1
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Marangou J, Rwebembera J, Mwita J, Thorup L, Remenyi B, Nascimento BR, Beaton A, Kumar K, Okello E, Raltson K, Sable C, Wheaton G, Wilson N, Zuhlke L, Mota C, Mocumbi A. The Echocardiographic Diagnosis of Rheumatic Heart Disease: A Review of the Performance of the World Heart Federation Criteria 2012-2023. Glob Heart 2024; 19:47. [PMID: 38765776 PMCID: PMC11100538 DOI: 10.5334/gh.1327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/19/2024] [Indexed: 05/22/2024] Open
Abstract
Background The World Heart Federation (WHF) published the first evidence-based guidelines on the echocardiographic diagnosis of rheumatic heart disease (RHD) in 2012. These guidelines have since been applied internationally in research and clinical practice. Substantial research has assessed the utility of the 2012 WHF criteria, including its applicability in low-resource settings. This article summarises the evidence regarding the performance of the guidelines. Methods A scoping review assessing the performance of the guidelines was performed. Cochrane, Embase, Medline, PubMed Lilacs, Sielo, and Portal BVS databases were searched for studies on the performance of the guidelines between January 2012-March 2023, and 4047 manuscripts met the search criteria, of which 34 were included. This included papers assessing the specificity, inter-rater reliability, application using hand-carried ultrasound, and modification of the criteria for simplicity. The review followed the PRISMA Extension for Scoping Reviews guideline. Results The WHF 2012 criteria were 100% specific for definite RHD when applied in low-prevalence populations. The criteria demonstrated substantial and moderate inter-rater reliability for detecting definite and borderline RHD, respectively. The inter-rater reliability for morphological features was lower than for valvular regurgitation. When applied to hand-carried ultrasound performed by an expert, modified versions of the criteria demonstrated a sensitivity and specificity range of 79-90% and 87-93% respectively for detecting any RHD, performing best for definite RHD. The sensitivity and the specificity were reduced when performed in task-sharing but remains moderately accurate. Conclusion The WHF 2012 criteria provide clear guidance for the echocardiographic diagnosis of RHD that is reproducible and applicable to a range of echocardiographic technology. Furthermore, the criteria are highly specific and particularly accurate for detecting definite RHD. There are limitations in applying all aspects of the criteria in specific settings, including task-sharing. This summary of evidence can inform the updated version of the WHF guidelines to ensure improved applicability in all RHD endemic regions.
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Affiliation(s)
- James Marangou
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Australia
- Department of Cardiology, Fiona Stanley Hospital, Perth, Australia
| | | | - Julius Mwita
- Department of Internal Medicine, University of Botswana and Princess Marina Hospital, Botswana
| | - Lene Thorup
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Bo Remenyi
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia and NT Cardiac, Darwin, Australia
| | - Bruno Ramos Nascimento
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Serviço de Cardiologia e Cirurgia Cardiovascular, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Andrea Beaton
- Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Cardiology, The Heart Institute, Cincinnati Children’s Medical Center, Cincinnati, Ohio, USA
| | - Krishna Kumar
- Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Emmy Okello
- Division of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
| | | | - Craig Sable
- Division of Cardiology, Children’s National Hospital, Washington, DC, USA
| | - Gavin Wheaton
- Women’s and Children’s Hospital, Adelaide, South Australia, Australia
| | - Nigel Wilson
- Green Lane Paediatric and Congenital Cardiac Services, Auckland, Te Whatu Ora, New Zealand
| | - Liesl Zuhlke
- Vice President-Extramural Research & Internal Portfolio, South Africa Medical Research Council, South Africa
- Division of Paediatric Cardiology, Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Cleonice Mota
- Departamento de Pediatria, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Divisão de Cardiologia Pediátrica e Fetal/Serviço de Cardiologia e Cirurgia Cardiovascular e Serviço de Pediatria, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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2
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Williamson J, Remenyi B, Francis J, Morris P, Whalley G. Echocardiographic Screening for Rheumatic Heart Disease: A Brief History and Implications for the Future. Heart Lung Circ 2024:S1443-9506(24)00162-8. [PMID: 38670880 DOI: 10.1016/j.hlc.2024.02.021] [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: 09/16/2023] [Revised: 02/05/2024] [Accepted: 02/26/2024] [Indexed: 04/28/2024]
Abstract
Transthoracic echocardiography is the gold standard for early detection of rheumatic heart disease (RHD) in asymptomatic children living in high-risk regions. Advances in technology allowing miniaturisation and increased portability of echocardiography devices have improved the accessibility of this vital diagnostic tool in RHD-endemic locations. Automation of image optimisation techniques and simplified RHD screening protocols permit use by non-experts after a brief period of training. While these changes are welcome advances in the battle to manage RHD, it is important that the sensitivity and specificity of RHD detection be maintained by all echocardiography users on any device to ensure accurate and timely diagnosis of RHD to facilitate initiation of appropriate therapy. This review of the evolution of echocardiography and its use in the detection of rheumatic valve disease may serve as a reminder of the key strengths and potential pitfalls of this increasingly relied-upon diagnostic test.
