G Davis
- The Francis Crick Institute, Midland Road, London NW1 1AT, United Kingdom
- Faculty of Life Sciences, University College London, WC1E 6BT, United Kingdom
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory 7925, South Africa
| | - Robert J Wilkinson
- The Francis Crick Institute, Midland Road, London NW1 1AT, United Kingdom
- Faculty of Life Sciences, University College London, WC1E 6BT, United Kingdom
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory 7925, South Africa
- Department of Infectious Diseases, Imperial College London, W12 0NN, United Kingdom
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Abstract
The incidence of acute rheumatic fever (ARF) is 8 to 51 per 100,000 people worldwide. It most commonly affects children 5 to 15 years of age after a group A streptococcal infection. Overcrowding and poor socioeconomic conditions are directly proportional to the incidence of ARF. Rheumatic carditis is a manifestation of ARF that may lead to rheumatic heart disease (RHD). Timely treatment of group A streptococcal infection can prevent ARF, and penicillin prophylaxis can prevent recurrence of ARF. Prevention of recurrent ARF is the most effective way to prevent RHD. ARF is diagnosed using the 2015 modified Jones criteria. There is no gold standard laboratory test. Therefore, clinicians need to be aware of the clinical signs and symptoms of ARF to include in their differential diagnosis when seeing such patients. Secondary prophylaxis with benzathine penicillin G has been shown to decrease the incidence of RHD and is key to RHD control. Clinicians need to understand the implications of secondary prophylaxis for ARF. There is also a need to improve ARF diagnosis, to find novel therapies to reduce the incidence of ARF, and to reduce the prevalence of RHD. RHD research is neglected and underfunded. Thus, there is also a need for RHD advocacy and public health awareness to increase research on RHD.
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Affiliation(s)
- Subhrajit Lahiri
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Amy Sanyahumbi
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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Passos LSA, Nunes MCP, Aikawa E. Rheumatic Heart Valve Disease Pathophysiology and Underlying Mechanisms. Front Cardiovasc Med 2021; 7:612716. [PMID: 33537348 PMCID: PMC7848031 DOI: 10.3389/fcvm.2020.612716] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/21/2020] [Indexed: 12/27/2022] Open
Abstract
Rheumatic heart valve disease (RHVD) is a post-infectious sequel of acute rheumatic fever resulting from an abnormal immune response to a streptococcal pharyngitis that triggers valvular damage. RHVD is the leading cause of cardiovascular death in children and young adults, mainly in women from low and middle-income countries. It is known that long-term inflammation and high degree of fibrosis leads to valve dysfunction due to anatomic disruption of the valve apparatus. However, since public and private investments in RHVD studies are practically inexistent the number of publications is scarce. This disease shows different natural history and clinical presentations as compared to other degenerative heart valve diseases. Although more than five decades passed after the pioneering studies on the pathogenesis of RHVD, it is still unclear how self-tolerance mechanisms fail in this disease, and how humoral and cellular inflammatory responses are interconnected. Despite that pathological mechanisms have been already proposed for RHVD, none of them are able to explain the preferential involvement of the mitral valve. This review focuses on pathophysiology and underlying mechanisms of RHVD.
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Affiliation(s)
- Livia S A Passos
- The Center for Excellence in Vascular Biology, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Maria Carmo P Nunes
- Hospital das Clínicas e Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Elena Aikawa
- The Center for Excellence in Vascular Biology, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States.,Department of Human Pathology, Sechenov First Moscow State Medical University, Moscow, Russia
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Ferrara G, Petrillo MG, Giani T, Marrani E, Filippeschi C, Oranges T, Simonini G, Cimaz R. Clinical Use and Molecular Action of Corticosteroids in the Pediatric Age. Int J Mol Sci 2019; 20:ijms20020444. [PMID: 30669566 PMCID: PMC6359239 DOI: 10.3390/ijms20020444] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 01/14/2019] [Accepted: 01/15/2019] [Indexed: 12/19/2022] Open
Abstract
Corticosteroids are the mainstay of therapy for many pediatric disorders and sometimes are life-saving. Both endogenous and synthetic derivatives diffuse across the cell membrane and, by binding to their cognate glucocorticoid receptor, modulate a variety of physiological functions, such as glucose metabolism, immune homeostasis, organ development, and the endocrine system. However, despite their proved and known efficacy, corticosteroids show a lot of side effects, among which growth retardation is of particular concern and specific for pediatric age. The aim of this review is to discuss the mechanism of action of corticosteroids, and how their genomic effects have both beneficial and adverse consequences. We will focus on the use of corticosteroids in different pediatric subspecialties and most common diseases, analyzing the most recent evidence.
