1
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Bolman RM, Zilla P, Beyersdorf F, Boateng P, Bavaria J, Dearani J, Pomar J, Kumar S, Chotivatanapong T, Sliwa K, Eisele JL, Enumah Z, Podesser B, Farkas EA, Kofidis T, Zühlke LJ, Higgins R. Making a Difference: 5 Years of Cardiac Surgery Intersociety Alliance (CSIA). Ann Thorac Surg 2024; 118:338-351. [PMID: 38864803 DOI: 10.1016/j.athoracsur.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 06/13/2024]
Abstract
Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programs that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of "assisting only." In Rwanda, Team Heart, a US and Rwanda-based non-governmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, its "Seal of Approval" for the sustainability of endorsed programs in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programs could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.
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Affiliation(s)
- R M Bolman
- Division of Cardio-Thoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - P Zilla
- Christiaan Barnard Department of Cardiothoracic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
| | - F Beyersdorf
- Department of Cardiovascular Surgery, University Hospital Freiburg, Medical Faculty of the Albert-Ludwigs-University, Freiburg, Germany
| | - P Boateng
- Department of Cardiovascular Surgery, Icahn School of Medicine, Mount Sinai (ISMMS) Medical Center, New York, New York
| | - J Bavaria
- Division of Cardiovascular Surgery, Penn Medicine and Heart and Vascular Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - J Pomar
- Department of Cardiovascular Surgery, University of Barcelona, Barcelona, Spain
| | - S Kumar
- Department of Cardiovascular and Thoracic Surgery, All India Institute for Medical Sciences, Delhi, India
| | - T Chotivatanapong
- Department of Cardiothoracic Surgery, Central Chest Institute of Thailand and, Bangkok Heart Center, Bangkok, Thailand
| | - K Sliwa
- Cape Heart Institute and Division of Cardiology, University of Cape Town, Cape Town, South Africa
| | - J L Eisele
- World Heart Federation (WHF), Geneva, Switzerland
| | - Z Enumah
- Department of General Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - B Podesser
- Center for Biomedical Research and Translational Medicine, University of Vienna, Vienna, Austria; Department of Cardiothoracic Surgery, University Hospital St. Pölten, St. Pölten, Austria
| | - E A Farkas
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - T Kofidis
- Department of Cardiac-, Thoracic- and Vascular Surgery, National Univ. Hospital of Singapore, Singapore
| | - L J Zühlke
- South African Medical Research Council, Cape Town, South Africa
| | - R Higgins
- Brigham and Women's Hospital and Mass General Hospital, Harvard University, Boston, Massachusetts
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Doh CY, An C, Chang AY, Rwebembera J, Mwambu TP, Beaton AZ, Nakagaayi D, Ruda Vega PF, Sable CA, Longenecker CT, Lwabi P. Preintervention Wait Time and Survival in People With Rheumatic Heart Disease in Uganda. Ann Thorac Surg 2024:S0003-4975(24)00480-6. [PMID: 38908768 DOI: 10.1016/j.athoracsur.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/04/2024] [Accepted: 06/05/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND There is an unmet surgical burden among people living with rheumatic heart disease (RHD) in Uganda. Nevertheless, risk factors associated with time to first intervention and preoperative mortality are poorly understood. METHODS Individuals with RHD who met indications for valve surgery were identified using the Uganda National RHD Registry (January 2010-August 2022). Kaplan-Meier estimates and multivariable Cox proportional hazard models were used. RESULTS Of the cohort with clinical RHD, 64% (1452 of 2269) met criteria for an index operation. Of those, 13.5% obtained a surgical intervention, whereas 30.6% died before the operation. The estimated likelihood of first operation was 50% at 9.3 years of follow-up (95% CI, 8.1-upper limit not reached). Intervention was more likely in men vs women (hazard ratio [HR], 1.78; 95% CI, 1.21-2.64), those with postsecondary education vs primary school or less (HR, 3.60; 95% CI, 1.88-6.89), and those with a history of atrial fibrillation (HR, 2.78; 95% CI, 1.63-4.76). Surgical intervention was less likely for adults vs those aged <18 years (HR, 0.49; 95% CI, 0.32-0.77) and those with New York Heart Association Functional Class III/IV vs I/II (HR, 0.51; 95% CI, 0.32-0.83). The median preoperative survival time among those awaiting first operation was 4.6 years (95% CI, 3.9-5.7 years). History of infective endocarditis, right ventricular dysfunction, pericardial effusion, atrial fibrillation, and having surgical indications for multiple valves were associated with increased probability of death. CONCLUSIONS Our analysis revealed a prolonged time to first surgical intervention and high preintervention death for RHD in Uganda, with factors such as age, sex, and education level remaining barriers to obtaining surgery.