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Affiliation(s)
- Jacqueline Williamson
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; NT Cardiac, Darwin, NT, Australia.
| | - Bo Remenyi
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; NT Cardiac, Darwin, NT, Australia; Department of Paediatrics, Royal Darwin Hospital, Darwin, NT, Australia
| | - Joshua Francis
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Paediatrics, Royal Darwin Hospital, Darwin, NT, Australia
| | - Peter Morris
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Paediatrics, Royal Darwin Hospital, Darwin, NT, Australia
| | - Gillian Whalley
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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3
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Nakakana U, Serry-Bangura A, Edem BE, Tessitore P, Di Cesare L, Moriel DG, Podda A, De Ryck IS, Arora AK. Application of Transthoracic Echocardiography for Cardiac Safety Evaluation in the Clinical Development Process of Vaccines Against Streptococcus pyogenes. Drugs R D 2024; 24:1-12. [PMID: 38494581 PMCID: PMC11035538 DOI: 10.1007/s40268-024-00452-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2024] [Indexed: 03/19/2024] Open
Abstract
Superficial infections with Streptococcus pyogenes (Strep A), pharyngitis and impetigo can induce acute rheumatic fever, an autoimmune sequela manifesting mostly with arthritis and rheumatic carditis. Valvular heart damage can persist or advance following repeated episodes of acute rheumatic fever, causing rheumatic heart disease. Acute rheumatic fever and rheumatic heart disease disproportionately affect children and young adults in developing countries and disadvantaged communities in developed countries. People living with rheumatic heart disease are at risk of experiencing potentially fatal complications such as heart failure, bacterial endocarditis or stroke. Transthoracic echocardiography plays a central role in diagnosing both rheumatic carditis and rheumatic heart disease. Despite the obvious medical need, no licensed Strep A vaccines are currently available, as their clinical development process faces several challenges, including concerns for cardiac safety. However, the development of Strep A vaccines has been recently relaunched by many vaccine developers. In this context, a reliable and consistent safety evaluation of Strep A vaccine candidates, including the use of transthoracic echocardiography for detecting cardiac adverse events, could greatly contribute to developing a safe and efficacious product in the near future. Here, we propose a framework for the consistent use of transthoracic echocardiography to proactively detect cardiac safety events in clinical trials of Strep A vaccine candidates.
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Affiliation(s)
- Usman Nakakana
- Vaccines Institute for Global Health (Global Health Vaccines R&D), GSK, Siena, Italy.
| | | | - Bassey Effiom Edem
- Vaccines Institute for Global Health (Global Health Vaccines R&D), GSK, Siena, Italy
- Janssen Biologics BV, Leiden, the Netherlands
| | | | - Leonardo Di Cesare
- Vaccines Institute for Global Health (Global Health Vaccines R&D), GSK, Siena, Italy
| | - Danilo Gomes Moriel
- Vaccines Institute for Global Health (Global Health Vaccines R&D), GSK, Siena, Italy
| | - Audino Podda
- Vaccines Institute for Global Health (Global Health Vaccines R&D), GSK, Siena, Italy
- Independent consultant, Siena, Italy
| | | | - Ashwani Kumar Arora
- Vaccines Institute for Global Health (Global Health Vaccines R&D), GSK, Siena, Italy
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4
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Webb R, Culliford-Semmens N, ChanMow A, Doughty R, Tilton E, Peat B, Stirling J, Gentles TL, Wilson NJ. High burden of rheumatic heart disease confirmed by echocardiography among Pacific adults living in New Zealand. Open Heart 2023; 10:openhrt-2023-002253. [PMID: 37121603 DOI: 10.1136/openhrt-2023-002253] [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: 01/09/2023] [Accepted: 03/29/2023] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND Despite numerous echocardiographic screening studies of children in high incidence acute rheumatic fever (ARF)/rheumatic heart disease (RHD) communities, little is known about the prevalence of RHD in adults in these populations.We sought to determine the prevalence of RHD in an urban area of South Auckland, New Zealand, where previous studies had shown the prevalence of RHD in children to be around 2%. METHODS A cross-sectional screening study was conducted between 2014 and 2016. Echocardiography clinics were conducted at an urban Pacific-led primary healthcare clinic in New Zealand. Eligible persons aged 16-40 years were recruited according to a stratified randomised approach. Echocardiograms were performed with a standardised image acquisition protocol and reported by cardiologists. RESULTS There were 465 individuals who underwent echocardiograms. The overall prevalence of RHD (define and borderline) was 56 per 1000 (95% CI 36 to 78 per 1000). Definite RHD was found in 10 individuals (4 of whom were already under cardiology review at a hospital clinic) with a prevalence of 22 per 1000 (95% CI 9 to 36 per 1000). Non-rheumatic cardiac abnormalities were found in 29 individuals. CONCLUSIONS There is a high burden of both rheumatic and non-rheumatic cardiac abnormalities in this population. Rates described in New Zealand are as high as lower-middle-income countries in Africa. Addressing knowledge gaps regarding the natural history of RHD detected by echocardiography in adults is a priority issue for the international RHD community.