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Affiliation(s)
| | - Maria Grazia Petrillo
- Signal Transduction laboratory, NIEHS, NIH, Department of Health and Human Services, Research Triangle Park, Durham, NC 27709, USA.
| | - Teresa Giani
- Pediatric Rheumatology, Anna Meyer Children University Hospital, 50139 Florence, Italy.
- Department of Medical Biotechnology, University of Siena, 53100 Siena, Italy.
| | | | - Cesare Filippeschi
- Department of Dermatology, Anna Meyer Children's University Hospital, 50139 Florence, Italy.
| | - Teresa Oranges
- Department of Dermatology, Anna Meyer Children's University Hospital, 50139 Florence, Italy.
| | - Gabriele Simonini
- Pediatric Rheumatology, Anna Meyer Children University Hospital, 50139 Florence, Italy.
| | - Rolando Cimaz
- Pediatric Rheumatology, Anna Meyer Children University Hospital, 50139 Florence, Italy.
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Mai NTH, Dobbs N, Phu NH, Colas RA, Thao LTP, Thuong NTT, Nghia HDT, Hanh NHH, Hang NT, Heemskerk AD, Day JN, Ly L, Thu DDA, Merson L, Kestelyn E, Wolbers M, Geskus R, Summers D, Chau NVV, Dalli J, Thwaites GE. A randomised double blind placebo controlled phase 2 trial of adjunctive aspirin for tuberculous meningitis in HIV-uninfected adults. eLife 2018; 7:33478. [PMID: 29482717 PMCID: PMC5862527 DOI: 10.7554/elife.33478] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 02/12/2018] [Indexed: 01/01/2023] Open
Abstract
Adjunctive dexamethasone reduces mortality from tuberculous meningitis (TBM) but not disability, which is associated with brain infarction. We hypothesised that aspirin prevents TBM-related brain infarction through its anti-thrombotic, anti-inflammatory, and pro-resolution properties. We conducted a randomised controlled trial in HIV-uninfected adults with TBM of daily aspirin 81 mg or 1000 mg, or placebo, added to the first 60 days of anti-tuberculosis drugs and dexamethasone (NCT02237365). The primary safety endpoint was gastro-intestinal or cerebral bleeding by 60 days; the primary efficacy endpoint was new brain infarction confirmed by magnetic resonance imaging or death by 60 days. Secondary endpoints included 8-month survival and neuro-disability; the number of grade 3 and 4 and serious adverse events; and cerebrospinal fluid (CSF) inflammatory lipid mediator profiles. 41 participants were randomised to placebo, 39 to aspirin 81 mg/day, and 40 to aspirin 1000 mg/day between October 2014 and May 2016. TBM was proven microbiologically in 92/120 (76.7%) and baseline brain imaging revealed ≥1 infarct in 40/114 (35.1%) participants. The primary safety outcome occurred in 5/36 (13.9%) given placebo, and in 8/35 (22.9%) and 8/40 (20.0%) given 81 mg and 1000 mg aspirin, respectively (p=0.59). The primary efficacy outcome occurred in 11/38 (28.9%) given placebo, 8/36 (22.2%) given aspirin 81 mg, and 6/38 (15.8%) given 1000 mg aspirin (p=0.40). Planned subgroup analysis showed a significant interaction between aspirin treatment effect and diagnostic category (Pheterogeneity = 0.01) and suggested a potential reduction in new infarcts and deaths by day 60 in the aspirin treated participants with microbiologically confirmed TBM (11/32 (34.4%) events in placebo vs. 4/27 (14.8%) in aspirin 81 mg vs. 3/28 (10.7%) in aspirin 1000 mg; p=0.06). CSF analysis demonstrated aspirin dose-dependent inhibition of thromboxane A2 and upregulation of pro-resolving CSF protectins. The addition of aspirin to dexamethasone may improve outcomes from TBM and warrants investigation in a large phase 3 trial.
