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Robinson SJA, McLeod E, Nestel D, Pacilli M, Nataraja RM. Simulation-based education in the Pacific Islands: educational experience, access, and perspectives of healthcare workers. ANZ J Surg 2024. [PMID: 39205429 DOI: 10.1111/ans.19188] [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: 02/28/2024] [Revised: 07/08/2024] [Accepted: 07/24/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND The World Health Organization (WHO) recommends simulation-based education (SBE) to acquire skills and accelerate learning. Literature focusing on SBE in the Pacific Islands is limited. The aim of this study was to determine Pacific Island healthcare workers' experiences, perspectives, and access to SBE. METHODS This was a cross-sectional survey of Pacific Island healthcare workers. We designed an online questionnaire based on existing literature and expert consultation. The questionnaire included Likert scales, multiple-choice, multi-select and open-ended questions. Participants were healthcare workers recruited from professional networks across the region. Descriptive statistics and relative frequencies summarized data, and comparative testing included unpaired t-tests, Mann-Whitney U, Chi-squared and Fisher's exact tests. Free-text responses were presented to illustrate findings. RESULTS Responses from 56 clinicians working in 11 Pacific Island countries were included. Fifty were medical doctors (89%), including 31 (55%) surgeons. Participants reported experience with scenario-based simulation (73%), mannequins (71%), and simulated patients (61%). Discrepancies were identified between previous simulation experience and current access for simulated patients (P = 0.002) and animal-based part-task trainers (P = 0.002). SBE was seen as beneficial for procedural skills, communication, decision-making and teamwork. Interest in further SBE was reported by most participants (96%). Barriers included equipment access (59%), clinical workload (45%) and COVID-19 restrictions (45%). CONCLUSION Some Pacific Island healthcare workers have experience with SBE, but their ongoing access is predominantly limited to low-technology modalities. Despite challenges, there is interest in SBE initiatives. These findings may inform planning for SBE in the Pacific Islands and may be considered prior to programme implementation.
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Affiliation(s)
- Samuel James Alexander Robinson
- Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Paediatric Surgery and Surgical Simulation, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Elizabeth McLeod
- Department of Paediatric and Neonatal Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Debra Nestel
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Surgery (Austin Precinct), University of Melbourne, Heidelberg, Victoria, Australia
| | - Maurizio Pacilli
- Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Paediatric Surgery and Surgical Simulation, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Ramesh Mark Nataraja
- Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Paediatric Surgery and Surgical Simulation, Monash Children's Hospital, Melbourne, Victoria, Australia
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Robinson SJA, McLeod E, Nestel D, Pacilli M, Hansell L, Nataraja RM. "I've yet to meet anyone who's not keen for simulation" - a qualitative study of simulation-based education in the Pacific Islands. ANZ J Surg 2024. [PMID: 39051180 DOI: 10.1111/ans.19156] [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: 03/25/2024] [Revised: 06/12/2024] [Accepted: 06/25/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Simulation-based education (SBE) has been increasingly used to train healthcare workers in low-resource settings and has been endorsed by the World Health Organization (WHO). Consideration of the educational and cultural context is important to maximize the effectiveness of SBE. Despite its demonstrable benefits, there have been no studies of the general approach in the Pacific Islands. This study aimed to determine the factors that influence the uptake and success of SBE in the Pacific Islands. METHODS In this qualitative study, participants were recruited via professional networks to contribute to focus groups. Questions focused on participants' previous experiences and perspectives on SBE. Data were manually transcribed before thematic analysis. The reporting of the research was guided by the Standards for Reporting Qualitative Research (SRQR). Human Research Ethics Committee approval was obtained. RESULTS Two focus groups were conducted with 16 participants from six Pacific Island countries. Six themes and 15 subthemes were conceptualized from the data. Uptake of SBE is challenged by resource availability, clinical workloads and geographic remoteness. However, locally-driven solutions and positive attitudes towards SBE facilitate its success. CONCLUSION This study reveals the complexity of factors affecting the uptake and success of SBE in the Pacific Islands. These findings can serve to optimize the impact of existing and future SBE programmes and may be considered by educators prior to programme implementation.
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Affiliation(s)
- Samuel J A Robinson
- Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Paediatric Surgery and Monash Children's Simulation, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Elizabeth McLeod
- Department of Paediatric and Neonatal Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Debra Nestel
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Surgery (Austin Precinct), University of Melbourne, Heidelberg, Victoria, Australia
| | - Maurizio Pacilli
- Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Paediatric Surgery and Monash Children's Simulation, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Lamour Hansell
- Clinical Services Programme, Public Health Division, Pacific Community (SPC), Suva, Fiji
| | - Ramesh Mark Nataraja
- Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Paediatric Surgery and Monash Children's Simulation, Monash Children's Hospital, Melbourne, Victoria, Australia
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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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Rwebembera J, Marangou J, Mwita JC, Mocumbi AO, Mota C, Okello E, Nascimento B, Thorup L, Beaton A, Kado J, Kaethner A, Kumar RK, Lawrenson J, Marijon E, Mirabel M, Nunes MCP, Piñeiro D, Pinto F, Ralston K, Sable C, Sanyahumbi A, Saxena A, Sliwa K, Steer A, Viali S, Wheaton G, Wilson N, Zühlke L, Reményi B. 2023 World Heart Federation guidelines for the echocardiographic diagnosis of rheumatic heart disease. Nat Rev Cardiol 2024; 21:250-263. [PMID: 37914787 DOI: 10.1038/s41569-023-00940-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 11/03/2023]
Abstract
Rheumatic heart disease (RHD) is an important and preventable cause of morbidity and mortality among children and young adults in low-income and middle-income countries, as well as among certain at-risk populations living in high-income countries. The 2012 World Heart Federation echocardiographic criteria provided a standardized approach for the identification of RHD and facilitated an improvement in early case detection. The 2012 criteria were used to define disease burden in numerous epidemiological studies, but researchers and clinicians have since highlighted limitations that have prompted a revision. In this updated version of the guidelines, we incorporate evidence from a scoping review, an expert panel and end-user feedback and present an approach for active case finding for RHD, including the use of screening and confirmatory criteria. These guidelines also introduce a new stage-based classification for RHD to identify the risk of disease progression. They describe the latest evidence and recommendations on population-based echocardiographic active case finding and risk stratification. Secondary antibiotic prophylaxis, echocardiography equipment and task sharing for RHD active case finding are also discussed. These World Heart Federation 2023 guidelines provide a concise and updated resource for clinical and research applications in 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, Northern Territory, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Julius Chacha Mwita
- Department of Internal Medicine, University of Botswana and Princess Marina Hospital, Gaborone, Botswana
| | | | - Cleonice Mota
- Departamento de Paediatria, 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 Paediatria, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo, Horizonte, Brazil
| | - Emmy Okello
- Division of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Bruno 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
| | - Lene Thorup
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Andrea Beaton
- Department of Paediatrics, School of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Cardiology, The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Joseph Kado
- Wesfarmers Centre of Vaccine and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Alexander Kaethner
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- NT Cardiac, Darwin, Northern Territory, Australia
| | | | - John Lawrenson
- Paediatric Cardiology Service of the Western Cape, Red Cross War Memorial Children's Hospital and Tygerberg Hospital, Cape Town, South Africa
- Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Eloi Marijon
- Division of Cardiology, European Georges Pompidou Hospital, Paris, France
| | | | - Maria Carmo Pereira Nunes
- 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
| | - Daniel Piñeiro
- Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Fausto Pinto
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, The Cardiovascular Centre of the University of Lisbon, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | | | - Craig Sable
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Amy Sanyahumbi
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Anita Saxena
- Pt BD Sharma University of Health Sciences, Rohtak, India
| | - Karen Sliwa
- Cape Heart Institute, Department of Medicine and Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Andrew Steer
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | | | - Gavin Wheaton
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Nigel Wilson
- Green Lane Paediatric and Congenital Cardiac Services, Starship Hospital, Te Whatu Ora, Auckland, New Zealand
| | - Liesl Zühlke
- South African Medical Research Council, Extramural Research & Internal Portfolio, Cape Town, South Africa
- Division of Paediatric Cardiology, Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Bo Reményi
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- NT Cardiac, Darwin, Northern Territory, Australia
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia
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5
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Diniz MG, Fraga LL, Nunes MCP, Oliveira KKB, Amaral IB, Chavez LMT, de Paula LH, Haiashi BC, Ferreira AM, Silva MHA, Veloso JEM, Silva CA, Gelape FA, Santos LPA, Amaral AM, Coelho CT, Diamante LC, Correia JS, Meira ZMA, Ribeiro ALP, Spaziani AM, Sable C, Nascimento BR. Agreement between Handheld and Standard Echocardiography for Diagnosis of Latent Rheumatic Heart Disease in Brazilian Schoolchildren from High-Prevalence Settings (Agreement between Screening and Standard Echo for RHD). Diagnostics (Basel) 2024; 14:392. [PMID: 38396431 PMCID: PMC10888211 DOI: 10.3390/diagnostics14040392] [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: 01/09/2024] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
Introduction: Handheld echocardiography (echo) is the tool of choice for rheumatic heart disease (RHD) screening. We aimed to assess the agreement between screening and standard echo for latent RHD diagnosis in schoolchildren from an endemic setting. Methods: Over 14 months, 3 nonphysicians used handheld machines and the 2012 WHF Criteria to determine RHD prevalence in consented schoolchildren from Brazilian low-income public schools. Studies were interpreted by telemedicine by 3 experts (Brazil, US). RHD-positive children (borderline/definite) and those with congenital heart disease (CHD) were referred for standard echo, acquired and interpreted by a cardiologist. Agreement between screening and standard echo, by WHF subgroups, was assessed. Results: 1390 students were screened in 6 schools, with 110 (7.9%, 95% CI 6.5-9.5) being screen positive (14 ± 2 years, 72% women). Among 16 cases initially diagnosed as definite RHD, 11 (69%) were confirmed, 4 (25%) reclassified to borderline, and 1 to normal. Among 79 cases flagged as borderline RHD, 19 (24%) were confirmed, 50 (63%) reclassified to normal, 8 (10%) reclassified as definite RHD, and 2 had mild CHD. Considering the 4 diagnostic categories, kappa was 0.18. In patients with borderline RHD reclassified to non-RHD, the most frequent WHF criterion was B (isolated mitral regurgitation, 64%), followed by A (2 mitral valve morphological features, 31%). In 1 patient with definite RHD reclassified to normal, the WHF criterion was D (borderline RHD in aortic and mitral valves). After standard echo, RHD prevalence was 3.2% (95% CI 2.3-4.2). Conclusions: Although practical, RHD screening with handheld devices tends to overestimate prevalence.
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Affiliation(s)
- Marina G. Diniz
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Lucas L. Fraga
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Maria Carmo P. Nunes
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Kaciane K. B. Oliveira
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
| | - Ingred Beatriz Amaral
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
| | - Luz Marina T. Chavez
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
| | - Luiza Haikal de Paula
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Beatriz C. Haiashi
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Alexandre M. Ferreira
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Mauro Henrique A. Silva
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Jéssica Elvira M. Veloso
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
| | - Cássia Aparecida Silva
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
| | - Fernanda A. Gelape
- Curso de Medicina, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte 30130-110, MG, Brazil; (F.A.G.); (L.P.A.S.)
| | - Luiza P. A. Santos
- Curso de Medicina, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte 30130-110, MG, Brazil; (F.A.G.); (L.P.A.S.)
| | - Arthur M. Amaral
- Departamento de Medicina, Universidade Federal de Ouro Preto, Ouro Preto 35400-000, MG, Brazil;
| | - Cecília T. Coelho
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Lucas C. Diamante
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Juliane S. Correia
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Zilda Maria A. Meira
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
| | - Antonio Luiz P. Ribeiro
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Alison M. Spaziani
- Cardiology, Children’s National Health System, Washington, DC 20010, USA; (A.M.S.); (C.S.)
| | - Craig Sable
- Cardiology, Children’s National Health System, Washington, DC 20010, USA; (A.M.S.); (C.S.)
| | - Bruno R. Nascimento
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
- Serviço de Hemodinâmica, Hospital Madre Teresa, Belo Horizonte 30441-070, MG, Brazil
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Brown K, Roshanitabrizi P, Rwebembera J, Okello E, Beaton A, Linguraru MG, Sable CA. Using Artificial Intelligence for Rheumatic Heart Disease Detection by Echocardiography: Focus on Mitral Regurgitation. J Am Heart Assoc 2024; 13:e031257. [PMID: 38226515 PMCID: PMC10926790 DOI: 10.1161/jaha.123.031257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/18/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Identification of children with latent rheumatic heart disease (RHD) by echocardiography, before onset of symptoms, provides an opportunity to initiate secondary prophylaxis and prevent disease progression. There have been limited artificial intelligence studies published assessing the potential of machine learning to detect and analyze mitral regurgitation or to detect the presence of RHD on standard portable echocardiograms. METHODS AND RESULTS We used 511 echocardiograms in children, focusing on color Doppler images of the mitral valve. Echocardiograms were independently reviewed by an expert adjudication panel. Among 511 cases, 229 were normal, and 282 had RHD. Our automated method included harmonization of echocardiograms to localize the left atrium during systole using convolutional neural networks and RHD detection using mitral regurgitation jet analysis and deep learning models with an attention mechanism. We identified the correct view with an average accuracy of 0.99 and the correct systolic frame with an average accuracy of 0.94 (apical) and 0.93 (parasternal long axis). It localized the left atrium with an average Dice coefficient of 0.88 (apical) and 0.9 (parasternal long axis). Maximum mitral regurgitation jet measurements were similar to expert manual measurements (P value=0.83) and a 9-feature mitral regurgitation analysis showed an area under the receiver operating characteristics curve of 0.93, precision of 0.83, recall of 0.92, and F1 score of 0.87. Our deep learning model showed an area under the receiver operating characteristics curve of 0.84, precision of 0.78, recall of 0.98, and F1 score of 0.87. CONCLUSIONS Artificial intelligence has the potential to detect RHD as accurately as expert cardiologists and to improve with more data. These innovative approaches hold promise to scale echocardiography screening for RHD.