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Affiliation(s)
- Rachel Webb
- Department of Paediatrics: Child and Youth Health, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
- Kidz First Children's Hospital, Te Whatu Ora, Counties Manukau, Auckland, New Zealand
- Department of Paediatric Infectious Diseases, Te Whatu Ora, Starship Children's Hospital, Auckland, New Zealand
| | - Nicola Culliford-Semmens
- Department of Paediatric and Congenital Cardiac Services, Te Whatu Ora, Starship Children's Hospital, Auckland, New Zealand
| | - Andrew ChanMow
- South Seas Health Care Integrated Family Health Centre, Manukau, New Zealand
| | - Robert Doughty
- Department of Medicine, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Elizabeth Tilton
- Department of Paediatric and Congenital Cardiac Services, Te Whatu Ora, Starship Children's Hospital, Auckland, New Zealand
| | - Briar Peat
- Department of Medicine, South Auckland Clinical School, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - John Stirling
- Department of Paediatric and Congenital Cardiac Services, Te Whatu Ora, Starship Children's Hospital, Auckland, New Zealand
| | - Thomas L Gentles
- Department of Paediatric and Congenital Cardiac Services, Te Whatu Ora, Starship Children's Hospital, Auckland, New Zealand
| | - Nigel J Wilson
- Department of Paediatric and Congenital Cardiac Services, Te Whatu Ora, Starship Children's Hospital, Auckland, New Zealand
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5
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Rwebembera J, Beaton A, Okello E, Engelman D, Fall N, Mirabel M, Nakitto M, Pereira Nunes MC, Pulle J, Sarnacki R, Scheel A, Zuhlke L, Grobler A, Steer AC, Sable C. Comparison of approaches to determine echocardiographic outcomes for children with latent rheumatic heart disease. Open Heart 2022; 9:openhrt-2022-002160. [PMID: 36455994 PMCID: PMC9716950 DOI: 10.1136/openhrt-2022-002160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/14/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Screening programmes using echocardiography offer opportunity for intervention through identification and treatment of early (latent) rheumatic heart disease (RHD). We aimed to compare two methods for classifying progression or regression of latent RHD: serial review method and blinded, side-by-side review. METHODS A four-member expert panel reviewed 799 enrolment (in 2018) and completion (in 2020) echocardiograms from the GOAL Trial of latent RHD in Uganda to make consensus determination of normal, borderline RHD or definite RHD. Serial interpretations (enrolment and completion echocardiograms read at two different time points, 2 years apart, not beside one another) were compared with blinded side-by-side comparisons (enrolment and completion echocardiograms displayed beside one another in random order on same screen) to determine outcomes according to prespecified definitions of disease progression (worsening), regression (improving) or no change. We calculated inter-rater agreement using Cohen's kappa. RESULTS There were 799 pairs of echocardiogram assessments included. A higher number, 54 vs 38 (6.8% vs 4.5%), were deemed as progression by serial interpretation compared with side-by-side comparison. There was good inter-rater agreement between the serial interpretation and side-by-side comparison methods (kappa 0.89). Disagreement was most often a result of the difference in classification between borderline RHD and mild definite RHD. Most discrepancies between interpretation methods (46 of 47, 98%) resulted from differences in valvular morphological evaluation, with valves judged to be morphologically similar between enrolment and final echocardiograms when compared side by side but classified differently on serial interpretation. CONCLUSIONS There was good agreement between the methods of serial and side-by-side interpretation of echocardiograms for change over time, using the World Heart Federation criteria. Side-by-side interpretation has higher specificity for change, with fewer differences in the interpretation of valvular morphology, as compared with serial interpretation.