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Affiliation(s)
- Chang Yoon Doh
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Crystal An
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Andrew Y Chang
- Department of Epidemiology and Population Health, Stanford University, Stanford, California; Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California; Center for Innovation in Global Health, Stanford University, Stanford, California
| | - Joselyn Rwebembera
- Department of Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Tom P Mwambu
- Department of Cardiovascular Surgery, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda; School of Medicine, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Andrea Z Beaton
- Department of Pediatric Cardiology, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Doreen Nakagaayi
- Department of Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda; Department of Pediatric Cardiology, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Pablo F Ruda Vega
- Division of Cardiac Surgery, Harrington Heart & Vascular Institute Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Craig A Sable
- Department of Pediatric Cardiology, Children's National Hospital, Washington, DC; The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Chris T Longenecker
- Department of Cardiology and Global Health, University of Washington, Seattle, Washington.
| | - Peter Lwabi
- Department of Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda; School of Medicine, Makerere University, College of Health Sciences, Kampala, Uganda
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3
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Bolman RM, Zilla P, Beyersdorf F, Boateng P, Bavaria J, Dearani J, Pomar J, Kumar S, Chotivatanapong T, Sliwa K, Eisele JL, Enumah Z, Podesser B, Farkas EA, Kofidis T, Zühlke LJ, Higgins R. Making a difference: 5 years of Cardiac Surgery Intersociety Alliance (CSIA). Asian Cardiovasc Thorac Ann 2024:2184923241259191. [PMID: 38872357 DOI: 10.1177/02184923241259191] [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: 06/15/2024]
Abstract
Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries.
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Affiliation(s)
- R M Bolman
- Division of Cardio-Thoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, USA
| | - P Zilla
- Christiaan Barnard Department of Cardiothoracic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - F Beyersdorf
- Department of Cardiovascular Surgery, University Hospital Freiburg, Medical Faculty of the Albert-Ludwigs-University, Freiburg, Germany
| | - P Boateng
- Department of Cardiovascular Surgery, Icahn School of Medicine, Mount Sinai (ISMMS) Medical Center, New York, NY, USA
| | - J Bavaria
- Division of Cardiovascular Surgery, Penn Medicine and Heart and Vascular Center, University of Pennsylvania, Philadelphia, PA, USA
| | - J Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - J Pomar
- Department of Cardiovascular Surgery, University of Barcelona, Barcelona, Spain
| | - S Kumar
- Department of Cardiovascular and Thoracic Surgery, All India Institute for Medical Sciences, Delhi, India
| | - T Chotivatanapong
- Department of Cardiothoracic Surgery, Central Chest Institute of Thailand and, Bangkok Heart Center, Bangkok, Thailand
| | - K Sliwa
- Cape Heart Institute and Division of Cardiology, University of Cape Town, Cape Town, South Africa
| | - J L Eisele
- World Heart Federation (WHF), Geneva, Switzerland
| | - Z Enumah
- Department of General Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - B Podesser
- Center for Biomedical Research and Translational Medicine, University of Vienna, Vienna, Austria
- Department of Cardiothoracic Surgery, University Clinic St. Pölten, Austria
| | - E A Farkas
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - T Kofidis
- Department of Cardiac-, Thoracic- and Vascular Surgery, National Univ. Hospital of Singapore, Singapore
| | - L J Zühlke
- South African Medical Research Council, Cape Town, South Africa
| | - R Higgins
- Brigham and Women's Hosp. and Mass General Hospital, Harvard University, Boston, MA, USA
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Ochora M, Kyasimire L, Lutasingwa D, Namata T, Ahmed M, Favina A, Kumbakumba E, Nampijja D. Primary Healthcare Workers' Awareness of Acute Rheumatic Fever & Rheumatic Heart Disease: A Study in Public Health Facilities in South Western Uganda. Pediatric Health Med Ther 2024; 15:223-229. [PMID: 38860188 PMCID: PMC11162961 DOI: 10.2147/phmt.s461168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 05/31/2024] [Indexed: 06/12/2024] Open
Abstract