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Affiliation(s)
- Kelsey Brown
- Department of Pediatric CardiologyChildren’s National HospitalWashingtonDCUSA
| | - Pooneh Roshanitabrizi
- Sheikh Zayed Institute for Pediatric Surgical InnovationChildren’s National HospitalWashingtonDCUSA
| | | | | | - Andrea Beaton
- Department of Pediatric CardiologyCincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
| | - Marius George Linguraru
- Sheikh Zayed Institute for Pediatric Surgical InnovationChildren’s National HospitalWashingtonDCUSA
- Departments of Radiology and Pediatrics, School of Medicine and Health SciencesGeorge Washington UniversityWashingtonDCUSA
| | - Craig A. Sable
- Department of Pediatric CardiologyChildren’s National HospitalWashingtonDCUSA
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Lamichhane P, Patel F, Al Mefleh R, Mohamed Gasimelseed SY, Ala A, Gawad G, Soni S. Detection and management of latent rheumatic heart disease: a narrative review. Ann Med Surg (Lond) 2023; 85:6048-6056. [PMID: 38098553 PMCID: PMC10718380 DOI: 10.1097/ms9.0000000000001402] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/08/2023] [Indexed: 12/17/2023] Open
Abstract
Rheumatic heart disease (RHD) is a public health concern in many developing nations around the world. Early detection of latent or subclinical RHD can help in reversing mild lesions, retarding disease progression, reducing morbidity and mortality, and improving the quality of life of patients. Echocardiography is the gold-standard method for screening and confirming latent RHD cases. The rates and determinants of progression of latent RHD cases as assessed by echocardiography have been found to be variable through studies. Even though latent RHD has a slow rate of progression, the rate of progression of its subtype, 'definite' RHD, is substantial. A brief training of nonexpert operators on the use of handheld echocardiography with a simplified protocol is an important strategy to scale up the screening program to detect latent cases. Newer advancements in screening, such as deep-learning digital stethoscopes and telehealth services, have provided an opportunity to expand screening programs even in resource-constrained settings. Newer studies have established the efficacy and safety profile of secondary antibiotic prophylaxis in latent RHD. The concerned authorities in endemic regions of the world should work on improving the availability and accessibility of antibiotic prophylaxis.
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Affiliation(s)
| | - Fiuna Patel
- American University of Barbados School of Medicine, Wildey, Barbados
| | - Renad Al Mefleh
- Department of Pediatrics, Jordanian Royal Medical Services, Amman, Jordan
| | | | - Abdul Ala
- Faculty of Pharmacy, University of Tripoli, Tripoli, Libya
| | - Gamal Gawad
- Saba University School of Medicine, Saba, Dutch Caribbean
| | - Siddharath Soni
- Department of General Medicine, Shree Narayan Medical Institute and Hospital, Saharsa, Bihar Bihar, India
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Kaltenborn ZP, Zewde A, Kirsch JD, Yates M, Tessier KM, Nemec E, Johannsen RA. The Impact of a Handheld Ultrasound Device in a Rheumatic Heart Disease Screening Program in Ethiopia. POCUS JOURNAL 2023; 8:193-201. [PMID: 38099177 PMCID: PMC10721305 DOI: 10.24908/pocus.v8i2.16390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Background: Rheumatic heart disease (RHD) affects 33 million people in low and middle income countries and is the leading cause of cardiovascular death among children and young adults. Penicillin prophylaxis prevents progression in asymptomatic disease. Efforts to expand echocardiographic screening are focusing on simplified protocols, non-physician ultrasonographers, and portable ultrasound devices, including handheld ultrasound. Recent advances support the use of single-view screening protocols. With the increasing availability and low cost of handheld devices, studies are needed to evaluate their performance in these settings. Methods: We conducted a retrospective study comparing the rate of screen positive ultrasounds before and after the use of a handheld ultrasound in an RHD screening program in Ethiopia. We also performed a cross-sectional device comparison in 19 at-risk school-children participating in the rheumatic heart disease screening program. Results: Between March of 2019 and January of 2022, 6631 children were screened for rheumatic heart disease of whom 4029 were screened after the introduction of a handheld device. Before the use of the handheld ultrasound device 291 (11.2%) children had a screen positive ultrasounds compared with 167 (4.1%) afterwards (p<0.001). We also compared non-expert to expert interpretation by device and found a significant difference in interpretation for the Lumify (p=0.025). There was a trend towards shorter jet length by color Doppler in the handheld ultrasound device for both expert and non-expert review. Conclusions: Our study highlights that the screen-positive rate in a RHD screening program is influenced by the device being used in the screening process.
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Affiliation(s)
- Zachary P Kaltenborn
- Departments of General Internal Medicine and Pediatrics, University of Minnesota Medical SchoolMinneapolis , MNUSA
| | - Anteneh Zewde
- Department of General Internal Medicine, University of Minnesota Medical SchoolMinneapolis, MNUSA
| | - Jonathan D Kirsch
- Department of General Internal Medicine, University of Minnesota Medical SchoolMinneapolis, MNUSA
| | | | - Katelyn M Tessier
- Masonic Cancer Center, Division of Cardiology, University of Minnesota, Biostatistics CoreMinneapolis, MNUSA
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Peck D, Rwebembera J, Nakagaayi D, Minja NW, Ollberding NJ, Pulle J, Klein J, Adams D, Martin R, Koepsell K, Sanyahumbi A, Beaton A, Okello E, Sable C. The Use of Artificial Intelligence Guidance for Rheumatic Heart Disease Screening by Novices. J Am Soc Echocardiogr 2023; 36:724-732. [PMID: 36906047 DOI: 10.1016/j.echo.2023.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 03/11/2023]
Abstract
INTRODUCTION A novel technology utilizing artificial intelligence (AI) to provide real-time image-acquisition guidance, enabling novices to obtain diagnostic echocardiographic images, holds promise to expand the reach of echo screening for rheumatic heart disease (RHD). We evaluated the ability of nonexperts to obtain diagnostic-quality images in patients with RHD using AI guidance with color Doppler. METHODS Novice providers without prior ultrasound experience underwent a 1-day training curriculum to complete a 7-view screening protocol using AI guidance in Kampala, Uganda. All trainees then scanned 8 to 10 volunteer patients using AI guidance, half RHD and half normal. The same patients were scanned by 2 expert sonographers without the use of AI guidance. Images were evaluated by expert blinded cardiologists to assess (1) diagnostic quality to determine presence/absence of RHD and (2) valvular function and (3) to assign an American College of Emergency Physicians score of 1 to 5 for each view. RESULTS Thirty-six novice participants scanned a total of 50 patients, resulting in a total of 462 echocardiogram studies, 362 obtained by nonexperts using AI guidance and 100 obtained by expert sonographers without AI guidance. Novice images enabled diagnostic interpretation in >90% of studies for presence/absence of RHD, abnormal MV morphology, and mitral regurgitation (vs 99% by experts, P ≤ .001). Images were less diagnostic for aortic valve disease (79% for aortic regurgitation, 50% for aortic stenosis, vs 99% and 91% by experts, P < .001). The American College of Emergency Physicians scores of nonexpert images were highest in the parasternal long-axis images (mean, 3.45; 81% ≥ 3) compared with lower scores for apical 4-chamber (mean, 3.20; 74% ≥ 3) and apical 5-chamber images (mean, 2.43; 38% ≥ 3). CONCLUSIONS Artificial intelligence guidance with color Doppler is feasible to enable RHD screening by nonexperts, performing significantly better for assessment of the mitral than aortic valve. Further refinement is needed to optimize acquisition of color Doppler apical views.
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Affiliation(s)
- Daniel Peck
- University of Minnesota, Minneapolis, Minnesota.
| | | | - Doreen Nakagaayi
- Uganda Heart Institute, Kampala, Uganda; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Neema W Minja
- Uganda Heart Institute, Kampala, Uganda; Department of Global Health, University of Washington, Seattle, Washington; Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Nicholas J Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Jennifer Klein
- Children's National Hospital, Washington, District of Columbia
| | | | | | | | - Amy Sanyahumbi
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Andrea Beaton
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Craig Sable
- Children's National Hospital, Washington, District of Columbia
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Francis JR, Fairhurst H, Yan J, Fernandes Monteiro A, Lee AM, Maurays J, Kaethner A, Whalley GA, Hardefeldt H, Williamson J, Marangou J, Reeves B, Wheaton G, Robertson T, Horton A, Cush J, Wade V, Monteiro A, Draper ADK, Morris PS, Ralph AP, Remenyi B. Abbreviated Echocardiographic Screening for Rheumatic Heart Disease by Nonexperts with and without Offsite Expert Review: A Diagnostic Accuracy Study. J Am Soc Echocardiogr 2023; 36:733-745. [PMID: 36806665 DOI: 10.1016/j.echo.2023.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Early detection of rheumatic heart disease (RHD) through echocardiographic screening can facilitate early access to effective treatment, which reduces the risk for progression. Accurate, feasible approaches to echocardiographic screening that can be incorporated into routine health services are needed. The authors hypothesized that offsite expert review could improve the diagnostic accuracy of nonexpert-obtained echocardiographic images. METHODS This prospective cross-sectional study was performed to evaluate the diagnostic accuracy of health worker-conducted single parasternal long-axis view with a sweep of the heart using hand-carried ultrasound for the detection of RHD in high-risk populations in Timor-Leste and Australia. In the primary analysis, the presence of any mitral or aortic regurgitation met the criteria for a positive screening result. Sensitivity and specificity were calculated for a screen-and-refer approach based on nonexpert practitioner assessment (approach 1) and for an approach using offsite expert review of nonexpert practitioner-obtained images to decide onward referral (approach 2). Each participant had a reference test performed by an expert echocardiographer on the same day as the index test. Diagnosis of RHD was determined by a panel of three experts, using 2012 World Heart Federation criteria. RESULTS The prevalence of borderline or definite RHD among 3,329 participants was 4.0% (95% CI, 3.4%-4.7%). The sensitivity of approach 1 for borderline or definite RHD was 86.5% (95% CI, 79.5%-91.8%), and the specificity was 61.4% (95% CI, 59.7%-63.1%). Approach 2 achieved similar sensitivity (88.4%; 95% CI, 81.5%-93.3%) and improved specificity (77.1%; 95% CI, 75.6%-78.6%). CONCLUSION Nonexpert practitioner-obtained single parasternal long-axis view with a sweep of the heart images, reviewed by an offsite expert, can detect borderline and definite RHD on screening with reasonable sensitivity and specificity. Brief training of nonexpert practitioners with ongoing support could be used as an effective strategy for scaling up echocardiographic screening for RHD in high-risk settings.