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Affiliation(s)
| | - Andrea Beaton
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Emmy Okello
- Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda.,Mulago National Referral Hospital, Kampala, Uganda
| | - Daniel Engelman
- Centre for International Child Heath, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Group A Streptococcal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Ndate Fall
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Mariana Mirabel
- Cardiovascular Research Center PARCC, Université de Paris 1, Paris, France.,Cardio-oncology Unit, Hôpital Européen Georges Pompidou Chirurgie cardio vasculaire, Paris, France
| | | | | | - Jafesi Pulle
- Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
| | - Rachel Sarnacki
- Children's National Medical Center, Washington, District of Columbia, USA
| | - Amy Scheel
- Children's Hospital of Philadelphia Pediatrics Residency Program, Philadelphia, Pennsylvania, USA
| | - Liesl Zuhlke
- Paediatric Cardiology, University of Cape Town, Rondebosch, South Africa
| | - Anneke Grobler
- Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Pediatrics, University of Melbourne VCCC, Parkville, Victoria, Australia
| | - Andrew Craig Steer
- Group A Streptococcal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Pediatrics, University of Melbourne VCCC, Parkville, Victoria, Australia
| | - Craig Sable
- Pediatric Cardiology, Children's National Hospital, Washington, District of Columbia, USA
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6
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Francis JR, Whalley GA, Kaethner A, Fairhurst H, Hardefeldt H, Reeves B, Auld B, Marangou J, Horton A, Wheaton G, Robertson T, Ryan C, Brown S, Smith G, Dos Santos J, Flavio R, Embaum K, da Graca Noronha M, Lopes Belo S, Madeira Santos C, Georginha Dos Santos M, Cabral J, do Rosario I, Harries J, Francis LA, Draper ADK, James CL, Davis K, Yan J, Mitchell A, da Silva Almeida I, Engelman D, Roberts KV, Ralph AP, Remenyi B. Single-View Echocardiography by Nonexpert Practitioners to Detect Rheumatic Heart Disease: A Prospective Study of Diagnostic Accuracy. Circ Cardiovasc Imaging 2021; 14:e011790. [PMID: 34384239 PMCID: PMC8373443 DOI: 10.1161/circimaging.120.011790] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Echocardiographic screening can detect asymptomatic cases of rheumatic heart disease (RHD), facilitating access to treatment. Barriers to implementation of echocardiographic screening include the requirement for expensive equipment and expert practitioners. We aimed to evaluate the diagnostic accuracy of an abbreviated echocardiographic screening protocol (single parasternal-long-axis view with a sweep of the heart) performed by briefly trained, nonexpert practitioners using handheld ultrasound devices. Methods: Participants aged 5 to 20 years in Timor-Leste and the Northern Territory of Australia had 2 echocardiograms: one performed by an expert echocardiographer using a GE Vivid I or Vivid Q portable ultrasound device (reference test), and one performed by a nonexpert practitioner using a GE Vscan handheld ultrasound device (index test). The accuracy of the index test, compared with the reference test, for identifying cases with definite or borderline RHD was determined. Results: There were 3111 enrolled participants; 2573 had both an index test and reference test. Median age was 12 years (interquartile range, 10–15); 58.2% were female. Proportion with definite or borderline RHD was 5.52% (95% CI, 4.70–6.47); proportion with definite RHD was 3.23% (95% CI, 2.61–3.98). Compared with the reference test, sensitivity of the index test for definite or borderline RHD was 70.4% (95% CI, 62.2–77.8), specificity was 78.1% (95% CI, 76.4–79.8). Conclusions: Nonexpert practitioners can be trained to perform single parasternal-long-axis view with a sweep of the heart echocardiography. However, the specificity and sensitivity are inadequate for echocardiographic screening. Improved training for nonexpert practitioners should be investigated.
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Affiliation(s)
- Joshua R Francis
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Australia (J.R.F., H.F., J.M., J.Y., A.P.R., B.R.).,Department of Pediatrics, Royal Darwin Hospital, Australia (J.R.F., H.H., A.H., L.A.F., K.D., J.Y., K.V.R., B.R.).,Maluk Timor, Timor-Leste (J.R.F., J.D.S., R.F., K.E.)
| | - Gillian A Whalley
- Dunedin School of Medicine, University of Otago, New Zealand (G.A.W.)
| | | | - Helen Fairhurst
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Australia (J.R.F., H.F., J.M., J.Y., A.P.R., B.R.)
| | - Hilary Hardefeldt
- Department of Pediatrics, Royal Darwin Hospital, Australia (J.R.F., H.H., A.H., L.A.F., K.D., J.Y., K.V.R., B.R.)
| | | | - Benjamin Auld
- Department of Cardiology, Queensland Children's Hospital, Australia (B.A.)
| | - James Marangou
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Australia (J.R.F., H.F., J.M., J.Y., A.P.R., B.R.).,NT Cardiac, Australia (A.K., J.M., B.R.)
| | - Ari Horton
- Department of Pediatrics, Royal Darwin Hospital, Australia (J.R.F., H.H., A.H., L.A.F., K.D., J.Y., K.V.R., B.R.)
| | - Gavin Wheaton
- Department of Cardiology, Women's and Children's Hospital, Australia (G.W., T.R.)
| | - Terry Robertson
- Department of Cardiology, Women's and Children's Hospital, Australia (G.W., T.R.)