Introduction Timely identification and treatment of a streptococcal throat infection prevents acute rheumatic fever (ARF) and its progression to Rheumatic Heart Disease (RHD). However, children in developing countries still present with established RHD, due to either missed, untreated or sub-optimally treated sore throats and ARF. We aimed to determine the level of knowledge, skills, and practices of primary health workers in South Western Uganda in providing care such children. Methods We conducted a comparative quantitative cross-sectional study to assess knowledge, practices, and skills regarding the care of a child with a sore throat, ARF, and RHD. The responses were scored against a structured guide. The Fisher's exact test and the chi-squared test with level of significance set at 0.05 were utilized to compare differences in knowledge, skills, and practices among health workers in private and public health facilities about ARF and RHD. Results Eighty health workers from health facilities were interviewed in Mbarara district with a median age of 29.5 years (IQR 27.34) and median duration in practice of 5 years (IQR: 2, 10). On average, there were at least 3 children with sore throats weekly. At least 95% (CI: 87.25%-98.80%) of the health worker had awareness about ARF and RHD. Only 43.75% (95% CI: 33.18%-54.91%) had good knowledge about ARF and RHD. Majority, 61.25% (95% CI: 50.03%-71.39%) did not know the proper prophylaxis and investigations for a child with ARF. There were no statistically significant differences but a clinically meaningful differentials in the level of knowledge among health workers in public and private facilities. Conclusion The knowledge and skill level of health workers in primary healthcare facilities about ARF and RHD in South Western Uganda remains low, with no difference between practitioners in public and private facilities.
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Affiliation(s)
- Moses Ochora
- Department of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Lydia Kyasimire
- Department of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Dan Lutasingwa
- Department of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Tamara Namata
- Department of Community Health, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Muna Ahmed
- Department of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Alain Favina
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Elias Kumbakumba
- Department of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara City, Uganda
| | - Dorah Nampijja
- Department of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara City, Uganda
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5
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Bolman RM, Zilla P, Beyersdorf F, Boateng P, Bavaria J, Dearani J, Pomar J, Kumar S, Chotivatanapong T, Sliwa K, Eisele JL, Enumah Z, Podesser B, Farkas EA, Kofidis T, Zühlke LJ, Higgins R. Making a difference: 5 years of Cardiac Surgery Intersociety Alliance (CSIA). Eur J Cardiothorac Surg 2024; 65:ezae048. [PMID: 38856237 PMCID: PMC11163458 DOI: 10.1093/ejcts/ezae048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/08/2024] [Accepted: 02/15/2024] [Indexed: 06/11/2024] Open
Abstract
Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programmes that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of 'assisting only'. In Rwanda, Team Heart, a US and Rwanda-based non-governmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, its 'Seal of Approval' for the sustainability of endorsed programmes in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programmes could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.
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Affiliation(s)
- R M Bolman
- Division of Cardio-Thoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - P Zilla
- Christiaan Barnard Department of Cardiothoracic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - F Beyersdorf
- Department of Cardiovascular Surgery, University Hospital Freiburg, Medical Faculty of the Albert-Ludwigs-University, Freiburg, Germany
| | - P Boateng
- Department of Cardiovascular Surgery, Icahn School of Medicine, Mount Sinai (ISMMS) Medical Center, New York, NY, USA
| | - J Bavaria
- Division of Cardiovascular Surgery, Penn Medicine and Heart and Vascular Center, University of Pennsylvania, Philadelphia, PA, USA
| | - J Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - J Pomar
- Department of Cardiovascular Surgery, University of Barcelona, Barcelona, Spain
| | - S Kumar
- Department of Cardiovascular and Thoracic Surgery, All India Institute for Medical Sciences, Delhi, India
| | - T Chotivatanapong
- Department of Cardiothoracic Surgery, Central Chest Institute of Thailand and, Bangkok Heart Center, Bangkok, Thailand
| | - K Sliwa
- Cape Heart Institute and Division of Cardiology, University of Cape Town, Cape Town, South Africa
| | - J L Eisele
- World Heart Federation (WHF), Geneva, Switzerland
| | - Z Enumah
- Department of General Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - B Podesser