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Affiliation(s)
- Joshua R Francis
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia; Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia.
| | - Helen Fairhurst
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Jennifer Yan
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia; Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia
| | - Anferida Fernandes Monteiro
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | | | | | - Alex Kaethner
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia; NT Cardiac, Darwin, Australia
| | - Gillian A Whalley
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | | | - Jacqui Williamson
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - James Marangou
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia; NT Cardiac, Darwin, Australia; Division of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - Benjamin Reeves
- Department of Paediatric Cardiology, Cairns Hospital, Cairns, Australia
| | - Gavin Wheaton
- Department of Cardiology, Women's and Children's Hospital, Adelaide, Australia
| | - Terry Robertson
- Department of Cardiology, Women's and Children's Hospital, Adelaide, Australia
| | - Ari Horton
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia; NT Cardiac, Darwin, Australia; Paediatric Cardiology, Monash Heart and Monash Children's Hospital, Melbourne, Australia
| | - James Cush
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia
| | - Vicki Wade
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Andre Monteiro
- Department of Cardiology, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Anthony D K Draper
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia; Centre for Disease Control, Northern Territory Department of Health, Darwin, Australia; National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia
| | - Peter S Morris
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia; Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia
| | - Anna P Ralph
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia; Division of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - 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; NT Cardiac, Darwin, Australia
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Chillo P, Mutagaywa R, Nkya D, Njelekela M, Kwesigabo G, Kahabuka F, Kerry V, Kamuhabwa A. Sub-clinical rheumatic heart disease (RHD) detected by hand-held echocardiogram in children participating in a school-based RHD prevention program in Tanzania. BMC Cardiovasc Disord 2023; 23:155. [PMID: 36966309 PMCID: PMC10040127 DOI: 10.1186/s12872-023-03186-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 03/15/2023] [Indexed: 03/27/2023] Open
Abstract
BACKGROUND Rheumatic Heart Disease (RHD) continues to cause suffering and premature deaths in many sub-Saharan Africa (SSA) countries, where the disease is still endemic. RHD is largely preventable and determining its community burden is an important critical step in any RHD prevention program. METHODS We conducted a cross-sectional study of 5-16 years old pupils from 11 primary schools participating in an RHD prevention program in 4 districts in Tanzania, between 2018 and 2019. At the school, all children were invited to participate after receiving consent from their parents/guardians. Participating children filled a questionnaire and were auscultated for cardiac murmurs. Echocardiographic screening was done by two experienced cardiologists, using a hand-held machine (V-Scan, GE®). All positive screening tests were stored for further examination by the same two cardiologists to reach to a consensus of definite, borderline or no RHD, using a modified World Heart Federation (WHF) criterion. RESULTS Of the 6895 children invited, 4738 (68.7%) were screened and 4436 (64.3%) had complete data. The mean (SD) age was 10.04 (2.43) years, and 2422 (54.6%) were girls. Fifty three (1.2%) children were found to have a murmur. The proportion of children with trace or mild valvular regurgitation, sub-valvular/chordal thickening and valvular thickening/deformity were 8.3%, 1.3%, and 1.0%, respectively. Sub-clinical RHD was found in 95 children (59 definite and 36 borderline), giving a prevalence of 2.1%, [95% CI 1.7% - 2.6%]. Sub-clinical RHD was independently associated with female sex (aOR 1.83, 95% CI 1.18-2.85, p = 0.007), older age groups (aOR 1.73, 95% CI 1.10-2.72, p = 0.018 for age group 11-14 years; and aOR 3.02 95% CI 1.01-9.05, p = 0.048 for age group 15-16 years), as well as presence of a cardiac murmur, aOR 5.63 95% CI 2.31-13.69, p < 0.0001. None of the studied socio- or economic factors was associated with the presence of sub-clinical RHD in this study. CONCLUSION The prevalence of sub-clinical RHD among primary school children in Tanzania is 2.1%, similar to previous reports in SSA. Efforts to prevent and control RHD in our communities are highly warranted.
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Affiliation(s)
- Pilly Chillo
- Department of Internal Medicine, Section of Cardiology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Reuben Mutagaywa
- Department of Internal Medicine, Section of Cardiology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Deogratias Nkya
- Department of Paediatric and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Marina Njelekela
- Department of Physiology, Muhimbili University of Health and Allied Sciences and Deloitte Consulting Limited, Dar es Salaam, Tanzania
| | - Gideon Kwesigabo
- Department of Epidemiology and Community Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Febronia Kahabuka
- Department of Orthodontics Paedodontics & Community Dentistry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Vanessa Kerry
- Department of Global Health and Social Medicine, Seed Global Health Partnerships, Boston, USA
- Harvard Medical School, Center for Global Health, Mass General Hospital, Boston, MA, USA
| | - Appolinary Kamuhabwa
- Department of Clinical Pharmacy and Pharmacology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Edwards P, Anyaogu C, Mezue K, Baugh D, Goha A, Egbuche O, Nunura F, Madu E. Focused cardiac ultrasound in pregnancy. J Investig Med 2023; 71:81-91. [PMID: 36691704 DOI: 10.1177/10815589221142195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Cardiac disease in pregnancy is an important cause of maternal morbidity and mortality. In many high-income countries, acquired cardiac disease is now the largest cause of maternal mortality. Given its prevalence in low- and middle-income countries (LMICs), rheumatic heart disease is the most common cause of cardiac disease in pregnancy worldwide and is associated with poor maternal outcome. The diagnosis of cardiac disease in pregnancy is often delayed resulting in excess maternal morbidity and mortality. Maternal mortality review committees have suggested that prompt recognition and treatment of heart disease in pregnancy may improve maternal outcome. Given the similarities between symptoms of normal pregnancy and those of cardiac disease, the clinical diagnosis of heart disease in pregnancy is challenging with echocardiography being the primary diagnostic modality. Focused cardiac ultrasound (FOCUS) at the point of care provides supplemental data to the history and physical examination and has been demonstrated to permit early diagnosis and improvement in the management of cardiac disease in emergency medicine, intensive care, and anesthesia. It has also been demonstrated to be useful in surveillance for rheumatic heart disease in LMICs. The use of FOCUS may allow earlier and more accurate diagnosis of cardiac disease in pregnancy with the potential to decrease morbidity and mortality in both developed and developing countries.
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Affiliation(s)
- Paul Edwards
- Heart Institute of the Caribbean, Kingston, Jamaica
| | | | - Kenechukwu Mezue
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Dainia Baugh
- Heart Institute of the Caribbean, Kingston, Jamaica
| | - Ahmed Goha
- Cardiology department, Cardiac Center Hail, Hail, Saudi Arabia
| | - Obiora Egbuche
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Felix Nunura
- Heart Institute of the Caribbean, Kingston, Jamaica
| | - Ernest Madu
- Heart Institute of the Caribbean, Kingston, Jamaica
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13
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Edwards LA, Feng F, Iqbal M, Fu Y, Sanyahumbi A, Hao S, McElhinney DB, Ling XB, Sable C, Luo J. Machine Learning for Pediatric Echocardiographic Mitral Regurgitation Detection. J Am Soc Echocardiogr 2023; 36:96-104.e4. [PMID: 36191670 DOI: 10.1016/j.echo.2022.09.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Echocardiography-based screening for valvular disease in at-risk asymptomatic children can result in early diagnosis. These screening programs, however, are resource intensive and may not be feasible in many resource-limited settings. Automated echocardiographic diagnosis may enable more widespread echocardiographic screening, early diagnosis, and improved outcomes. In this feasibility study, the authors sought to build a machine learning model capable of identifying mitral regurgitation (MR) on echocardiography. METHODS Echocardiograms were labeled by clip for view and by frame for the presence of MR. The labeled data were used to build two convolutional neural networks to perform the stepwise tasks of classifying the clips (1) by view and (2) by the presence of any MR, including physiologic, in parasternal long-axis color Doppler views. The view classification model was developed using 66,330 frames, and model performance was evaluated using a hold-out testing data set with 45 echocardiograms (11,730 frames). The MR detection model was developed using 938 frames, and model performance was evaluated using a hold-out testing data set with 42 echocardiograms (182 frames). Metrics to evaluate model performance included accuracy, precision, recall, F1 score (average of precision and recall, ranging from 0 to 1, with 1 suggesting perfect precision and recall), and receiver operating characteristic analysis. RESULTS For the parasternal long-axis view with color Doppler, the view classification convolutional neural network achieved an F1 score of 0.97. The MR detection convolutional neural network achieved testing accuracy of 0.86 and an area under the receiver operating characteristic curve of 0.91. CONCLUSIONS A machine learning model is capable of discerning MR on transthoracic echocardiography. This is an encouraging step toward machine learning-based diagnosis of valvular heart disease on pediatric echocardiography.
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Affiliation(s)
- Lindsay A Edwards
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Fei Feng
- University of Michigan-Shanghai Jiao Tong University Joint Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Mehreen Iqbal
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Yong Fu
- University of Michigan-Shanghai Jiao Tong University Joint Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Amy Sanyahumbi
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Shiying Hao
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Doff B McElhinney
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - X Bruce Ling
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Craig Sable
- Department of Pediatrics, Children's National Health System, Washington, District of Columbia
| | - Jiajia Luo
- Biomedical Engineering Department, Peking University, Beijing, China.
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14
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Beaton A, Okello E, Rwebembera J, Grobler A, Engelman D, Alepere J, Canales L, Carapetis J, DeWyer A, Lwabi P, Mirabel M, Mocumbi AO, Murali M, Nakitto M, Ndagire E, Nunes MCP, Omara IO, Sarnacki R, Scheel A, Wilson N, Zimmerman M, Zühlke L, Karthikeyan G, Sable CA, Steer AC. Secondary Antibiotic Prophylaxis for Latent Rheumatic Heart Disease. N Engl J Med 2022; 386:230-240. [PMID: 34767321 DOI: 10.1056/nejmoa2102074] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Rheumatic heart disease affects more than 40.5 million people worldwide and results in 306,000 deaths annually. Echocardiographic screening detects rheumatic heart disease at an early, latent stage. Whether secondary antibiotic prophylaxis is effective in preventing progression of latent rheumatic heart disease is unknown. METHODS We conducted a randomized, controlled trial of secondary antibiotic prophylaxis in Ugandan children and adolescents 5 to 17 years of age with latent rheumatic heart disease. Participants were randomly assigned to receive either injections of penicillin G benzathine (also known as benzathine benzylpenicillin) every 4 weeks for 2 years or no prophylaxis. All the participants underwent echocardiography at baseline and at 2 years after randomization. Changes from baseline were adjudicated by a panel whose members were unaware of the trial-group assignments. The primary outcome was echocardiographic progression of latent rheumatic heart disease at 2 years. RESULTS Among 102,200 children and adolescents who had screening echocardiograms, 3327 were initially assessed as having latent rheumatic heart disease, and 926 of the 3327 subsequently received a definitive diagnosis on the basis of confirmatory echocardiography and were determined to be eligible for the trial. Consent or assent for participation was provided for 916 persons, and all underwent randomization; 818 participants were included in the modified intention-to-treat analysis, and 799 (97.7%) completed the trial. A total of 3 participants (0.8%) in the prophylaxis group had echocardiographic progression at 2 years, as compared with 33 (8.2%) in the control group (risk difference, -7.5 percentage points; 95% confidence interval, -10.2 to -4.7; P<0.001). Two participants in the prophylaxis group had serious adverse events that were attributable to receipt of prophylaxis, including one episode of a mild anaphylactic reaction (representing <0.1% of all administered doses of prophylaxis). CONCLUSIONS Among children and adolescents 5 to 17 years of age with latent rheumatic heart disease, secondary antibiotic prophylaxis reduced the risk of disease progression at 2 years. Further research is needed before the implementation of population-level screening can be recommended. (Funded by the Thrasher Research Fund and others; GOAL ClinicalTrials.gov number, NCT03346525.).
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Affiliation(s)
- Andrea Beaton
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Emmy Okello
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Joselyn Rwebembera
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Anneke Grobler
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Daniel Engelman
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Juliet Alepere
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Lesley Canales
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Jonathan Carapetis
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Alyssa DeWyer
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Peter Lwabi
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Mariana Mirabel
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Ana O Mocumbi
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Meghna Murali
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Miriam Nakitto
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Emma Ndagire
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Maria C P Nunes
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Isaac O Omara
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Rachel Sarnacki
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Amy Scheel
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Nigel Wilson
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Meghan Zimmerman
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Liesl Zühlke
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Ganesan Karthikeyan
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Craig A Sable
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
| | - Andrew C Steer
- From Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati School of Medicine - both in Cincinnati (A.B.); Uganda Heart Institute (E.O., J.R., J.A., P.L., M.N., E.N., I.O.O.), and the Department of Medicine, Makerere University (E.O.) - both in Kampala, Uganda; Children's National Hospital, Washington, DC (L.C., M. Murali, R.S., C.A.S.); Murdoch Children's Research Institute (A.G., D.E., A.C.S.), and Melbourne Children's Global Health, Royal Children's Hospital (D.E., A.C.S.), Melbourne, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth (J.C.) - all in Australia; Virginia Tech Carilion School of Medicine, Roanoke, VA (A.D.W.); Assistance Publique-Hôpitaux de Paris, Université de Paris, and Cardio-Oncologie, Hôpital Européen Georges-Pompidou - both in Paris (M. Mirabel); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (M.C.P.N.); Emory University School of Medicine, Atlanta (A.S.); Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand (N.W.); Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.Z.); the Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital - both in Cape Town, South Africa (L.Z.); and All India Institute of Medical Sciences, New Delhi, India (G.K.)