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Affiliation(s)
- Nguyen TH Mai
- Oxford University Clinical Research UnitHo Chi Minh CityVietnam
- Hospital for Tropical DiseasesHo Chi Minh CityVietnam
| | | | - Nguyen Hoan Phu
- Oxford University Clinical Research UnitHo Chi Minh CityVietnam
- Hospital for Tropical DiseasesHo Chi Minh CityVietnam
| | - Romain A Colas
- Lipid Mediator Unit, William Harvey Research Institute, Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUnited Kingdom
| | - Le TP Thao
- Oxford University Clinical Research UnitHo Chi Minh CityVietnam
| | | | - Ho DT Nghia
- Oxford University Clinical Research UnitHo Chi Minh CityVietnam
- Hospital for Tropical DiseasesHo Chi Minh CityVietnam
| | - Nguyen HH Hanh
- Oxford University Clinical Research UnitHo Chi Minh CityVietnam
- Hospital for Tropical DiseasesHo Chi Minh CityVietnam
| | - Nguyen T Hang
- Oxford University Clinical Research UnitHo Chi Minh CityVietnam
| | - A Dorothee Heemskerk
- Oxford University Clinical Research UnitHo Chi Minh CityVietnam
- Department of Medical Microbiology and Infection Control, VU medical centreVU University AmsterdamAmsterdamNetherlands
| | - Jeremy N Day
- Oxford University Clinical Research UnitHo Chi Minh CityVietnam
- Centre for Tropical Medicine and Global HealthNuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | - Lucy Ly
- Lipid Mediator Unit, William Harvey Research Institute, Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUnited Kingdom
| | - Do DA Thu
- Oxford University Clinical Research UnitHo Chi Minh CityVietnam
| | - Laura Merson
- Centre for Tropical Medicine and Global HealthNuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | - Evelyne Kestelyn
- Oxford University Clinical Research UnitHo Chi Minh CityVietnam
- Centre for Tropical Medicine and Global HealthNuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | - Marcel Wolbers
- Oxford University Clinical Research UnitHo Chi Minh CityVietnam
| | - Ronald Geskus
- Oxford University Clinical Research UnitHo Chi Minh CityVietnam
- Centre for Tropical Medicine and Global HealthNuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | | | - Nguyen VV Chau
- Oxford University Clinical Research UnitHo Chi Minh CityVietnam
- Hospital for Tropical DiseasesHo Chi Minh CityVietnam
| | - Jesmond Dalli
- Lipid Mediator Unit, William Harvey Research Institute, Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUnited Kingdom
| | - Guy E Thwaites
- Oxford University Clinical Research UnitHo Chi Minh CityVietnam
- Centre for Tropical Medicine and Global HealthNuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
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15
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Bi W, Hu L, Man MQ. ANTI-ULCEROGENIC EFFICACY AND MECHANISMS OF EDIBLE AND NATURAL INGREDIENTS IN NSAID-INDUCED ANIMAL MODELS. AFRICAN JOURNAL OF TRADITIONAL, COMPLEMENTARY, AND ALTERNATIVE MEDICINES 2017. [PMID: 28638885 PMCID: PMC5471470 DOI: 10.21010/ajtcam.v14i4.25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) are a class of the most commonly used medicines and proven to be effective for certain disorders. Some people use NSAIDs on daily basis for preventive purpose. But a variety of severe side effects can be induced by NSAIDs. Studies have shown that edible natural ingredients exhibit preventive benefit of gastric ulcer. This paper reviews the efficacy and safety of edible natural ingredients in preventing the development of gastric ulcer induced by NSAIDs in animal models. Methods: A systematic literature search was conducted on PubMed, using the terms “herbal medicines” and “gastric ulcer”, “herbal medicines” and “peptic ulcer”, “food” and “peptic ulcer”, “food” and “gastric ulcer”, “natural ingredient” and “peptic ulcer”, “natural ingredient” and “gastric ulcer”, “alternative medicine” and “peptic ulcer”, “alternative medicine” and “gastric ulcer”, “complementary medicine” and “peptic ulcer”, “complementary medicine” and “gastric ulcer” in papers published in English between January 1, 1960 and January 31, 2016, resulting in a total of 6146 articles containing these terms. After exclusion of studies not related prevention, not in NSAID model or using non-edible natural ingredients, 54 articles were included in this review. Results: Numerous studies have demonstrated that edible natural ingredients exhibit antiulcerogenic benefit in NSAID-induced animal models. The mechanisms by which edible, ingredient-induced anti-ulcerogenic effects include stimulation of mucous cell proliferation, antioxidation, inhibition of gastric acid secretion, as well as inhibition of H (+), K (+)- ATPase activities. Utilization of edible, natural ingredients could be a safe, valuable alternative to prevent the development of NSAID-induced gastric ulcer, particularly for the subjects who are long-term users of NSAIDs.