| | - Chelsea Ryan
- Maningrida Health Center (C.R., S.B., G.S.), Top End Health Services, Australia
| | - Shannon Brown
- Maningrida Health Center (C.R., S.B., G.S.), Top End Health Services, Australia
| | - Greg Smith
- Maningrida Health Center (C.R., S.B., G.S.), Top End Health Services, Australia
| | | | | | | | - Mario da Graca Noronha
- Department of Pediatrics, Hospital Nacional Guido Valadares, Timor-Leste (M.d.G.N., S.L.B., C.M.S., M.G.d.S., J.C., I.d.R., I.d.S.A.)
| | - Sonia Lopes Belo
- Department of Pediatrics, Hospital Nacional Guido Valadares, Timor-Leste (M.d.G.N., S.L.B., C.M.S., M.G.d.S., J.C., I.d.R., I.d.S.A.)
| | - Carla Madeira Santos
- Department of Pediatrics, Hospital Nacional Guido Valadares, Timor-Leste (M.d.G.N., S.L.B., C.M.S., M.G.d.S., J.C., I.d.R., I.d.S.A.)
| | - Maria Georginha Dos Santos
- Department of Pediatrics, Hospital Nacional Guido Valadares, Timor-Leste (M.d.G.N., S.L.B., C.M.S., M.G.d.S., J.C., I.d.R., I.d.S.A.)
| | - Jose Cabral
- Department of Pediatrics, Hospital Nacional Guido Valadares, Timor-Leste (M.d.G.N., S.L.B., C.M.S., M.G.d.S., J.C., I.d.R., I.d.S.A.)
| | - Ivonia do Rosario
- Department of Pediatrics, Hospital Nacional Guido Valadares, Timor-Leste (M.d.G.N., S.L.B., C.M.S., M.G.d.S., J.C., I.d.R., I.d.S.A.)
| | | | - Laura A Francis
- Department of Pediatrics, Royal Darwin Hospital, Australia (J.R.F., H.H., A.H., L.A.F., K.D., J.Y., K.V.R., B.R.).,Center for Disease Control (L.A.F., A.D.K.D., C.L.J.), Top End Health Services, Australia
| | - Anthony D K Draper
- Center for Disease Control (L.A.F., A.D.K.D., C.L.J.), Top End Health Services, Australia
| | - Christian L James
- Center for Disease Control (L.A.F., A.D.K.D., C.L.J.), Top End Health Services, Australia
| | - Kimberly Davis
- Department of Pediatrics, Royal Darwin Hospital, Australia (J.R.F., H.H., A.H., L.A.F., K.D., J.Y., K.V.R., B.R.)
| | - Jennifer Yan
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Australia (J.R.F., H.F., J.M., J.Y., A.P.R., B.R.).,Department of Pediatrics, Royal Darwin Hospital, Australia (J.R.F., H.H., A.H., L.A.F., K.D., J.Y., K.V.R., B.R.)
| | | | - Ines da Silva Almeida
- Department of Pediatrics, Hospital Nacional Guido Valadares, Timor-Leste (M.d.G.N., S.L.B., C.M.S., M.G.d.S., J.C., I.d.R., I.d.S.A.)
| | - Daniel Engelman
- Tropical Diseases, Murdoch Children's Research Institute, Australia (D.E.)
| | - Kathryn V Roberts
- Department of Pediatrics, Royal Darwin Hospital, Australia (J.R.F., H.H., A.H., L.A.F., K.D., J.Y., K.V.R., B.R.)
| | - Anna P Ralph
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Australia (J.R.F., H.F., J.M., J.Y., A.P.R., B.R.).,Division of Medicine, Royal Darwin Hospital, Australia (A.P.R.)
| | - Bo Remenyi
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Australia (J.R.F., H.F., J.M., J.Y., A.P.R., B.R.).,Department of Pediatrics, Royal Darwin Hospital, Australia (J.R.F., H.H., A.H., L.A.F., K.D., J.Y., K.V.R., B.R.).,NT Cardiac, Australia (A.K., J.M., B.R.).,Department of Pediatrics, Cairns Base Hospital, Australia (B.R.)