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15
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Johannsen RA, Kaltenborn ZP, Shroff GR. Saving time saves lives! A time focused evaluation of a single-view echocardiographic screening protocol for subclinical rheumatic heart disease. Int J Cardiol 2021; 351:111-114. [PMID: 34942302 DOI: 10.1016/j.ijcard.2021.12.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 12/10/2021] [Accepted: 12/17/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Rheumatic heart disease affects 33 million people in low and middle income countries and is the leading cause of cardiovascular death among children and young adults. Evidence increasingly supports that simplified screening protocols can identify at risk children with good accuracy. One of the more proximal and pragmatic hurdles that has not been completely explored is the time required for executing the screening exam. METHODS We conducted an observational study comparing three different echocardiographic strategies in four separate school-based screening programs in Kenya and Cameroon. RESULTS In a sample of 911 children, we found that a single-view screening strategy can be obtained in an average time of 1.2 min/child, the two-view in an average of 2.1 min/child, and multi-view in an average of 5 min/child. CONCLUSIONS Our study demonstrates that there are significant differences in the time required to execute different screening protocols and is an essential consideration in the feasibility of large scale populations based rheumatic heart disease screening programs.
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Affiliation(s)
- Ronald A Johannsen
- Division of Cardiology, Department of Internal Medicine, Hennepin County Medical Center, 716 S 7th St, Minneapolis, MN 55415, United States of America
| | - Zachary P Kaltenborn
- Division of General Internal Medicine and Hospital Pediatrics, Department of Internal Medicine and Pediatrics, University of Minnesota Medical School, Division Mailbox - MMC 741, 420 Delaware Street SE, Minneapolis, MN 55455, United States of America.
| | - Gautam R Shroff
- Division of Cardiology, Department of Internal Medicine, Hennepin County Medical Center, 716 S 7th St, Minneapolis, MN 55415, United States of America; Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, Minneapolis, MN 55455, United States of America
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16
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Focused Cardiac Ultrasound for the Evaluation of Heart Valve Disease in Resource-Limited Settings. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00945-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Cardiac point of care ultrasound in resource limited settings to manage children with congenital and acquired heart disease. Cardiol Young 2021; 31:1651-1657. [PMID: 33682650 DOI: 10.1017/s1047951121000834] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In resource limited settings, children with cardiac disease present late, have poor outcomes and access to paediatric cardiology programmes is limited. Cardiac point of care ultrasound was introduced at several Médecins Sans Frontières sites to facilitate cardiopulmonary assessment. We describe the spectrum of disease, case management and outcomes of cases reviewed over the Telemedicine platform. METHODS Previously ultrasound naïve, remotely placed clinical teams received ultrasound training on focussed image acquisition. The Médecins Sans Frontières Telemedicine platform was utilised for remote case and imaging review to diagnose congenital and acquired heart disease and guide management supported by a remotely situated paediatric cardiologist. RESULTS Two-hundred thirty-three cases were reviewed between 2016 and 2018. Of 191 who underwent focussed cardiac ultrasound, diagnoses included atrial and ventricular septal defects 11%, atrioventricular septal defects 7%, Tetralogy of Fallot 9%, cardiomyopathy/myocarditis 8%, rheumatic heart disease 8%, isolated pericardiac effusion 6%, complex congenital heart disease 4% and multiple other diagnoses in 15%. In 17%, there was no identifiable abnormality while 15% had inadequate imaging to make a diagnosis. Cardiologist involvement led to management changes in 75% of cases with a diagnosis. Mortality in the entire group was disproportionately higher among neonates (38%, 11/29) and infants (20%, 16/81). There was good agreement on independent review of selected cases between two independent paediatric cardiologists. CONCLUSION Cardiac point of care ultrasound performed by remote clinical teams facilitated diagnosis and influenced management in cases reviewed over a Telemedicine platform. This is a feasible method to support clinical care in resource limited settings.
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18
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Nascimento BR, Nunes MCP, Lima EM, Sanyahumbi AE, Wilson N, Tilton E, Rémond MGW, Maguire GP, Ribeiro ALP, Kazembe PN, Sable C, Beaton AZ. Outcomes of Echocardiography-Detected Rheumatic Heart Disease: Validating a Simplified Score in Cohorts From Different Countries. J Am Heart Assoc 2021; 10:e021622. [PMID: 34533041 PMCID: PMC8649515 DOI: 10.1161/jaha.121.021622] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The natural history of latent rheumatic heart disease (RHD) detected by echocardiography remains unclear. We aimed to assess the accuracy of a simplified score based on the 2012 World Heart Federation criteria in predicting mid-term RHD echocardiography outcomes in children from 4 different countries. Methods and Results Patient-level baseline and follow-up data of children with latent RHD from 4 countries (Australia, n=62; Brazil, n=197; Malawi, n=40; New Zealand, n=94) were combined. A simplified echocardiographic scoring system previously developed from Brazilian and Ugandan cohorts, consisting of 5 point-based variables with respective weights, was applied: mitral valveanterior leaflet thickening (weight=3), excessive leaflet
tip motion (3), regurgitation jet length ≥2 cm (6), aortic valve
focal thickening (4), and any regurgitation (5). Unfavorable outcome was defined as worsening diagnostic category, persistent definite RHD or development/worsening of valve regurgitation/stenosis. The score model was updated using methods for recalibration. 393 patients (314 borderline, 79 definite RHD) with median follow-up of 36 (interquartile range, 25-48) months were included. Median age was 14 (interquartile range, 11-16) years and secondary prophylaxis was prescribed to 16%. The echocardiographic score model applied to this external population showed significant association with unfavorable outcome (hazard ratio, 1.10; 95% CI, 1.04-1.16; P=0.001). Unfavorable outcome rates in low (≤5 points), intermediate (6-9), and high-risk (≥10) children at 3-year follow-up were 14.3%, 20.8%, and 38.5% respectively (P<0.001). The updated score model showed good performance in predicting unfavorable outcome. Conclusions The echocardiographic score model for predicting RHD outcome was updated and validated for different latent RHD populations. It has potential utility in the clinical and screening setting for risk stratification of latent RHD.
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Affiliation(s)
- Bruno R Nascimento
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde Hospital das Clínicas da Universidade Federal de Minas Gerais Belo Horizonte Minas Gerais Brazil.,Departamento de Clínica Médica Faculdade de Medicina da Universidade Federal de Minas Gerais Belo Horizonte Minas Gerais Brazil
| | - Maria Carmo P Nunes
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde Hospital das Clínicas da Universidade Federal de Minas Gerais Belo Horizonte Minas Gerais Brazil.,Departamento de Clínica Médica Faculdade de Medicina da Universidade Federal de Minas Gerais Belo Horizonte Minas Gerais Brazil
| | - Emily M Lima
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde Hospital das Clínicas da Universidade Federal de Minas Gerais Belo Horizonte Minas Gerais Brazil
| | | | - Nigel Wilson
- Department of Paediatric and Congenital Cardiac Services Starship Children's Hospital Auckland New Zealand
| | - Elizabeth Tilton
- Department of Paediatric and Congenital Cardiac Services Starship Children's Hospital Auckland New Zealand
| | - Marc G W Rémond
- Faculty of Health and Medicine University of Newcastle Callaghan New South Wales Australia
| | - Graeme P Maguire
- Faculty of Health and Medicine University of Newcastle Callaghan New South Wales Australia.,Western Clinical School University of Melbourne Melbourne Victoria Australia
| | - Antonio Luiz P Ribeiro
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde Hospital das Clínicas da Universidade Federal de Minas Gerais Belo Horizonte Minas Gerais Brazil.,Departamento de Clínica Médica Faculdade de Medicina da Universidade Federal de Minas Gerais Belo Horizonte Minas Gerais Brazil
| | | | - Craig Sable
- Cardiology Children's National Health System Washington DC
| | - Andrea Z Beaton
- The Heart InstituteCincinnati Childrens Hospital Medical Center, and the University of Cincinnati School of Medicine Cincinnati OH
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19
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Bennett J, Rentta NN, Leung W, Atkinson J, Wilson N, Webb R, Baker MG. Early diagnosis of acute rheumatic fever and rheumatic heart disease as part of a secondary prevention strategy: Narrative review. J Paediatr Child Health 2021; 57:1385-1390. [PMID: 34296804 DOI: 10.1111/jpc.15664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 07/05/2021] [Accepted: 07/14/2021] [Indexed: 01/07/2023]
Abstract
Acute rheumatic fever (ARF) and its sequela rheumatic heart disease (RHD) remain significant causes of morbidity and mortality. In New Zealand, ARF almost exclusively affects Indigenous Māori and Pacific children. This narrative review aims to present secondary interventions to improve early and accurate diagnosis of ARF and RHD, in order to minimise disease progression in New Zealand. Medline, EMBASE and Scopus databases were searched as well as other electronic publications. Included were 56 publications from 1980 onwards. Diagnosing ARF and RHD as early as possible is central to reducing disease progression. Recent identification of specific ARF biomarkers offer the opportunity to aid initial diagnosis and portable echocardiography has the potential to detect undiagnosed RHD in high-risk areas. However, further research into the benefits and risks to children with subclinical RHD is necessary, as well as an economic evaluation.
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Affiliation(s)
- Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Neilenuo N Rentta
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - William Leung
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - June Atkinson
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Nigel Wilson
- Green Lane Paediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand.,Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Rachel Webb
- Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand.,KidzFirst Children's Hospital, Counties Manukau District Health Board, Auckland, New Zealand.,Department of Paediatric Infectious Diseases, Starship Children's Hospital, Auckland, New Zealand
| | - Michael G Baker
- Department of Public Health, University of Otago, Wellington, New Zealand
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20
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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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21
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Thean LJ, Jenney A, Engelman D, Romani L, Wand H, Mani J, Paka J, Cua T, Taole S, Soqo V, Sahukhan A, Kama M, Tuicakau M, Kado J, Carvalho N, Whitfeld M, Kaldor J, Steer AC. Prospective surveillance for invasive Staphylococcus aureus and group A Streptococcus infections in a setting with high community burden of scabies and impetigo. Int J Infect Dis 2021; 108:333-339. [PMID: 34022330 DOI: 10.1016/j.ijid.2021.05.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/12/2021] [Accepted: 05/15/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Invasive Staphylococcus aureus (iSA) and group A Streptococcus (iGAS) impose significant health burdens globally. Both bacteria commonly cause skin and soft tissue infections (SSTIs), which can result in invasive disease. Understanding of the incidence of iSA and iGAS remains limited in settings with a high SSTI burden. METHODS Prospective surveillance for admissions with iSA or iGAS was conducted at the referral hospital in Fiji's Northern Division over 48 weeks between July 2018 and June 2019. RESULTS There were 55 admissions for iSA and 15 admissions for iGAS (incidence 45.2 and 12.3 per 100,000 person-years, respectively). The highest incidence was found in patients aged ≥65 years (59.6 per 100,000 person-years for iSA and iGAS). The incidence of iSA was higher in indigenous Fijians (iTaukei) (71.1 per 100,000 person-years) compared with other ethnicities (incidence rate ratio 9.7, 95% confidence interval 3.5-36.9). SSTIs were found in the majority of cases of iSA (75%) and iGAS (53.3%). Thirteen of the 14 iGAS strains isolated belonged to emm cluster D (n = 5) or E (n = 8). The case fatality rate was high for both iSA (10.9%) and iGAS (33.3%). CONCLUSIONS The incidence of iSA and iGAS in Fiji is very high. SSTIs are common clinical foci for both iSA and iGAS. Both iSA and iGAS carry a substantial risk of death. Improved control strategies are needed to reduce the burden of iSA and iGAS in Fiji.