- Center for Biomedical Research and Translational Medicine, University of Vienna, Vienna, Austria
- Department of Cardiothoracic Surgery, University Hospital St. Pölten, St. Pölten, Austria
| | - E A Farkas
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - T Kofidis
- Department of Cardiac-, Thoracic- and Vascular Surgery, National Univ. Hospital of Singapore, Singapore
| | - L J Zühlke
- South African Medical Research Council, Cape Town, South Africa
| | - R Higgins
- Brigham and Women’s Hosp. and Mass General Hospital, Harvard University, Boston, MA, USA
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6
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Bolman RM, Zilla P, Beyersdorf F, Boateng P, Bavaria J, Dearani J, Pomar J, Kumar S, Chotivatanapong T, Sliwa K, Eisele JL, Enumah Z, Podesser B, Farkas EA, Kofidis T, Zühlke LJ, Higgins R. Making a difference: 5 years of Cardiac Surgery Intersociety Alliance (CSIA). J Thorac Cardiovasc Surg 2024:S0022-5223(24)00377-5. [PMID: 38864805 DOI: 10.1016/j.jtcvs.2024.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/08/2024] [Accepted: 02/15/2024] [Indexed: 06/13/2024]
Abstract
Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programs that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of "assisting only." In Rwanda, Team Heart, a US and Rwanda-based nongovernmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, its "Seal of Approval" for the sustainability of endorsed programs in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programs could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.
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Affiliation(s)
- R M Bolman
- Division of Cardio-Thoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minn
| | - P Zilla
- Christiaan Barnard Department of Cardiothoracic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
| | - F Beyersdorf
- Department of Cardiovascular Surgery, University Hospital Freiburg, Medical Faculty of the Albert-Ludwigs-University, Freiburg, Germany
| | - P Boateng
- Department of Cardiovascular Surgery, Icahn School of Medicine, Mount Sinai (ISMMS) Medical Center, New York, NY
| | - J Bavaria
- Division of Cardiovascular Surgery, Penn Medicine and Heart and Vascular Center, University of Pennsylvania, Philadelphia, Pa
| | - J Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - J Pomar
- Department of Cardiovascular Surgery, University of Barcelona, Barcelona, Spain
| | - S Kumar
- Department of Cardiovascular and Thoracic Surgery, All India Institute for Medical Sciences, Delhi, India
| | - T Chotivatanapong
- Department of Cardiothoracic Surgery, Central Chest Institute of Thailand, and Bangkok Heart Center, Bangkok, Thailand
| | - K Sliwa
- Cape Heart Institute and Division of Cardiology, University of Cape Town, Cape Town, South Africa
| | - J L Eisele
- World Heart Federation (WHF), Geneva, Switzerland
| | - Z Enumah
- Department of General Surgery, Johns Hopkins School of Medicine, Baltimore, Md
| | - B Podesser
- Center for Biomedical Research and Translational Medicine, University of Vienna, Vienna, Austria; Department of Cardiothoracic Surgery, University Clinic St. Pölten, St. Pölten, Austria
| | - E A Farkas
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - T Kofidis
- Department of Cardiac-, Thoracic- and Vascular Surgery, National Univ. Hospital of Singapore, Singapore
| | - L J Zühlke
- South African Medical Research Council, Cape Town, South Africa
| | - R Higgins
- Brigham and Women's Hosp. and Mass General Hospital, Harvard University, Boston, Mass
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7
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Searchinger C, Nalubwama H, Pulle J, Mehta R, Tumwbaze H, Kyarimpa R, Mwima R, Atukunda E, Bua B, Sarnacki R, Sherman MG, Oketcho M, Zimmerman M, Nakitto M, Longenecker CT, Webel A, Scheel A, Lwabi PS, Sable CA. Quality of Life in Ugandan Children and Young Adults After Surgery for Congenital Heart Disease: Mixed Methods Approach. Glob Heart 2024; 19:36. [PMID: 38638125 PMCID: PMC11025577 DOI: 10.5334/gh.1320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 03/26/2024] [Indexed: 04/20/2024] Open
Abstract