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7
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Culliford-Semmens N, Tilton E, Wilson N, Stirling J, Doughty R, Gentles T, Peat B, Dimalapang E, Webb R. Echocardiography for latent rheumatic heart disease in first degree relatives of children with acute rheumatic fever: Implications for active case finding in family members. EClinicalMedicine 2021; 37:100935. [PMID: 34386737 PMCID: PMC8343257 DOI: 10.1016/j.eclinm.2021.100935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/30/2021] [Accepted: 05/13/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Individuals with Acute Rheumatic Fever (ARF) often report a family history of ARF or Rheumatic Heart Disease (RHD) however the degree of familial susceptibility to RHD is poorly defined. This study aimed to determine RHD prevalence among first degree relatives of ARF patients using echocardiography. METHODS Children with ARF were recruited from Auckland, New Zealand. Parents and siblings ≥ 4years were offered echocardiography. Echocardiograms were reported according to World Heart Federation 2012 criteria. RHD prevalence in first degree relatives was compared to previously established population rates in the region. FINDINGS In total, 70 index cases with ARF were recruited. Echocardiography was performed in 94 parents and 132 siblings. There were 3 siblings with definite RHD and 9 with borderline RHD. There were 4 parents with definite RHD. Overall prevalence of RHD (definite and borderline) in siblings was 90/1,000 (95% CI 45-143/1,000) compared to 36/1,000 (95% CI 30-42/1,000) in New Zealand children from high ARF incidence populations (p 0.001). Prevalence of definite RHD in parents was 42/1,000 (95% CI 7-87/1,000) compared to 22/1,000 (95% CI 9-36/1,000) in adults from a high ARF incidence New Zealand population (p 0.249). INTERPRETATION RHD prevalence in siblings and parents of ARF cases is significantly greater than in comparable background populations. The contribution of hereditary versus environmental risk factors remains uncertain. We recommend targeted echocardiographic case-finding among siblings and parents of ARF/RHD cases in order to detect previously unrecognized latent RHD.
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Affiliation(s)
- Nicola Culliford-Semmens
- Department of Paediatric and Congenital Cardiac Services, Starship Children's Hospital, New Zealand
| | - Elizabeth Tilton
- Department of Paediatric and Congenital Cardiac Services, Starship Children's Hospital, New Zealand
| | - Nigel Wilson
- Department of Paediatric and Congenital Cardiac Services, Starship Children's Hospital, New Zealand
| | - John Stirling
- Department of Paediatric and Congenital Cardiac Services, Starship Children's Hospital, New Zealand
| | - Robert Doughty
- Department of Medicine, University of Auckland, New Zealand
| | - Thomas Gentles
- Department of Paediatric and Congenital Cardiac Services, Starship Children's Hospital, New Zealand
| | - Briar Peat
- Department of Medicine, University of Auckland, New Zealand
- Middlemore Hospital, Counties Manukau District Health Board, New Zealand
| | - Eliazar Dimalapang
- Green Lane Cardiovascular Services, Auckland District Health Board, New Zealand
| | - Rachel Webb
- KidzFirst Children's Hospital, Counties Manukau District Health Board, New Zealand
- Department of Paediatric Infectious Diseases, Starship Children's Hospital, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, New Zealand
- Corresponding author at: KidzFirst Children's Hospital, Counties Manukau District Health Board, New Zealand.
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8
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Scheel A, Mirabel M, Nunes MCP, Okello E, Sarnacki R, Steer AC, Engelman D, Zimmerman M, Zühlke L, Sable C, Beaton A. The inter-rater reliability and individual reviewer performance of the 2012 world heart federation guidelines for the echocardiographic diagnosis of latent rheumatic heart disease. Int J Cardiol 2021; 328:146-151. [PMID: 33186665 DOI: 10.1016/j.ijcard.2020.11.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/29/2020] [Accepted: 11/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND In 2012, the World Heart Federation (WHF) published guidelines for the echocardiographic diagnosis of rheumatic heart disease (RHD). This study assesses individual reviewer performance and inter-rater agreement and reliability on the presence of any RHD, as well classification of RHD based on the 2012 WHF criteria. METHODS Four cardiologists individually reviewed echocardiograms in the context of a randomized clinical trial (ClinicalTrials.gov:NCT03346525) and participated in a blinded adjudication panel. Panel decision was the reference standard for diagnosis. Performance of individual reviewers to panel adjudication was compared through sensitivity and specificity analyses and inter-rater reliability was assessed between individual panelists using Fleiss free marginal multirater kappa. RESULTS Echocardiograms from 784 children had two independent reports and panel adjudication. The accuracy of independent reviewers for any RHD had high sensitivity (94%, 95% CI 93-95%) and moderate specificity (62%, 95% CI 53-70%). Sensitivity and specificity for definite RHD was 61.3 (95% CI, 55.3-67.1) and 93.1 (95% CI, 91.6-94.4), with 86.8 (84.7-88.7) and 65.8 (61.0-70.4) for borderline RHD. There was moderate inter-rater agreement (κ = 0.66) on the presence of any RHD while agreement for specific 2012 WHF classification was only fair (κ = 0.51). CONCLUSIONS The 2012 WHF guidelines are moderately reproducible when used by expert cardiologists. More cases of RHD were diagnosed by an consensus panel than by individual reviewers. A revision to the criteria is now warranted to further increase the reliability of the WHF criteria.