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Affiliation(s)
- Li Jun Thean
- Tropical Diseases Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.
| | - Adam Jenney
- College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
| | - Daniel Engelman
- Tropical Diseases Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Melbourne Children's Global Health, Melbourne Children's Campus, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Lucia Romani
- Kirby Institute, University of New South Wales, Kensington, New South Wales, Australia
| | - Handan Wand
- Kirby Institute, University of New South Wales, Kensington, New South Wales, Australia
| | - Jyotishna Mani
- Tropical Diseases Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Jessica Paka
- Tropical Diseases Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Tuliana Cua
- Tropical Diseases Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Sera Taole
- Tropical Diseases Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Vika Soqo
- Ministry of Health and Medical Services, Suva, Fiji
| | | | - Mike Kama
- Ministry of Health and Medical Services, Suva, Fiji
| | | | - Joseph Kado
- Ministry of Health and Medical Services, Suva, Fiji; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Natalie Carvalho
- School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Margot Whitfeld
- Department of Dermatology, St. Vincent's Hospital, Darlinghurst, New South Wales, Australia; School of Medicine, University of New South Wales, Kensington, New South Wales, Australia
| | - John Kaldor
- Kirby Institute, University of New South Wales, Kensington, New South Wales, Australia
| | - Andrew C Steer
- Tropical Diseases Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Melbourne Children's Global Health, Melbourne Children's Campus, The Royal Children's Hospital, Parkville, Victoria, Australia
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22
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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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23
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Kumar RK, Antunes MJ, Beaton A, Mirabel M, Nkomo VT, Okello E, Regmi PR, Reményi B, Sliwa-Hähnle K, Zühlke LJ, Sable C. Contemporary Diagnosis and Management of Rheumatic Heart Disease: Implications for Closing the Gap: A Scientific Statement From the American Heart Association. Circulation 2020; 142:e337-e357. [PMID: 33073615 DOI: 10.1161/cir.0000000000000921] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The global burden of rheumatic heart disease continues to be significant although it is largely limited to poor and marginalized populations. In most endemic regions, affected patients present with heart failure. This statement will seek to examine the current state-of-the-art recommendations and to identify gaps in diagnosis and treatment globally that can inform strategies for reducing disease burden. Echocardiography screening based on World Heart Federation echocardiographic criteria holds promise to identify patients earlier, when prophylaxis is more likely to be effective; however, several important questions need to be answered before this can translate into public policy. Population-based registries effectively enable optimal care and secondary penicillin prophylaxis within available resources. Benzathine penicillin injections remain the cornerstone of secondary prevention. Challenges with penicillin procurement and concern with adverse reactions in patients with advanced disease remain important issues. Heart failure management, prevention, early diagnosis and treatment of endocarditis, oral anticoagulation for atrial fibrillation, and prosthetic valves are vital therapeutic adjuncts. Management of health of women with unoperated and operated rheumatic heart disease before, during, and after pregnancy is a significant challenge that requires a multidisciplinary team effort. Patients with isolated mitral stenosis often benefit from percutaneous balloon mitral valvuloplasty. Timely heart valve surgery can mitigate the progression to heart failure, disability, and death. Valve repair is preferable over replacement for rheumatic mitral regurgitation but is not available to the vast majority of patients in endemic regions. This body of work forms a foundation on which a companion document on advocacy for rheumatic heart disease has been developed. Ultimately, the combination of expanded treatment options, research, and advocacy built on existing knowledge and science provides the best opportunity to address the burden of rheumatic heart disease.
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24
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Telford LH, Abdullahi LH, Ochodo EA, Zuhlke LJ, Engel ME. Standard echocardiography versus handheld echocardiography for the detection of subclinical rheumatic heart disease: a systematic review and meta-analysis of diagnostic accuracy. BMJ Open 2020; 10:e038449. [PMID: 33122317 PMCID: PMC7597508 DOI: 10.1136/bmjopen-2020-038449] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To summarise the accuracy of handheld echocardiography (HAND) which, if shown to be sufficiently similar to that of standard echocardiography (STAND), could usher in a new age of rheumatic heart disease (RHD) screening in endemic areas. DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, Scopus, EBSCOHost and ISI Web of Science were initially searched on 27 September 2017 and again on 3 March 2020 for studies published from 2012 onwards. ELIGIBILITY CRITERIA Studies assessing the accuracy of HAND compared with STAND when performed by an experienced cardiologist in conjunction with the 2012 World Heart Federation criteria among populations of children and adolescents living in endemic areas were included. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data and assessed the methodological quality of included studies against review-specific Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 criteria. A meta-analysis using the hierarchical summary receiver operating characteristic model was conducted to produce summary results of sensitivity and specificity. Forest plots and scatter plots in receiver operating characteristic space in combination with subgroup analyses were used to investigate heterogeneity. Publication bias was not investigated. RESULTS Six studies (N=4208) were included in the analysis. For any RHD detection, the pooled results from six studies were as follows: sensitivity: 81.56% (95% CI 76.52% to 86.61%) and specificity: 89.75% (84.48% to 95.01%). Meta-analytical results from five of the six included studies were as follows: sensitivity: 91.06% (80.46% to 100%) and specificity: 91.96% (85.57% to 98.36%) for the detection of definite RHD only and sensitivity: 62.01% (31.80% to 92.22%) and specificity: 82.33% (65.15% to 99.52%) for the detection of borderline RHD only. CONCLUSIONS HAND displayed good accuracy for detecting definite RHD only and modest accuracy for detecting any RHD but demonstrated poor accuracy for the detection of borderline RHD alone. Findings from this review provide some evidence for the potential of HAND to increase access to echocardiographic screening for RHD in resource-limited and remote settings; however, further research into feasibility and cost-effectiveness of wide-scale screening is still needed. PROSPERO REGISTRATION NUMBER CRD42016051261.
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Affiliation(s)
- Lisa Helen Telford
- Department of Medicine, Groote Schuur Hospital, University of Cape Town Faculty of Health Sciences, Cape Town, Western Cape, South Africa
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town Faculty of Health Sciences, Cape Town, Western Cape, South Africa
| | - Leila Hussein Abdullahi
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town Faculty of Health Sciences, Cape Town, Western Cape, South Africa
- Department of Policy and Research, African Institute for Development Policy (AFIDEP), Nairobi, Kenya
| | - Eleanor Atieno Ochodo
- Department of Global Health, Faculty of Medicine and Health Sciences, University of Stellenbosch Centre for Evidence-Based Health Care, Cape Town, Western Cape, South Africa
| | - Liesl Joanna Zuhlke
- Division of Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town Faculty of Health Sciences, Cape Town, Western Cape, South Africa
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, University of Cape Town Faculty of Health Sciences, Cape Town, Western Cape, South Africa
| | - Mark Emmanuel Engel
- Department of Medicine, Groote Schuur Hospital, University of Cape Town Faculty of Health Sciences, Cape Town, Western Cape, South Africa
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25
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Raiten J, Ahmed N, Amatya A, Sharma A, Acharya S, Lanahan J, Werlhof H, Ko HA, Tsui C, Reza T, Bajracharya S, Hagen O, Shrestha G. Perioperative Point-of-Care Ultrasound and Transesophageal Echocardiography in Resource- Limited Settings—A Focus on Nepal and Bangladesh. J Cardiothorac Vasc Anesth 2020; 34:2604-2610. [DOI: 10.1053/j.jvca.2020.06.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 06/01/2020] [Accepted: 06/04/2020] [Indexed: 11/11/2022]
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26
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Soesanto AM, Suastika LOS. Echocardiography Screening for Latent Rheumatic Heart Disease: What Can We Do in Indonesia? Front Surg 2020; 7:46. [PMID: 32974379 PMCID: PMC7466630 DOI: 10.3389/fsurg.2020.00046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/19/2020] [Indexed: 11/29/2022] Open
Abstract
Rheumatic heart disease (RHD), a sequela of acute rheumatic fever (ARF), is a preventable disease but remains a significant health problem, especially in developing countries. It causes disability, poor quality of life, early mortality, and national economic burden. The World Heart Federation (WHF) aimed to achieve a 25% reduction in premature deaths from ARF and RHD among individuals aged <25 years by 2025. Primordial and primary prophylaxis of RHD is aimed to prevent the occurrence of ARF, while the goal of secondary and tertiary prophylaxis is to limit the progression and reduce the consequences of RHD. Early recognition of RHD is important for early prophylaxis strategies to inhibit any progression to advanced stages. In 2012, WHF introduced the latest echocardiographic criteria to recognize the early stage of RHD. This includes the evaluation of pathological regurgitation jet and morphological features of RHD based on 2D, color, and spectral Doppler criteria. In remote areas, portable echocardiography is preferable for RHD screening. Previous portable devices were only capable of producing 2D and color images. Hence, a simplified echocardiographic criterion without spectral Doppler evaluation is needed in selected areas. Indonesia is a developing country, an archipelago with a population of over 250 million. Currently, there are no data on ARF incidence and RHD prevalence nationwide. The only data available are the number of patients in advanced stages who came to referral centers for further management. The screening program has to be introduced in Indonesia as part of national RHD prophylaxis.
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Affiliation(s)
- Amiliana M Soesanto
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Luh Oliva Saraswati Suastika
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Udayana University, Udayana University Hospital, Denpasar, Indonesia
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27
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Morikawa MJ. Global Health Lessons from a District Hospital. South Med J 2020; 113:418-419. [PMID: 32885256 DOI: 10.14423/smj.0000000000001135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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28
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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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Abstract
Ancestral and geographical issues underlie the need to develop Africa-specific guidelines for the return of genomic research results in Africa. In this Commentary, we outline the challenges that will inform policies and practices moving forward.
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Affiliation(s)
- Ambroise Wonkam
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
- Institute of Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Jantina de Vries
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Eberly LA, Rusingiza E, Park PH, Ngoga G, Dusabeyezu S, Mutabazi F, Harerimana E, Mucumbitsi J, Nyembo PF, Borg R, Gahamanyi C, Mutumbira C, Ntaganda E, Rusangwa C, Kwan GF, Bukhman G. Nurse-Driven Echocardiography and Management of Heart Failure at District Hospitals in Rural Rwanda. Circ Cardiovasc Qual Outcomes 2019; 11:e004881. [PMID: 30562070 DOI: 10.1161/circoutcomes.118.004881] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lauren A Eberly
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA (L.A.E., G.B.)
| | - Emmanuel Rusingiza
- Department of Pediatrics, Pediatric Cardiology Unit, Centre Hospitalier Universitaire de Kigali, Rwanda (E.R.).,Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | - Paul H Park
- Partners in Health, Boston, MA (P.H.P., G.F.K., G.B.).,Program in Global NCDs and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA (P.H.P., G.F.K., G.B.)
| | - Gedeon Ngoga
- Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | - Symaque Dusabeyezu
- Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | - Francis Mutabazi
- Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | - Emmanuel Harerimana
- Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | - Joseph Mucumbitsi
- Department of Paediatrics, King Faisal Hospital, Kigali, Rwanda (J.M.)
| | | | - Ryan Borg
- Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | - Cyprien Gahamanyi
- Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | - Cadet Mutumbira
- Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | | | - Christian Rusangwa
- Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | - Gene F Kwan
- Partners in Health, Boston, MA (P.H.P., G.F.K., G.B.).,Program in Global NCDs and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA (P.H.P., G.F.K., G.B.).,Section of Cardiology, Department of Medicine, Boston Medical Center, MA (G.F.K.)
| | - Gene Bukhman
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA (L.A.E., G.B.).,Partners in Health, Boston, MA (P.H.P., G.F.K., G.B.).,Program in Global NCDs and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA (P.H.P., G.F.K., G.B.).,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.B.)
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Beaton A, Okello E, Engelman D, Grobler A, Scheel A, DeWyer A, Sarnacki R, Omara IO, Rwebembera J, Sable C, Steer A. Determining the impact of Benzathine penicillin G prophylaxis in children with latent rheumatic heart disease (GOAL trial): Study protocol for a randomized controlled trial. Am Heart J 2019; 215:95-105. [PMID: 31301533 DOI: 10.1016/j.ahj.2019.06.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 06/01/2019] [Indexed: 11/15/2022]
Abstract
Rheumatic heart disease (RHD) remains a high prevalence condition in low- and middle-income countries. Most individuals with RHD present late, missing the opportunity to benefit from secondary antibiotic prophylaxis. Echocardiographic screening can detect latent RHD, but the impact of secondary prophylaxis in screen-detected individuals is not known. METHODS/DESIGN This trial aims to determine if secondary prophylaxis with every-4-week injectable Benzathine penicillin G (BPG) improves outcomes for children diagnosed with latent RHD. This is a randomized controlled trial in consenting children, aged 5 to 17 years in Northern Uganda, confirmed to have borderline RHD or mild definite RHD on echocardiography, according to the 2012 World Heart Federation criteria. Qualifying children will be randomized to every-4-week injectable intramuscular BPG or no medical intervention and followed for a period of 2 years. Ongoing intervention adherence and retention in the trial will be supported through the establishment of peer support groups for participants in the intervention and control arms. A blinded echocardiography adjudication panel consisting of four independent experts will determine the echocardiographic classification at enrollment and trajectory through consensus review. The primary outcome is the proportion of children in the BPG-arm who demonstrate echocardiographic progression of latent RHD compared to those in the control arm. The secondary outcome is the proportion of children in the BPG-arm who demonstrate echocardiographic regression of latent RHD compared to those in the control arm. A sample size of 916 participants will provide 90% power to detect a 50% relative risk reduction assuming a 15% progression in the control group. The planned study duration is from 2018-2021. DISCUSSION Policy decisions on the role of echocardiographic screening for RHD have stalled because of the lack of evidence of the benefit of secondary prophylaxis. The results of our study will immediately inform the standard of care for children diagnosed with latent RHD and will shape, over 2-3 years, practical and scalable programs that could substantially decrease the burden of RHD in our lifetime. TRIAL REGISTRATION ClinicalTrials.gov: NCT03346525. Date Registered: November 17, 2017.