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Affiliation(s)
- Weiping Bi
- Weihai Central Hospital, Wendeng City, Shandong, 264400, P.R. China
| | - Lizhi Hu
- Department of Pathogen Biology and Immunology, Basic Medical College, Tianjin Medical University, Tianjin 300070, P. R. China
| | - Mao-Qiang Man
- Dermatology Service, Veterans Affairs Medical Center San Francisco, and Department of Dermatology, University of California San Francisco, CA, USA
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16
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Ralph AP, Noonan S, Boardman C, Halkon C, Currie BJ. Prescribing for people with acute rheumatic fever. Aust Prescr 2017; 40:70-75. [PMID: 28507400 DOI: 10.18773/austprescr.2017.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Anna P Ralph
- Department of Infectious Diseases, Royal Darwin Hospital, Darwin
| | | | | | | | - Bart J Currie
- Department of Infectious Diseases, Royal Darwin Hospital, Darwin
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17
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Poryo M, Khosrawikatoli S, Abdul-Khaliq H, Meyer S. Potential and Limitations of Cochrane Reviews in Pediatric Cardiology: A Systematic Analysis. Pediatr Cardiol 2017; 38:719-733. [PMID: 28239752 DOI: 10.1007/s00246-017-1572-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 01/19/2017] [Indexed: 11/28/2022]
Abstract
Evidence-based medicine has contributed substantially to the quality of medical care in pediatric and adult cardiology. However, our impression from the bedside is that a substantial number of Cochrane reviews generate inconclusive data that are of limited clinical benefit. We performed a systematic synopsis of Cochrane reviews published between 2001 and 2015 in the field of pediatric cardiology. Main outcome parameters were the number and percentage of conclusive, partly conclusive, and inconclusive reviews as well as their recommendations and their development over three a priori defined intervals. In total, 69 reviews were analyzed. Most of them examined preterm and term neonates (36.2%), whereas 33.3% included also non-pediatric patients. Leading topics were pharmacological issues (71.0%) followed by interventional (10.1%) and operative procedures (2.9%). The majority of reviews were inconclusive (42.9%), while 36.2% were conclusive and 21.7% partly conclusive. Although the number of published reviews increased during the three a priori defined time intervals, reviews with "no specific recommendations" remained stable while "recommendations in favor of an intervention" clearly increased. Main reasons for missing recommendations were insufficient data (n = 41) as well as an insufficient number of trials (n = 22) or poor study quality (n = 19). There is still need for high-quality research, which will likely yield a greater number of Cochrane reviews with conclusive results.
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Affiliation(s)
- Martin Poryo
- Department of Pediatric Cardiology, Saarland University Hospital, Kirrberger Straße, 66421, Homburg/saar, Germany.
| | | | - Hashim Abdul-Khaliq
- Department of Pediatric Cardiology, Saarland University Hospital, Kirrberger Straße, 66421, Homburg/saar, Germany
| | - Sascha Meyer
- Department of Pediatrics and Neonatology, Saarland University Hospital, Homburg/saar, Germany.,Department of Pediatric Neurology, Saarland University Hospital, Homburg/saar, Germany
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