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Affiliation(s)
- Amy Scheel
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30329, USA.
| | - Mariana Mirabel
- Université de Paris, Paris Cardiovascular Research Center PARCC, INSERM, 56 Rue Leblanc, 75015 Paris, France; Cardio-oncology unit, AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, 75015 Paris, France.
| | - Maria Carmo Pereira Nunes
- School of Medicine of the Federal University of Minas Gerais, Av. Prof. Alfredo Balena, 190 - Santa Efigênia, Belo Horizonte, MG 30130-100, Brazil.
| | - Emmy Okello
- The Uganda Heart Institute, Block C, Mulago Hospital Complex, Kampala, Uganda
| | - Rachel Sarnacki
- Children's National Hospital, 111 Michigan Ave, NW, Washington, DC, 20010, USA.
| | - Andrew C Steer
- Tropical Diseases, Murdoch Children's Research Institute, Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, University of Melbourne, 50 Flemington Road Parkville, Victoria, Australia.
| | - Daniel Engelman
- Tropical Diseases, Murdoch Children's Research Institute, Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, University of Melbourne, 50 Flemington Road Parkville, Victoria, Australia.
| | - Meghan Zimmerman
- Dartmouth Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03766, USA
| | - Liesl Zühlke
- Red Cross War Memorial Children's Hospital, University of Cape Town, Klipfontein Rd, Rondebosch, Cape Town 7700, South Africa
| | - Craig Sable
- Children's National Hospital, 111 Michigan Ave, NW, Washington, DC, 20010, USA.
| | - Andrea Beaton
- Cincinnati Children's Hospital Medical Center, The Heart Institute, 3333 Burnet Ave, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45229, USA.
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9
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Midtbø H, Hauge SW, Haaverstad R, Dalen H. How reproducible is the diagnosis of borderline rheumatic heart disease? Int J Cardiol 2020; 328:163-164. [PMID: 33359287 DOI: 10.1016/j.ijcard.2020.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Helga Midtbø
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.
| | - Ståle W Hauge
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway; Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway; Clinic of Cardiology, St. Olavs University Hospital, Trondheim, Norway
| | - Rune Haaverstad
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Håvard Dalen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway; Clinic of Cardiology, St. Olavs University Hospital, Trondheim, Norway; Department of Medicine, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
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10
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Francis JR, Fairhurst H, Hardefeldt H, Brown S, Ryan C, Brown K, Smith G, Baartz R, Horton A, Whalley G, Marangou J, Kaethner A, Draper ADK, James CL, Mitchell AG, Yan J, Ralph A, Remenyi B. Hyperendemic rheumatic heart disease in a remote Australian town identified by echocardiographic screening. Med J Aust 2020; 213:118-123. [DOI: 10.5694/mja2.50682] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 04/23/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Joshua R Francis
- Menzies School of Health ResearchCharles Darwin University Darwin NT
- Royal Darwin Hospital Darwin NT
| | - Helen Fairhurst
- Menzies School of Health ResearchCharles Darwin University Darwin NT
| | | | - Shannon Brown
- Top End Health ServiceManingrida Health Centre Maningrida NT
| | - Chelsea Ryan
- Top End Health ServiceManingrida Health Centre Maningrida NT
| | - Kurt Brown
- Top End Health ServiceManingrida Health Centre Maningrida NT
| | - Greg Smith
- Top End Health ServiceManingrida Health Centre Maningrida NT
| | - Roz Baartz
- Top End Health ServiceManingrida Health Centre Maningrida NT
| | | | | | | | | | - Anthony DK Draper
- Centre for Disease ControlNorthern Territory Department of Health Darwin NT
| | - Christian L James
- Centre for Disease ControlNorthern Territory Department of Health Darwin NT
| | - Alice G Mitchell
- Menzies School of Health ResearchCharles Darwin University Darwin NT
| | - Jennifer Yan
- Menzies School of Health ResearchCharles Darwin University Darwin NT
- Royal Darwin Hospital Darwin NT
| | - Anna Ralph
- Menzies School of Health ResearchCharles Darwin University Darwin NT
| | - Bo Remenyi
- Royal Darwin Hospital Darwin NT
- NT Cardiac Darwin NT
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11
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Gutman SJ, Shemesh E, Marwick TH, Taylor AJ. Echocardiographic screening to determine progression of latent rheumatic heart disease in endemic areas: A systematic review and meta-analysis. PLoS One 2020; 15:e0234196. [PMID: 32497088 PMCID: PMC7272083 DOI: 10.1371/journal.pone.0234196] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 05/20/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The World Health Organisation previously recommended routine screening in school-aged children in countries with a high prevalence of rheumatic heart disease (RHD); however, it is unclear if screening-detected (latent) valve disease will inevitably evolve to a pathological lesion. Understanding the natural history of latent RHD is essential prior to recommendation of screening in endemic areas. Studies documenting the progression of latent RHD have had contrasting conclusions about the pathogenicity of latent valvular lesions. This review provides estimates of rates of progression of latent RHD. METHODS AND FINDINGS In this systematic review and meta-analysis, we searched EMBASE, MEDLINE, Global Index Medicus, Africa Wide, Cochrane Database of Systematic Reviews and Global Health Database for studies published before April 30, 2019. Study data were extracted