Acute rheumatic fever and rheumatic heart disease in resource-limited settings

Rates and Determinants of Hospital-Acquired Infection among ICU Patients Undergoing Cardiac Surgery in Developing Countries: Results from EMERGENCY'NGO's Hospital in Sudan

Introduction. Knowledge of local and regional antimicrobial resistance (AMR) is crucial in clinical decision-making, especially with critically ill patients. The aim of this study was to investigate the rate and pattern of infections in valvular heart disease patients admitted to the intensive care unit (ICU) at the Salam Centre for Cardiac Surgery in Khartoum, Sudan (run by EMERGENCY NGO). Methods. This is a retrospective, observational study from a single, large international referral centre (part of a Regional Programme), which enrolled patients admitted to the ICU between 1 January and 31 December 2019. Data collected for each patient included demographic data, operating theatre/ICU data and microbiological cultures. Results. Over the study period, 611 patients were enrolled (elective surgery n = 491, urgent surgery n = 34 and urgent medical care n = 86). The infection rate was 14.2% and turned out to be higher in medical than in surgical patients (25.6% vs. 12.4%; p = 0.002; OR = 2.43) and higher in those undergoing urgent surgery than those undergoing elective (29.4% vs. 11.2%; p = 0.004; OR = 3.3). Infection was related to (a) SOFA score (p < 0.001), (b) ICU length of stay (p < 0.001) and (c) days from ICU admission to OT (p = 0.003). A significant relationship between the type of admission (elective, urgent surgery or medical) and the presence of infections was found (p < 0.001). The mortality rate was higher among infected patients (infected vs. infection-free: 10.3% vs. 2.1%; p < 0.001; OR = 5.38; 95% CI: 2.16−13.4; p < 0.001). Conclusions. Hospital-acquired infections remain a relevant preventable cause of mortality in our particular population.

Diagnosis, management, and prevention of acute rheumatic fever in the United States

ABSTRACT

Acute rheumatic fever is a multisystem autoimmune disease caused by infection with group A streptococcus. The condition most commonly affects children ages 5 to 14 years who are from low-income populations. The diagnosis is clinical; however, the 2015 Jones Criteria can help support it. Acute rheumatic fever poses a significant health risk secondary to rheumatic heart disease. Although acute rheumatic fever is rare in the United States, outbreaks still occur, and certain populations continue to be at increased risk. This article describes how to identify acute rheumatic fever and provides prompt management and prevention strategies to reduce patient risk for lifelong complications.

Characteristic Quality of Life Children with Rheumatic Heart Disease

Background: Rheumatic heart disease is an acquired disease that has characterized damaged valve and it effects the quality of life in children. Aim: To asses quality of life in patient with rheumatic heart disease by using Pediatric Quality of Life Inventory (PedsQL) instrument at pediatric cardiologist. Methods: A descriptive study with cross sectional study conduct among children aged 5 to 18 years old attend the Pediatric Cardiology at Haji Adam Malik Hospital Medan, from 2016 to 2018. Result: A hundred children with rheumatic heart disease in this study who had affected quality of life-based on group age with 5 to 7 year old in physical function was 6 subjects (85.7%), social function was 1 subject (14.2%), and school function was 2 subjects (28.5%) (Table 3); group age with 8 to 12 year old in physical function was 100 subjects (100%), emotional function was 3 subjects (3%), social function was 1 subject (3%), and school function was 5 subjects (15.1%); group aged 13 to 18 year old in physical function was 60 subjects (100%), emotional function was 1 subject (16.7%), and school function was 51 subjects (85%). Conclusion: From 100 children with RHD dominant in group aged 13-18 years old and male, mal malnutrition status, using of erythromycin, high senior school of level parents’ education, and valve disorder was mitral regurgitation. The quality of life was affected in all age groups, especially in the domain of physical function, and school functions with RHD.

Integrating the Prevention and Control of Rheumatic Heart Disease into Country Health Systems: A Systematic Review and Meta-Analysis

Background:

National and international political commitments have been made recently on rheumatic heart disease (RHD), a preventable heart condition that is endemic in low-resource countries. To inform best practice and identify evidence gaps, we assessed the effectiveness of RHD prevention and control programmes and the extent and nature of their integration into local health systems.