Background Health-related quality of life (HRQOL) is a critical issue for patients undergoing surgery for congenital heart disease (CHD) but has never been assessed in a low-income country. We conducted a cross-sectional mixed methods study with age-matched healthy siblings serving as controls at the Uganda Heart Institute. Methods One-hundred fifteen CHD pediatric and young adult patients and sibling control participants were recruited. Health-related quality of life was assessed using the Pediatric Quality of Life Inventory Version 4.0 in participants ages 5-17 and 36-Item Short Form Survey for young adults aged 18-25. A subset of 27 participants completed face-to-face interviews to supplement quantitative findings. Results Eighty-six pediatric (age 5-17) sibling and parent pairs completed Peds QOL surveys, and 29 young adult (age 18-25) sibling pairs completed SF-36 surveys. One third of patients had surgery in Uganda. Ventricular septal defects and tetralogy of Fallot were the most common diagnoses. Health-related quality of life scores in patients were lower across all domains compared to control participants in children. Reductions in physical and emotional domains of HRQOL were also statistically significant for young adults. Variables associated with lower HRQOL score on multivariate analysis in pediatric patients were younger age in the physical and emotional domains, greater number of surgeries in the physical domain and surgery outside Uganda in the school domain. The only predictor of lower HRQOL score in young adults was surgery outside Uganda in the social domain. Qualitative interviews identified a number of themes that correlated with survey results including abandonment by family, isolation from peers and community, financial hardship and social stigmatization. Conclusion Health-related quality of life was lower in Ugandan patients after CHD surgery than siblings. Younger patients and those who had surgery outside of Uganda had lower HRQOL. These data have important implications for patients undergoing CHD surgery in LMIC and have potential to inform interventions.
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Affiliation(s)
- Chloe Searchinger
- Princeton University, Princeton, NJ, USA
- Division of Cardiology and Global Health Initiative, Children’s National Hospital, Washington, DC, USA
| | | | | | - Rittal Mehta
- Division of Cardiology and Global Health Initiative, Children’s National Hospital, Washington, DC, USA
| | | | | | | | | | | | - Rachel Sarnacki
- Division of Cardiology and Global Health Initiative, Children’s National Hospital, Washington, DC, USA
| | - Meredith G. Sherman
- Division of Cardiology and Global Health Initiative, Children’s National Hospital, Washington, DC, USA
| | | | | | | | - Chris T. Longenecker
- Division of Cardiology and Department of Global Health University of Washington School of Medicine, Seattle WA, USA
| | - Allison Webel
- University of Washington School of Nursing, Seattle WA, USA
| | - Amy Scheel
- Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Craig A. Sable
- Division of Cardiology and Global Health Initiative, Children’s National Hospital, Washington, DC, USA
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Muddu M, Jaffari A, Brant LCC, Kiplagat J, Okello E, Masyuko S, Su Y, Longenecker CT. Lifting all boats: strategies to promote equitable bidirectional research training opportunities to enhance global health reciprocal innovation. BMJ Glob Health 2023; 8:e013278. [PMID: 38103895 PMCID: PMC10729234 DOI: 10.1136/bmjgh-2023-013278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 11/28/2023] [Indexed: 12/19/2023] Open
Abstract
Inequities in global health research are well documented. For example, training opportunities for US investigators to conduct research in low-income and middle-income countries (LMIC) have exceeded opportunities for LMIC investigators to train and conduct research in high-income countries. Reciprocal innovation addresses these inequities through collaborative research across diverse global settings.The Fogarty International Center of the US National Institutes of Health (NIH) promotes research capacity building in LMICs. Fogarty K-grants for mentored career development in global health are available for both US and LMIC investigators, whereas the D43 is the standard grant to support institutional training programmes in LMIC. Other NIH institutes fund T32 training grants to support biomedical research training in the USA, but very few have any global health component. Most global health training partnerships have historically focused on research conducted solely in LMIC, with few examples of bidirectional training partnerships. Opportunities may exist to promote global health reciprocal innovation (GHRI) research by twinning K-awardees in the USA with those from LMIC or by intentionally creating partnerships between T32 and D43 training programmes.To sustain independent careers in GHRI research, trainees must be supported through the path to independence known as the K (mentored grantee)-to-R (independent grantee) transition. Opportunities to support this transition include comentorship, research training at both LMIC and US institutions and protected time and resources for research. Other opportunities for sustainability include postdoctoral training before and after the K-award period, absorption of trained researchers into home institutions, South-South training initiatives and innovations to mitigate brain drain.