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Affiliation(s)
- Andrea Beaton
- Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
| | | | - Daniel Engelman
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Anneke Grobler
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Amy Scheel
- Emory School of Medicine, Atlanta, GA, USA
| | - Alyssa DeWyer
- Children's National Medical Center, Washington, DC, USA
| | | | | | | | - Craig Sable
- Children's National Medical Center, Washington, DC, USA
| | - Andrew Steer
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Royal Children's Hospital, Melbourne, Victoria, Australia
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Marangou J, Beaton A, Aliku TO, Nunes MCP, Kangaharan N, Reményi B. Echocardiography in Indigenous Populations and Resource Poor Settings. Heart Lung Circ 2019; 28:1427-1435. [DOI: 10.1016/j.hlc.2019.05.176] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 04/25/2019] [Accepted: 05/17/2019] [Indexed: 01/07/2023]
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Loughran KA, Rush JE, Rozanski EA, Oyama MA, Larouche-Lebel É, Kraus MS. The use of focused cardiac ultrasound to screen for occult heart disease in asymptomatic cats. J Vet Intern Med 2019; 33:1892-1901. [PMID: 31317580 PMCID: PMC6766524 DOI: 10.1111/jvim.15549] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 06/19/2019] [Indexed: 12/13/2022] Open
Abstract
Background Focused cardiac ultrasound (FCU) helps detect occult heart disease in human patients. Hypothesis Focused cardiac ultrasound by a nonspecialist practitioner (NSP) will increase the detection of occult heart disease in asymptomatic cats compared with physical examination and ECG. Animals Three hundred forty‐three client‐owned cats: 54 excluded and 289 analyzed. Methods Multicenter prospective cohort study. Twenty‐two NSPs were trained to perform FCU. Cats without clinical signs of heart disease were recruited, and NSPs performed the following in sequential order: physical examination, ECG, FCU, and point‐of‐care N‐terminal pro‐B‐type natriuretic peptide assay (POC‐BNP). After each step, NSPs indicated yes, no, or equivocal as to whether they believed heart disease was present. The level of agreement between the NSP diagnosis and a blinded cardiologist's diagnosis after echocardiogram was evaluated using Cohen's kappa test. Results Cardiologist diagnoses included 148 normal cats, 102 with heart disease, and 39 equivocal ones. Agreement between NSP and cardiologist was slight after physical examination (kappa 0.253 [95% CI, 0.172‐0.340]), did not increase after ECG (0.256 [0.161‐0.345]; P = .96), increased after FCU (0.468 [0.376‐0.558]; P = .002), and the level of agreement was similar after POC‐BNP (0.498 [0.419‐0.580]; P = .67). In cats with mild, moderate, and marked occult heart disease, the proportion of cats having a NSP diagnosis of heart disease after FCU was 45.6%, 93.1%, and 100%, respectively. Conclusions and Clinical Importance Focused cardiac ultrasound performed by NSPs increased the detection of occult heart disease, especially in cats with moderate to marked disease. Focused cardiac ultrasound appears to be a feasible and useful tool to assist NSPs in the detection of heart disease in cats.
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Affiliation(s)
- Kerry A Loughran
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, North Grafton, Massachusetts.,Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John E Rush
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, North Grafton, Massachusetts
| | - Elizabeth A Rozanski
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, North Grafton, Massachusetts
| | - Mark A Oyama
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Éva Larouche-Lebel
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marc S Kraus
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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34
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Effect of anaemia on the diagnosis of rheumatic heart disease using World Heart Federation criteria. Cardiol Young 2019; 29:862-868. [PMID: 31218969 DOI: 10.1017/s1047951119000404] [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
BACKGROUND There is overlap between pathological mitral regurgitation seen in borderline rheumatic heart disease using World Heart Federation echocardiography criteria and physiologic regurgitation found in normal children. One possible contributing factor is higher rates of anaemia in endemic countries. OBJECTIVE To investigate the contribution of anaemia as a potential confounder in the diagnosis of rheumatic heart disease detected in echocardiographic screening. METHOD/DESIGN A novel Server 2012 data warehouse tool was used to incorporate haematology and echocardiography databases. The study included a convenience sample of patients from 5 to 18 years old without structural or functional heart disease that had a haemoglobin value within 1 month prior to an echocardiogram. Echocardiogram images were reviewed to determine presence or absence of World Heart Federation criteria for rheumatic heart disease. The rate of rheumatic heart disease among anaemic and non-anaemic children according to gender- and age-based norms groups was compared. RESULTS Of the 935 patients who met the study inclusion criteria, 406 were classified as anaemic. There was no difference in the rate of echocardiograms meeting criteria for borderline rheumatic heart disease in anaemic (2.0%, 95% CI 0.6-3.3%) and non-anaemic children (1.3%, 95% CI 0.3-2.3%). However, there was a statistically significant increase in rates of mitral regurgitation of unclear significance among anaemic versus non-anaemic patients (8.6 versus 3.6%; p = 0.0012). CONCLUSION Anaemia does not increase the likelihood of meeting echocardiographic criteria for borderline rheumatic heart disease. Future studies should evaluate for the correlation between anaemia and mitral regurgitation in endemic settings.
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35
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Spencer KT, Flachskampf FA. Focused Cardiac Ultrasonography. JACC Cardiovasc Imaging 2019; 12:1243-1253. [DOI: 10.1016/j.jcmg.2018.12.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 12/28/2018] [Indexed: 11/30/2022]
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Remenyi B, Davis K, Draper A, Bayley N, Paratz E, Reeves B, Appelbe A, Wheaton G, da Silva Almeida IT, Dos Santos J, Carapetis J, Francis JR. Single Parasternal-Long-Axis-View-Sweep Screening Echocardiographic Protocol to Detect Rheumatic Heart Disease: A Prospective Study of Diagnostic Accuracy. Heart Lung Circ 2019; 29:859-866. [PMID: 31320258 DOI: 10.1016/j.hlc.2019.02.196] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 01/28/2019] [Accepted: 02/05/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Echocardiographic screening in school-aged children can detect rheumatic heart disease (RHD) prior to the manifestation of symptoms of heart failure. The challenge is making this practical and affordable on a global scale. This study aims to evaluate the diagnostic utility of an ultra-abbreviated echocardiographic screening protocol involving a single parasternal-long-axis-view-sweep of the heart (SPLASH) in two dimensional (2D) and colour Doppler imaging (index test). METHODS This prospective study of diagnostic accuracy compared the diagnostic utility of the index screening test with a comprehensive reference test (standard echocardiographic screening protocols) as per World Heart Federation (WHF) echocardiographic criteria. School students in Timor-Leste aged 5-20 years were enrolled. Both index and reference test images were acquired by cardiologists on Vivid I or Q machines (GE Healthcare, Marlborough, MA, USA). RESULTS A total of 1,365 participants were screened; median age was 11 years. The estimated prevalence of definite and borderline RHD was 35.2 per 1,000. Congenital heart disease was identified in 11 children (0.8%) with two needing cardiac surgery. Abnormal SPLASH views were found in 109/1365 (7.99%). No cases of RHD or significant congenital heart disease were missed. Sensitivity and specificity of the abbreviated protocol for detecting RHD were 1.0 and 0.95 respectively. CONCLUSIONS A simplified echocardiography screening protocol using SPLASH is highly sensitive and specific and could significantly improve the efficiency of RHD screening. It has the potential to expedite training of health workers whilst protecting the modesty of students.
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Affiliation(s)
- Boglarka Remenyi
- Royal Darwin Hospital, Darwin, NT, Australia; Menzies School of Health Research, Darwin, NT, Australia.
| | - Kimberly Davis
- Royal Darwin Hospital, Darwin, NT, Australia; Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Anthony Draper
- Centre for Disease Control, Darwin, Darwin, NT, Australia
| | | | | | | | | | - Gavin Wheaton
- Women's and Children's Hospital, Adelaide, SA, Australia
| | | | | | - Jonathan Carapetis
- Telethon Kids Institute, University of Western Australia, Perth, WA, Australia; Perth Children's Hospital, Perth, WA, Australia
| | - Joshua R Francis
- Royal Darwin Hospital, Darwin, NT, Australia; Menzies School of Health Research, Darwin, NT, Australia
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Nunes MCP, Sable C, Nascimento BR, Lima EMD, da Silva JLP, Diamantino AC, Oliveira KK, Okello E, Aliku T, Lwabi P, Colosimo EA, Ribeiro ALP, Beaton AZ. Simplified Echocardiography Screening Criteria for Diagnosing and Predicting Progression of Latent Rheumatic Heart Disease. Circ Cardiovasc Imaging 2019; 12:e007928. [DOI: 10.1161/circimaging.118.007928] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Maria Carmo P. Nunes
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da UFMG, Belo Horizonte, Minas Gerais, Brazil (M.C.P.N., B.R.N., A.C.D., K.K.B.O., A.L.P.R.)
- Department of Internal Medicine, School of Medicine, Belo Horizonte, Minas Gerais, Brazil (M.C.P.N., B.R.N., A.L.P.R.)
| | - Craig Sable
- Children’s National Health System, Washington, DC (C.S.)
| | - Bruno R. Nascimento
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da UFMG, Belo Horizonte, Minas Gerais, Brazil (M.C.P.N., B.R.N., A.C.D., K.K.B.O., A.L.P.R.)
- Department of Internal Medicine, School of Medicine, Belo Horizonte, Minas Gerais, Brazil (M.C.P.N., B.R.N., A.L.P.R.)
| | - Emilly Malveira de Lima
- Statistical Department, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil (E.M.d.L., E.A.C.)
| | | | - Adriana C. Diamantino
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da UFMG, Belo Horizonte, Minas Gerais, Brazil (M.C.P.N., B.R.N., A.C.D., K.K.B.O., A.L.P.R.)
| | - Kaciane K.B. Oliveira
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da UFMG, Belo Horizonte, Minas Gerais, Brazil (M.C.P.N., B.R.N., A.C.D., K.K.B.O., A.L.P.R.)
| | - Emmy Okello
- Uganda Heart Institute, Kampala (E.O., T.A., P.L.)
| | - Twalib Aliku
- Uganda Heart Institute, Kampala (E.O., T.A., P.L.)
| | - Peter Lwabi
- Uganda Heart Institute, Kampala (E.O., T.A., P.L.)
| | - Enrico Antonio Colosimo
- Statistical Department, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil (E.M.d.L., E.A.C.)
| | - Antonio Luiz P. Ribeiro
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da UFMG, Belo Horizonte, Minas Gerais, Brazil (M.C.P.N., B.R.N., A.C.D., K.K.B.O., A.L.P.R.)
- Department of Internal Medicine, School of Medicine, Belo Horizonte, Minas Gerais, Brazil (M.C.P.N., B.R.N., A.L.P.R.)
| | - Andrea Z. Beaton
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (A.Z.B.)
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Remenyi B, Carapetis J, Stirling JW, Ferreira B, Kumar K, Lawrenson J, Marijon E, Mirabel M, Mocumbi AO, Mota C, Paar J, Saxena A, Scheel J, Viali S, Vijayalakshmi IB, Wheaton GR, Zuhlke L, Sidhu K, Dimalapang E, Gentles TL, Wilson NJ. Inter-rater and intra-rater reliability and agreement of echocardiographic diagnosis of rheumatic heart disease using the World Heart Federation evidence-based criteria. HEART ASIA 2019; 11:e011233. [PMID: 31297166 PMCID: PMC6591009 DOI: 10.1136/heartasia-2019-011233] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 06/05/2019] [Accepted: 06/06/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Different definitions have been used for screening for rheumatic heart disease (RHD). This led to the development of the 2012 evidence-based World Heart Federation (WHF) echocardiographic criteria. The objective of this study is to determine the intra-rater and inter-rater reliability and agreement in differentiating no RHD from mild RHD using the WHF echocardiographic criteria. METHODS A standard set of 200 echocardiograms was collated from prior population-based surveys and uploaded for blinded web-based reporting. Fifteen international cardiologists reported on and categorised each echocardiogram as no RHD, borderline or definite RHD. Intra-rater and inter-rater reliability was calculated using Cohen's and Fleiss' free-marginal multirater kappa (κ) statistics, respectively. Agreement assessment was expressed as percentages. Subanalyses assessed reproducibility and agreement parameters in detecting individual components of WHF criteria. RESULTS Sample size from a statistical standpoint was 3000, based on repeated reporting of the 200 studies. The inter-rater and intra-rater reliability of diagnosing definite RHD was substantial with a kappa of 0.65 and 0.69, respectively. The diagnosis of pathological mitral and aortic regurgitation was reliable and almost perfect, kappa of 0.79 and 0.86, respectively. Agreement for morphological changes of RHD was variable ranging from 0.54 to 0.93 κ. CONCLUSIONS The WHF echocardiographic criteria enable reproducible categorisation of echocardiograms as definite RHD versus no or borderline RHD and hence it would be a suitable tool for screening and monitoring disease progression. The study highlights the strengths and limitations of the WHF echo criteria and provides a platform for future revisions.