Methods:

We conducted a systematic review and meta-analysis using a previously published protocol that included electronic and manual searches for studies published between January 1990 and July 2019 reporting on prevention and control programmes for populations at risk for streptococcal pharyngitis, rheumatic fever, and/or RHD. We analysed programme integration according to a previously published framework and programme effectiveness using a results-chain framework. We meta-analysed secondary prophylaxis adherence using random-effects models. Study quality was assessed using peer-reviewed checklists (CASP and PRISM). PROSPERO registration: CRD42017076307.

Findings:

Five observational studies met with the inclusion criteria. Studies were similar in extent and nature of integration into health systems; no programme was completely integrated or non-integrated. A single study reported on programme impact. Secondary prophylaxis adherence improved among partially integrated RHD programmes (RR, 1.18 [95% CI, 1.03 to 1.36], 3 studies, n = 618). Risk of bias was low in two studies, and indeterminable in the remaining three studies.

Interpretation:

There is evidence that partially integrated RHD programmes are beneficial for a range of intermediate health outcomes. This review provides a starting point for the design and implementation of future RHD programmes by outlining current best practice for integration and identifying key gaps in knowledge.

Funding:

National Research Foundation of South Africa.

A glimpse of hope: cardiac surgery in low- and middle-income countries (LMICs)

Currently, more than five times more people live in low- and middle-income countries (LMICs) than in high-income countries (HICs). As such, the downward trend in cardiac surgical needs in HICs reflects only the situation of one sixth of the world population while the vast majority living in LMICs has still no or limited access to life saving heart operations. In these countries, rheumatic heart disease (RHD) still accounts for a significant proportion of cardiac surgical needs. In low- and lower-middle income countries it remains the single most common cardiovascular disease in young adult and adolescent patients in need of heart surgery outweighing other indications such as congenital cardiac defects almost 4-fold. Compared to HICs with their predominance of calcific aortic stenosis in the elderly mitral valve surgery is required in >90% of the largely young patients with RHD in low-income countries (LICs) and still in 70% of the often middle aged patients in middle-income countries (MICs). Although recent government initiatives in LICs led to the establishment of local, independent cardiac surgical services gradually replacing fly-in missions, these centers still only cover less than 2% of the needs of their populations. In MICs, cardiac surgical needs continually grow with the emergence of degenerative diseases. As such, in spite of the concomitant growth of cardiac surgical capacity, significantly less than half the estimated patients in need have access. Capacities in LICs range from 0.5 to 7 cardiac operations/million population; 100-481/million in MICs and >1,200/million in HICs such as the USA and Germany. While a new level of awareness of the scope and magnitude of the problem has begun to emerge in LICs and the establishment of local cardiac surgical capacity has given rise to a glimpse of hope, the challenges of expanding these fledgling services to a significant proportion of the population still seem insurmountable. Challenges in MICs are on the other hand the widening gap between private cardiac medicine for the affluent few and overwhelmed public services for the many and the rural urban divide with the underappreciation of the ongoing dominance of RHD in the rural and indigent population on the other. Overshadowing all LMICs is the low level of valve-repair skills associated with insufficient cardiac surgical capacity and the unavailability of suitable replacement valves which address the young age of the patients and the difficulties of anticoagulation in a socioeconomic environment distinctly different from the elderly patients of HICs.

Acute Rheumatic Fever: Global Persistence of a Preventable Disease

The persistence of acute rheumatic fever continues to be seen globally. Once thought to be eradicated in various parts of the world, the disease came back with a vengeance secondary to a lack of diligence on the part of providers. Today, the global burden of group A streptococcal infection, the culprit of the numerous sequelae manifested in acute rheumatic fever, is considerable. Although a completely preventable disease, rheumatic fever continues to exist. It is a devastating disease that involves long-term, multisystem treatment and monitoring for patients who were unsuccessful at eradicating the precipitating group A streptococcal infection. Prevention is the key to resolving the dilemma of the disease's global burden, yet the method to yield its prevention still remains unknown. Thus, meticulous attention to implementing proper treatment is the mainstay and remains a top priority.