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Affiliation(s)
- Martin Muddu
- Makerere University School of Medicine, Kampala, Uganda
| | - Adiya Jaffari
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Luisa C C Brant
- Faculty of Medicine and Hospital das Clínicas Telehealth Center, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Jepchirchir Kiplagat
- Moi University College of Health Sciences, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Emmy Okello
- Makerere University School of Medicine, Kampala, Uganda
- Uganda Heart Institute Ltd, Kampala, Uganda
| | - Sarah Masyuko
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Yanfang Su
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Chris Todd Longenecker
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
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Rwebembera J, Chang AY, Kitooleko SM, Kaudha G, de Loizaga S, Nalule M, Ahabwe K, Zhang W, Okello E, Sinha P, Mwambu T, Sable C, Beaton A, Longenecker CT. Clinical Profile and Outcomes of Rheumatic Heart Disease Patients Undergoing Surgical Valve Procedures in Uganda. Glob Heart 2023; 18:62. [PMID: 38028964 PMCID: PMC10655755 DOI: 10.5334/gh.1260] [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: 02/26/2023] [Accepted: 08/07/2023] [Indexed: 12/01/2023] Open
Abstract
Background Chronic valvular heart disease is a well-known, long-term complication of acute rheumatic fever (ARF), which remains a major public health problem in low- and middle-income countries. Access to surgical management remains limited. Outcomes of the minority proportion of patients that access surgery have not been described in Uganda. Objectives To describe the volume and type of rheumatic heart disease (RHD) valvular interventions and the outcomes of operated patients in the Uganda RHD registry. Methods We performed a retrospective cohort study of all valve surgery procedures identified in the Uganda RHD registry through December 2021. Results Three hundred and sixty-seven surgical procedures were performed among 359 patients. More than half were among young (55.9% were ≤20 years of age), female (59.9%) patients. All patients were censored at 15 years. The median (IQR) follow up period was 43 (22,79) months. Nearly half of surgeries (46.9%) included interventions on multiple valves, and most valvular operations were replacements with mechanical prostheses (96.6%). Over 70% of the procedures were sponsored by charity organizations. The overall mortality of patients who underwent surgery was 13% (47/359), with over half of the mortalities occurring within the first year following surgery (27/47; 57.4%). Fifteen-year survival or freedom from re-operation was not significantly different between those receiving valve replacements and those receiving valve repair (log-rank p = 0.76). Conclusions There has been increasing access to valve surgery among Ugandan patients with RHD. Post-operative survival is similar to regionally reported rates. The growing cohort of patients living with prosthetic valves necessitates national expansion and decentralization of post-operative care services. Major reliance on charity funding of surgery is unsustainable, thus calling for locally generated and controlled support mechanisms such as a national health insurance scheme. The central illustration (Figure 1) provides a summary of our findings and recommendations.
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Affiliation(s)
| | - Andrew Y. Chang
- Department of Epidemiology and Population Health, Stanford University School of Medicine, USA
- Center for Innovation in Global Health, Stanford University, USA
| | | | | | - Sarah de Loizaga
- Stanford Cardiovascular Institute, Stanford University, USA
- Cincinnati Children’s Hospital Medical Center, The Heart Institute, Cincinnati, OH 45229, USA
| | | | | | | | - Emmy Okello
- Uganda Heart Institute, Kampala, Uganda
- School of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Pranava Sinha
- Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Craig Sable
- Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Andrea Beaton
- Stanford Cardiovascular Institute, Stanford University, USA
- Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Chris T. Longenecker
- Pediatric Cardiology, Children’s National Hospital, Washington, District of Columbia, USA
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Nabawanuka E, Ameda F, Erem G, Bugeza S, Opoka RO, Kiguli S, Amorut D, Aloroker F, Olupot-Olupot P, Mnjalla H, Mpoya A, Maitland K. Cardiovascular abnormalities in chest radiographs of children with pneumonia, Uganda. Bull World Health Organ 2023; 101:202-210. [PMID: 36865598 PMCID: PMC9948502 DOI: 10.2471/blt.22.288801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 12/08/2022] [Accepted: 12/10/2022] [Indexed: 03/04/2023] Open