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Affiliation(s)
- Bo Remenyi
- Menzies School of Health Research, Casuarina, Northern Territory, Australia.,Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand
| | - Jonathan Carapetis
- Telethon Kids Institute, University of Western Australia, Subiaco, Western Australia, Australia
| | - John W Stirling
- Paediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand
| | | | - Krishnan Kumar
- Amrita Institute of Medical Sciences and Research Centre, Kochi, India
| | - John Lawrenson
- Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa.,Department of Paediatrics and Child Health, Cape Town, South Africa
| | | | - Mariana Mirabel
- INSERM U970, Paris Cardiovascular Research Center PARCC, Paris, France
| | | | - Cleonice Mota
- Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - John Paar
- Cardiology, Project Health for León, Raleigh, North Carolina, USA
| | - Anita Saxena
- All India Institute of Medical Sciences, New Delhi, India
| | - Janet Scheel
- Pediatric Cardiology, Children's National Health System, Washington, District of Columbia, USA
| | - Satu Viali
- Cardiology, Samoa National Hospital, Apia, Samoa
| | - I B Vijayalakshmi
- Pediatric Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India
| | - Gavin R Wheaton
- Cardiology, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Liesl Zuhlke
- Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Karishma Sidhu
- Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand
| | - Eliazar Dimalapang
- Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand
| | - Thomas L Gentles
- Paediatric and Congenital Cardiology, Starship Children's Hospital, Auckland, New Zealand
| | - Nigel J Wilson
- Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand.,University of Auckland, Auckland, New Zealand
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Musuku J, Engel ME, Musonda P, Lungu JC, Machila E, Schwaninger S, Mtaja A, Mulendele E, Kavindele D, Spector J, Tadmor B, Gutierrez MM, Van Dam J, Colin L, Long A, Fishman MC, Mayosi BM, Zühlke LJ. Prevalence of rheumatic heart disease in Zambian school children. BMC Cardiovasc Disord 2018; 18:135. [PMID: 29969998 PMCID: PMC6029054 DOI: 10.1186/s12872-018-0871-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 06/24/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The large global burden of rheumatic heart disease (RHD) has come to light in recent years following robust epidemiologic studies. As an operational research component of a broad program aimed at primary and secondary prevention of RHD, we sought to determine the current prevalence of RHD in the country's capital, Lusaka, using a modern imaging-based screening methodology. In addition, we wished to evaluate the practicality of training local radiographers in echocardiography screening methods. METHODS Echocardiography was conducted on a random sample of students in 15 schools utilizing a previously validated, abbreviated screening protocol. Through a task-shifting scheme, and in the spirit of capacity-building to enhance local diagnostic and research skills, general radiographers based at Lusaka University Teaching Hospital (UTH) were newly trained to use portable echocardiography devices. Students deemed as screen-positive were referred for comprehensive echocardiography and clinical examination at UTH. Cardiac abnormalities were classified according to standard World Heart Federation criteria. RESULTS Of 1102 students that were consented and screened, 53 students were referred for confirmatory echocardiography. Three students had definite RHD, 10 had borderline RHD, 29 were normal, and 11 students were lost to follow-up. The rates of definite, borderline, and total RHD were 2.7 per 1000, 9.1 per 1000, and 11.8 per 1000, respectively. Anterior mitral valve leaflet thickening and chordal thickening were the most common morphological defects. The pairwise kappa test showed fair agreement between the local radiographers and an echocardiographer quality assurance specialist. CONCLUSION The prevalence of asymptomatic RHD in urban communities in Zambia is within the range of results reported in other sub-Saharan African countries using the WHF criteria. Task-shifting local radiographers to conduct echocardiography was feasible. The results of this study will be used to inform ongoing efforts in Zambia to control and eventually eliminate RHD. TRIAL REGISTRATION The study was registered on clinicaltrials.gov ( #NCT02661763 ).
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Affiliation(s)
- John Musuku
- Department of Paediatrics & Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Mark E Engel
- Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Patrick Musonda
- School of Public Health University of Zambia, Lusaka, Zambia
| | - Joyce Chipili Lungu
- Department of Paediatrics & Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Elizabeth Machila
- Department of Paediatrics & Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Sherri Schwaninger
- Global Health, Novartis Institutes for BioMedical Research, Cambridge, MA, USA.
| | - Agnes Mtaja
- Department of Paediatrics & Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Evans Mulendele
- Department of Paediatrics & Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Dorothy Kavindele
- Department of Paediatrics & Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Jonathan Spector
- Global Health, Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Brigitta Tadmor
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Marcelo M Gutierrez
- Global Health, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Joris Van Dam
- Global Drug Development, Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Laurence Colin
- Global Drug Development, Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Aidan Long
- Department of Allergy and Clinical Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - Mark C Fishman
- Harvard Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, MA, USA
| | - Bongani M Mayosi
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Liesl J Zühlke
- Department of Paediatrics, Red Cross War Memorials Children's Hospital, Cape Town, South Africa
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Davis K, Remenyi B, Draper ADK, Dos Santos J, Bayley N, Paratz E, Reeves B, Appelbe A, Cochrane A, Johnson TD, Korte LM, Do Rosario IM, Da Silva Almeida IT, Roberts KV, Carapetis JR, Francis JR. Rheumatic heart disease in Timor‐Leste school students: an echocardiography‐based prevalence study. Med J Aust 2018; 208:303-307. [DOI: 10.5694/mja17.00666] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 11/23/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Kimberly Davis
- Royal Darwin Hospital, Darwin, NT
- Hospital Nacional Guido Valadares, Dili, Timor‐Leste
| | | | - Anthony DK Draper
- Centre for Disease Control, Northern Territory Department of Health, Darwin, NT
| | | | | | | | | | - Alan Appelbe
- Geelong Cardiology Group, Barwon Health, Geelong, VIC
| | | | | | - Laura M Korte
- Paediatric WA Country Health Service – Kimberley, Broome, WA
| | | | | | | | | | - Joshua R Francis
- Royal Darwin Hospital, Darwin, NT
- Global and Tropical Health Division Menzies School of Health Research, Darwin, NT
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Engelman D, Ah Kee M, Mataika RL, Kado JH, Colquhoun SM, Tulloch J, Steer AC. Secondary prevention for screening detected rheumatic heart disease: opportunities to improve adherence. Trans R Soc Trop Med Hyg 2018; 111:154-162. [PMID: 28673022 DOI: 10.1093/trstmh/trx035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 06/08/2017] [Indexed: 11/14/2022] Open
Abstract
Background Secondary prevention is an effective treatment for rheumatic heart disease (RHD), but ensuring high adherence to prophylaxis over many years is challenging and requires understanding of local factors. Methods Participants were young people diagnosed with RHD through echocardiographic screening in Fiji. We used a structured interview to evaluate the following: health seeking behaviours; attitudes, practice, barriers and potential improvement strategies for adherence to antibiotic prophylaxis; and adolescent-friendly qualities of the health service. Results One hundred and one participants were interviewed (median age, 17.2 years). Adherence was very low overall (adequate in 6%). Sore throat and fever with sore joints were experienced in the preceding year by 42% and 28%, respectively. Barriers to receiving treatment included taking alternate treatments and the perception that symptoms were benign and self-limiting. Reasons for missing prophylaxis injections included lack of awareness, feeling well, transport cost and access, and medication unavailability (>40% of participants each). The injection health service had many perceived strengths, but inclusion of adolescents in decision making, and quality of educational materials were deficiencies. Reminder strategies, particularly phone-based reminders, were considered helpful by 94%. Conclusions We identified several factors influencing secondary prevention that may be used to develop interventions to improve adherence.
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Affiliation(s)
- Daniel Engelman
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Group A Streptococcal Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Maureen Ah Kee
- Fiji Rheumatic Heart Disease Control Program, Ministry of Health and Medical Services, Suva, Fiji
| | - Reapi L Mataika
- Department of Paediatrics, Colonial War Memorial Hospital, Suva, Fiji
| | - Joseph H Kado
- Fiji Rheumatic Heart Disease Control Program, Ministry of Health and Medical Services, Suva, Fiji.,Department of Paediatrics, Colonial War Memorial Hospital, Suva, Fiji.,College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
| | - Samantha M Colquhoun
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Group A Streptococcal Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | | | - Andrew C Steer
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Group A Streptococcal Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
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Bhavnani SP, Sola S, Adams D, Venkateshvaran A, Dash P, Sengupta PP, Bhavnani S, Sola S, Venkateshvaran A, Adams D, Sengupta PP, Ryan T, Narula J, Thomas J, Lang R, Pellikka P, Choudhary V, Iyer VR, Barooah B, Sola S, Varyani R, Lingan A, Murugan V, Kini P, Venkateshvaran A, Srinivas N, Barooah AC, Subbarao G, Shivakumar C, Subramaniyan M, Sengupta SP, Bansal M, Rahaman A, Patil VN, Kumar NR, Gahlot MY, Damani IM, Gulati R, Joshi SS, Dubey S, Krupa J, Irfan S, Vidhyakar R, Bidarkar N, Shantesh B, Chavan SS, Chandramohan R, Kumar V, Tirkey S, Prasad G, Lakshmana SS, Malkar RM, Manjunath V, Kumar Reddy K, Ramesha L, Kumbhalkar S, Thadlani JA, Basha TN, Hafeez SA, Leelavathi V, Mathews R, Daubert M, Cleve J, Burdulis E, Fauss N, Lammertin G, Patel B, Petrovets E, Shah D, Thurmond K, Tomberlin D, Umamaheswar H, Kadakia A. A Randomized Trial of Pocket-Echocardiography Integrated Mobile Health Device Assessments in Modern Structural Heart Disease Clinics. JACC Cardiovasc Imaging 2018; 11:546-557. [DOI: 10.1016/j.jcmg.2017.06.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 06/19/2017] [Accepted: 06/19/2017] [Indexed: 12/14/2022]
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Myint NPST, Aung NM, Win MS, Htut TY, Ralph AP, Cooper DA, Nyein ML, Kyi MM, Hanson J. The clinical characteristics of adults with rheumatic heart disease in Yangon, Myanmar: An observational study. PLoS One 2018; 13:e0192880. [PMID: 29466408 PMCID: PMC5821331 DOI: 10.1371/journal.pone.0192880] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/31/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Rheumatic heart disease (RHD) is a major cause of premature death in low and middle-income countries. The greatest barrier to RHD control is neglect of the disease in national health policies and a lack of prevalence data that might inform control efforts. Myanmar is making remarkable progress against many infectious diseases, but there are almost no data to define the clinical burden of RHD in the country. This prospective audit was performed in an adult medical ward of a tertiary-referral hospital in Yangon, to gain an insight into the prevalence of RHD in Myanmar. PRINCIPAL FINDINGS All patients admitted to the ward between May 1, 2016 and April 30, 2017 were eligible for enrolment. RHD was confirmed in 96 patients who were admitted on 134 occasions, representing 1.1% of the 12,172 adult medical admissions during the study period. This compared with 410 (3.4%) admissions with HIV and 14 (0.1%) with malaria. Patients with RHD had a median age of 44 years (interquartile range: 35-59); 70 (73%) were female. Only one patient had ever had surgery despite 79 (82%) meeting criteria for intervention; 54 (56%) patients were not receiving any regular clinician review. Prior to hospitalisation only 18 (19%) patients were receiving regular penicillin. Only 8 (19%) of the 42 women <50 years were using contraception. Of 49 patients who had been hospitalised previously, 22 (45%) were receiving no regular therapy. During the study three (3.1%) patients died, and 28 (29%) were lost to follow-up. Of the 65 (68%) alive and retained in care, 21 (32%) were still experiencing moderate-severe RHD-related symptoms at the study's end. CONCLUSIONS There is a significant and unmet clinical burden of RHD in Myanmar. A national RHD programme would improve patient care, reducing morbidity and mortality from this preventable disease.