The spectrum of rheumatic in-patient diagnoses at a pediatric hospital in Kenya

BACKGROUND

Pediatric rheumatic diseases are chronic illnesses that can cause considerable disease burden to children and their families. There is limited epidemiologic data on these diseases in East Africa. The aim of this study was to assess the spectrum of pediatric rheumatic diagnoses in an in-patient setting and determine the accuracy of ICD-10 codes in identifying these conditions.

METHODS

Medical records from Gertrude's Children's Hospital in Kenya were reviewed for patients diagnosed with "diseases of the musculoskeletal system and connective tissue" as per ICD-10 diagnostic codes assigned at discharge between January and December 2011. Cases were classified as "rheumatic" or "non-rheumatic". Accuracy of the assigned ICD-10 code was ascertained. Death records were reviewed. Longitudinal follow-up of "rheumatic" cases was done by chart review up to March 2014.

RESULTS

Twenty six patients were classified as having a "rheumatic" condition accounting for 0.32% of patients admitted. Of these, 11 (42.3%) had an acute inflammatory arthropathy, 6 (23.1%) had septic arthritis, 4 (15.4%) had Kawasaki disease, 2 (7.7%) had pyomyositis, and there was one case each of septic bursitis, rheumatic fever, and a non-specific soft tissue disorder. No cases of juvenile idiopathic arthritis (JIA) were identified. One case of systemic lupus erythematosus was documented by death records. The agreement between the treating physician's discharge diagnosis and medical records ICD-10 code assignment was good (Kappa: 0.769). On follow-up, one child had recurrent knee swelling that was suspicious for JIA.

CONCLUSIONS

Pediatric rheumatic conditions represented 0.32% of admissions at a pediatric hospital in Kenya. Acute inflammatory arthropathies, septic arthritis and Kawasaki disease were the most frequent in-patient rheumatic diagnoses. Chronic pediatric rheumatic diseases were rare amongst this in-patient population. Despite limitations associated with the use of administrative diagnostic codes, they can be a first step in evaluating the spectrum of pediatric rheumatic conditions in Kenya and other countries in East Africa.

Cardiac surgery in Africa: a thirty-five year experience on open heart surgery in Cote d'Ivoire

BACKGROUND

Few centers for open heart surgery (OHS) are in Sub-Saharan Africa. Lack of OHS results is also noted. By reporting our African experience on OHS, the aim of this study was to fill the gap.

METHODS

It is a retrospective study on 2,612 patients who were subject to an OHS between 1978 and 2013. Data were collected from demographical, clinical, investigative studies, surgical and outcomes parameters.

RESULTS

There were 1,475 cases of rheumatic heart diseases (RHD), 126 endomyocardial fibrosis (EMF), 741 congenital heart diseases (CHDs) and 270 various affections. Related to rheumatic valvular surgery we enumerated 1,175 monovalvular (mitral n=778, aortic n=336, tricuspid n=61); 280 bivalvular (mitral + aortic n=150, mitral + tricuspid n=130) and 20 trivalvular. For RHD, average age was 26±10.1 years (4-69 years) and 60% of our patients presented a functional class III or IV according to New York Heart Association (NYHA) classification. A total of 1,481 valvular replacements (bioprostheses n=489, mechanical prostheses n=992) and 445 valvular repair were carried out with a global and late mortality surgery respectively at 7% and 8%. One hundred and twenty-six [126] cases of EMF with right sided form 39, left sided form 40, and bilateral form 47 were colligated. Average age was 12±0.6 years (2-15 years). All patients with EMF underwent surgery; an endocardectomy in all patients combined with valvular reconstruction (n=36) or valvular replacement (n=90) was carried out with a hospital mortality at 16% (n=20). Concerning CHD, the most frequent were ventricular septal defect (VSD) (n=240), atrial septal defect (ASD) (n=200), partial atrio-ventricular sepal defect (n=30) and tetralogy of Fallot (T4F) (n=220), a total correction was performed for those CHD with an early mortality at 6.4% (n=44).

CONCLUSIONS

OHS in Cote d'Ivoire was successfully performed in most of our patients, the spectrum of acquired valvular heart diseases and CHDs in our country is similar to others in Sub-Saharan Africa.