from all studies which reported follow-up data on progression of latent valve lesions. Studies with control cohorts were used to calculate comparative prevalence ratios. This study is registered with PROSPERO, number CRD42019119427. We identified 12 studies reporting follow-up data on latent RHD for 950 people in 9 countries. The estimated pooled prevalence rate for progression per year of latent RHD was 5%/year (95% CI 2-8). Eight studies reported on the progression of borderline latent RHD with an estimated pooled prevalence of 2%/year (95% CI 0-4). Three studies included control groups. There was a significant increase in the risk of progression of valvular disease in the latent group compared with controls (RR = 3.57 (95%CI = 1.65-7.70, P = 0.001). The overall risk of bias was low. Given most studies included penicillin administration we were unable to document the natural history of latent RHD. Furthermore, we were unable to perform a sensitivity analysis to determine the effect of administering penicillin prophylaxis on progression of valve disease given prescription of penicillin was not standardised. CONCLUSION Latent RHD has a slow rate of progression but it is significantly higher compared to controls, with definite latent RHD having a higher rate of progression compared with borderline latent disease. There are a massive number of individuals at risk for RHD in the developing world as well as logistical challenges of screening and delivering penicillin prophylaxis. The low rate of progression from untargeted screening may be an important consideration in resource-constrained environments.
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Affiliation(s)
- Sarah J. Gutman
- Baker Heart and Diabetes Institute, Melbourne, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Monash University, Melbourne, Australia
| | - Elad Shemesh
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Thomas H. Marwick
- Baker Heart and Diabetes Institute, Melbourne, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Monash University, Melbourne, Australia
| | - Andrew J. Taylor
- Baker Heart and Diabetes Institute, Melbourne, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Monash University, Melbourne, Australia
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12
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Francis JR, Fairhurst H, Whalley G, Kaethner A, Ralph A, Yan J, Cush J, Wade V, Monteiro A, Remenyi B. The RECARDINA Study protocol: diagnostic utility of ultra-abbreviated echocardiographic protocol for handheld machines used by non-experts to detect rheumatic heart disease. BMJ Open 2020; 10:e037609. [PMID: 32467256 PMCID: PMC7259846 DOI: 10.1136/bmjopen-2020-037609] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Rheumatic heart disease (RHD) causes significant morbidity and mortality in young people from disadvantaged populations. Early detection through echocardiography screening can facilitate early access to treatment. Large-scale implementation of screening could be feasible with the combination of inexpensive standalone ultrasound transducers and upskilling non-expert practitioners to perform abbreviated echocardiography. METHODS AND ANALYSIS A prospective cross-sectional study will evaluate an abbreviated echocardiography screening protocol for the detection of latent (asymptomatic) RHD in high-risk populations. The study will evaluate the diagnostic accuracy of health worker conducted single parasternal long axis view with a sweep using handheld devices (SPLASH) (Philips Lumify S4-1 phased array transducer). Each participant will have at least one reference test performed on the same day by an expert echocardiographer. Diagnosis of RHD will be determined by a panel of three experts, using 2012 World Heart Federation criteria. Sensitivity and specificity of the index test will be calculated with 95% CIs, to determine diagnostic accuracy of a screen-and-refer approach to echocardiography screening for RHD. Remote review of SPLASH images obtained by health workers will facilitate evaluation of the sensitivity and specificity of an alternative approach, using external review of health worker obtained SPLASH images to decide onward referral. ETHICS AND DISSEMINATION Ethics approval was obtained from the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research, for the project to be carried out in Timor-Leste (HREC 2019-3399), and in Australia, following review by the Aboriginal Ethics subcommittee (HREC 2019-334). Ethical and technical approval was granted in Timor-Leste, by the Institute National of Health Research Ethics and Technical Committee (1073-MS-INS/GDE/VII/2019). Study results will be disseminated in the communities involved in the study, and through peer-reviewed publications and conference abstracts. TRIAL REGISTRATION NUMBER The Australia New Zealand Clinical Trials Registry (ACTRN12620000122954).
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Affiliation(s)
- Joshua Reginald Francis
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Helen Fairhurst
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Gillian Whalley
- Department of Medicine, University of Otago Dunedin School of Medicine, Dunedin, New Zealand
| | | | - Anna Ralph
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Infectious Diseases, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Jennifer Yan
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - James Cush
- Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Vicki Wade
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Andre Monteiro
- Internal Medicine, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Bo Remenyi
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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