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Affiliation(s)
- Nan Phyu Sin Toe Myint
- Department of Medicine, Insein General Hospital, Yangon, Myanmar
- University of Medicine 2, Yangon, Myanmar
| | - Ne Myo Aung
- Department of Medicine, Insein General Hospital, Yangon, Myanmar
- University of Medicine 2, Yangon, Myanmar
| | - Myint Soe Win
- Department of Cardiology, North Okkalapa General Hospital, Yangon, Myanmar
| | - Thu Ya Htut
- Department of Medicine, Insein General Hospital, Yangon, Myanmar
| | - Anna P. Ralph
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - David A. Cooper
- Director’s Unit, Kirby Institute, University of New South Wales, Sydney, Australia
| | - Myo Lwin Nyein
- University of Medicine 2, Yangon, Myanmar
- Department of Cardiology, North Okkalapa General Hospital, Yangon, Myanmar
| | - Mar Mar Kyi
- Department of Medicine, Insein General Hospital, Yangon, Myanmar
- University of Medicine 2, Yangon, Myanmar
| | - Josh Hanson
- University of Medicine 2, Yangon, Myanmar
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Director’s Unit, Kirby Institute, University of New South Wales, Sydney, Australia
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Abstract
BACKGROUND Echocardiographic screening represents an opportunity for reduction in the global burden of rheumatic heart disease. A focussed single-view screening protocol could allow for the rapid training of healthcare providers and screening of patients. OBJECTIVE The aim of this study was to determine the sensitivity and specificity of a focussed single-view hand-held echocardiographic protocol for the diagnosis of rheumatic heart disease in children. METHODS A total of nine readers were divided into three reading groups; each interpreted 200 hand-held echocardiography studies retrospectively as screen-positive, if mitral regurgitation ⩾1.5 cm and/or any aortic insufficiency were observed, or screen-negative from a pooled study library. The performance of experts receiving focussed hand-held protocols, non-experts receiving focussed hand-held protocols, and experts receiving complete hand-held protocols were determined in comparison with consensus interpretations on fully functional echocardiography machines. RESULTS In all, 587 studies including 76 on definite rheumatic heart disease, 122 on borderline rheumatic heart disease, and 389 on normal cases were available for analysis. The focussed single-view protocol had a sensitivity of 81.1%, specificity of 75.5%, negative predictive value of 88.5%, and a positive predictive value of 63.2%; expert readers had higher specificity (86.1 versus 64.8%, p<0.01) but equal sensitivity. Sensitivity - experts, 96% and non-experts, 95% - and negative predictive value - experts, 99% and non-experts, 98% - were better for definite rheumatic heart disease. False-positive screening studies resulting from erroneous identification of mitral regurgitation and aortic insufficiency colour jets increased with shortened protocols and less experience (p<0.01). CONCLUSION Our data support a focussed screening protocol limited to parasternal long-axis images. This holds promise in making echocardiographic screening more practical in regions where rheumatic heart disease remains endemic.
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45
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Kotit S, Said K, ElFaramawy A, Mahmoud H, Phillips DIW, Yacoub MH. Prevalence and prognostic value of echocardiographic screening for rheumatic heart disease. Open Heart 2017; 4:e000702. [PMID: 29344370 PMCID: PMC5761310 DOI: 10.1136/openhrt-2017-000702] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 08/24/2017] [Accepted: 11/07/2017] [Indexed: 12/20/2022] Open
Abstract
Objective Rheumatic heart disease (RHD) remains a major health problem in many low-income and middle-income countries. The use of echocardiographic imaging suggests that subclinical disease is far more widespread than previously appreciated, but little is known as to how these mild forms of RHD progress. We have determined the prevalence of subclinical RHD in a large group of schoolchildren in Aswan, Egypt and have evaluated its subsequent progression. Methods Echocardiographic screening was performed on 3062 randomly selected schoolchildren, aged 5–15 years, in Aswan, Egypt. Follow-up of children with a definite or borderline diagnosis of RHD was carried out 48–60 months later to determine how the valvular abnormalities altered and to evaluate the factors influencing progression. Results Sixty children were initially diagnosed with definite RHD (19.6 per 1000 children) and 35 with borderline disease (11.4 per 1000); most had mitral valve disease. Of the 72 children followed up progression was documented in 14 children (19.4%) and regression in 30 (41.7%) children. Boys had lower rates of progression while older children had lower rates of regression. Functional defects of the valve even in the presence of structural features were associated with lower rates of progression and higher rates of regression than structural changes. Conclusions RHD has a high prevalence in Egypt. Although a high proportion of the abnormalities originally detected persisted at follow-up, both progression and regression of valve lesions were demonstrated.
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Affiliation(s)
- Susy Kotit
- National Heart and Lung Institute, Imperial College, London, UK.,Aswan Heart Centre, Aswan, Egypt.,Harefield Heart Science Centre, Imperial College London, London, UK
| | - Karim Said
- Aswan Heart Centre, Aswan, Egypt.,Cardiology Department, Kasr El Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr ElFaramawy
- Aswan Heart Centre, Aswan, Egypt.,Cardiology Department, Kasr El Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - David I W Phillips
- Developmental Origins of Health and Disease Division, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Magdi H Yacoub
- National Heart and Lung Institute, Imperial College, London, UK.,Aswan Heart Centre, Aswan, Egypt.,Harefield Heart Science Centre, Imperial College London, London, UK
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Katzenellenbogen JM, Ralph AP, Wyber R, Carapetis JR. Rheumatic heart disease: infectious disease origin, chronic care approach. BMC Health Serv Res 2017; 17:793. [PMID: 29187184 PMCID: PMC5708129 DOI: 10.1186/s12913-017-2747-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 11/20/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Rheumatic heart disease (RHD) is a chronic cardiac condition with an infectious aetiology, causing high disease burden in low-income settings. Affected individuals are young and associated morbidity is high. However, RHD is relatively neglected due to the populations involved and its lower incidence relative to other heart diseases. METHODS AND RESULTS In this narrative review, we describe how RHD care can be informed by and integrated with models of care developed for priority non-communicable diseases (coronary heart disease), and high-burden communicable diseases (tuberculosis). Examining the four-level prevention model (primordial through tertiary prevention) suggests primordial and primary prevention of RHD can leverage off existing tuberculosis control efforts, given shared risk factors. Successes in coronary heart disease control provide inspiration for similarly bold initiatives for RHD. Further, we illustrate how the Chronic Care Model (CCM), developed for use in non-communicable diseases, offers a relevant framework to approach RHD care. Systems strengthening through greater integration of services can improve RHD programs. CONCLUSION Strengthening of systems through integration/linkages with other well-performing and resourced services in conjunction with policies to adopt the CCM framework for the secondary and tertiary prevention of RHD in settings with limited resources, has the potential to significantly reduce the burden of RHD globally. More research is required to provide evidence-based recommendations for policy and service design.
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Affiliation(s)
- Judith M Katzenellenbogen
- Telethon Kids Institute, The University of Western Australia, Perth, Western, Australia.
- School of Population and Global Health, The University of Western Australia, Perth, Western, Australia.
| | - Anna P Ralph
- Global and Tropical Health, Menzies School of Health Research, Darwin, Northern Territory, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
| | - Rosemary Wyber
- Telethon Kids Institute, The University of Western Australia, Perth, Western, Australia
| | - Jonathan R Carapetis
- Telethon Kids Institute, The University of Western Australia, Perth, Western, Australia
- Princess Margaret Hospital for Children, Perth, Western, Australia
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Clinical outcomes for young people with screening-detected and clinically-diagnosed rheumatic heart disease in Fiji. Int J Cardiol 2017; 240:422-427. [DOI: 10.1016/j.ijcard.2017.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 03/28/2017] [Accepted: 04/03/2017] [Indexed: 11/18/2022]
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Bergmann T, Sengupta PP, Narula J. Is TAVR Ready for the Global Aging Population? Glob Heart 2017; 12:291-299. [PMID: 28433492 DOI: 10.1016/j.gheart.2017.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/24/2017] [Accepted: 02/14/2017] [Indexed: 11/26/2022] Open
Abstract
The emergence of the global pandemic of chronic diseases necessitates critical assessment of interventions that can be targeted at both the individual and population levels. Among cardiovascular diseases, the increasing prevalence of valvular heart diseases such as aortic stenosis parallels the rising burden of atherosclerotic cardiovascular diseases. As an alternative to surgical aortic valve replacement, technological innovation has allowed development of minimally invasive transcatheter aortic valve replacement (TAVR). This review examines whether TAVR can be applicable in low-resource regions across the world. Although revolutionary, TAVR is currently complex and requires a "Heart Team" approach for optimized patient care. We propose the emergence of telemedicine networks, newer valve designs that allow implementation of minimal approaches, and the use of minimal numbers of specialists for adapting TAVR to settings where surgical backup is not available. With efforts to reduce resource utilization, these alternate strategies have the potential to affect implementation of TAVR globally.
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Affiliation(s)
- Travis Bergmann
- Cardiac Ultrasound Research and Core Lab, Department of Medicine, Mount Sinai's Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry R. Kravis Center for Cardiovascular Health, New York, NY, USA
| | - Partho P Sengupta
- Cardiac Ultrasound Research and Core Lab, Department of Medicine, Mount Sinai's Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry R. Kravis Center for Cardiovascular Health, New York, NY, USA.
| | - Jagat Narula
- Cardiac Ultrasound Research and Core Lab, Department of Medicine, Mount Sinai's Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry R. Kravis Center for Cardiovascular Health, New York, NY, USA
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Webb RH, Culliford-Semmens N, Sidhu K, Wilson NJ. Normal echocardiographic mitral and aortic valve thickness in children. HEART ASIA 2017; 9:70-75. [PMID: 28405228 DOI: 10.1136/heartasia-2016-010872] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/14/2017] [Accepted: 02/15/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE We aimed to define the normal range of aortic and mitral valve thickness in healthy schoolchildren from a high prevalence rheumatic heart disease (RHD) region, using a standardised protocol for imaging and measurement. METHODS Measurements were performed in 288 children without RHD. Anterior mitral valve leaflet (AMVL) thickness measurements were performed at the midpoint and tip of the leaflet in the parasternal long axis (PSLA) in diastole, when the AMVL was approximately parallel to the ventricular septum. Thickness of the aortic valve was measured from PSLA imaging in systole when the leaflets were at maximum excursion. The right coronary and non-coronary closure lines of the aortic valve were measured in diastole in parasternal short axis (PSSA) imaging. Results were compared with 51 children with RHD classified by World Heart Federation diagnostic criteria. RESULTS In normal children, median AMVL tip thickness was 2.0 mm (IQR 1.7-2.4) and median AMVL midpoint thickness 2.0 mm (IQR 1.7-2.4). The median aortic valve thickness was 1.5 mm (IQR 1.3-1.6) in the PSLA view and 1.4 mm (IQR 1.2-1.6) in the PSSA view. The interclass correlation coefficient for the AMVL tip was 0.85 (0.71 to 0.92) and for the AMVL midpoint was 0.77 (0.54 to 0.87). CONCLUSIONS We have described a standardised method for mitral and aortic valve measurement in children which is objective and reproducible. Normal ranges of left heart valve thickness in a high prevalence RHD population are established. These results provide a reference range for school-age children in high prevalence RHD regions undergoing echocardiographic screening.
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Affiliation(s)
- Rachel H Webb
- Green Lane Paediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand; Paediatric Infectious Diseases, Starship Children's Hospital, Auckland, New Zealand
| | - Nicola Culliford-Semmens
- Green Lane Paediatric and Congenital Cardiac Services , Starship Children's Hospital , Auckland , New Zealand
| | - Karishma Sidhu
- Green Lane Cardiovascular Services , Auckland City Hospital , Auckland , New Zealand
| | - Nigel J Wilson
- Green Lane Paediatric and Congenital Cardiac Services , Starship Children's Hospital , Auckland , New Zealand
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50
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Abstract
Primarily affecting the young, rheumatic heart disease (RHD) is a neglected chronic disease commonly causing premature morbidity and mortality among the global poor. Standard clinical prevention and treatment is based on studies from the early antimicrobial era, as research investment halted soon after the virtual eradication of the disease from developed countries. The emergence of new global data on disease burden, new technologies, and a global health equity platform have revitalized interest and investment in RHD. This review surveys past and current evidence for standard RHD diagnosis and treatment, highlighting gaps in knowledge.
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Affiliation(s)
- Shanti Nulu
- Section of Cardiovascular Medicine, Yale School of Medicine, 789 Howard Avenue, New Haven, CT 06519, USA
| | - Gene Bukhman
- Division of Global Health Equity, Brigham and Women's Hospital, 641 Huntington Avenue, Boston, MA 02115, USA; Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Gene F Kwan
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA; Section of Cardiovascular Medicine, Boston University Medical Center, Boston University School of Medicine, 88 East Newton Street, D8, Boston, MA 02118, USA.
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