Abstract
Objective To describe chest radiograph findings among children hospitalized with clinically diagnosed severe pneumonia and hypoxaemia at three tertiary facilities in Uganda. Methods The study involved clinical and radiograph data on a random sample of 375 children aged 28 days to 12 years enrolled in the Children's Oxygen Administration Strategies Trial in 2017. Children were hospitalized with a history of respiratory illness and respiratory distress complicated by hypoxaemia, defined as a peripheral oxygen saturation (SpO2) < 92%. Radiologists blinded to clinical findings interpreted chest radiographs using standardized World Health Organization method for paediatric chest radiograph reporting. We report clinical and chest radiograph findings using descriptive statistics. Findings Overall, 45.9% (172/375) of children had radiological pneumonia, 36.3% (136/375) had a normal chest radiograph and 32.8% (123/375) had other radiograph abnormalities, with or without pneumonia. In addition, 28.3% (106/375) had a cardiovascular abnormality, including 14.9% (56/375) with both pneumonia and another abnormality. There was no significant difference in the prevalence of radiological pneumonia or of cardiovascular abnormalities or in 28-day mortality between children with severe hypoxaemia (SpO2: < 80%) and those with mild hypoxaemia (SpO2: 80 to < 92%). Conclusion Cardiovascular abnormalities were relatively common among children hospitalized with severe pneumonia in Uganda. The standard clinical criteria used to identify pneumonia among children in resource-poor settings were sensitive but lacked specificity. Chest radiographs should be performed routinely for all children with clinical signs of severe pneumonia because it provides useful information on both cardiovascular and respiratory systems.
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Affiliation(s)
- Eva Nabawanuka
- Department of Radiology, School of Medicine, Makerere University, PO Box 7051, Kampala, Uganda
| | - Faith Ameda
- Department of Radiology, School of Medicine, Makerere University, PO Box 7051, Kampala, Uganda
| | - Geoffrey Erem
- Department of Radiology, School of Medicine, Makerere University, PO Box 7051, Kampala, Uganda
| | - Samuel Bugeza
- Department of Radiology, School of Medicine, Makerere University, PO Box 7051, Kampala, Uganda
| | - RO Opoka
- Department of Paediatrics, School of Medicine, Makerere University, Kampala, Uganda
| | - Sarah Kiguli
- Mbale Clinical Research Institute, Mbale, Uganda
| | - Denis Amorut
- Soroti Regional Referral Hospital, Soroti, Uganda
| | | | | | - Hellen Mnjalla
- Kenya Medical Research Institute–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Ayub Mpoya
- Kenya Medical Research Institute–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Kathryn Maitland
- Department of Infectious Disease and Institute of Global Health and Innovation, Imperial College, London, England
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Minja NW, Nakagaayi D, Aliku T, Zhang W, Ssinabulya I, Nabaale J, Amutuhaire W, de Loizaga SR, Ndagire E, Rwebembera J, Okello E, Kayima J. Cardiovascular diseases in Africa in the twenty-first century: Gaps and priorities going forward. Front Cardiovasc Med 2022; 9:1008335. [PMID: 36440012 PMCID: PMC9686438 DOI: 10.3389/fcvm.2022.1008335] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022] Open
Abstract
In 2015, the United Nations set important targets to reduce premature cardiovascular disease (CVD) deaths by 33% by 2030. Africa disproportionately bears the brunt of CVD burden and has one of the highest risks of dying from non-communicable diseases (NCDs) worldwide. There is currently an epidemiological transition on the continent, where NCDs is projected to outpace communicable diseases within the current decade. Unchecked increases in CVD risk factors have contributed to the growing burden of three major CVDs-hypertension, cardiomyopathies, and atherosclerotic diseases- leading to devastating rates of stroke and heart failure. The highest age standardized disability-adjusted life years (DALYs) due to hypertensive heart disease (HHD) were recorded in Africa. The contributory causes of heart failure are changing-whilst HHD and cardiomyopathies still dominate, ischemic heart disease is rapidly becoming a significant contributor, whilst rheumatic heart disease (RHD) has shown a gradual decline. In a continent where health systems are traditionally geared toward addressing communicable diseases, several gaps exist to adequately meet the growing demand imposed by CVDs. Among these, high-quality research to inform interventions, underfunded health systems with high out-of-pocket costs, limited accessibility and affordability of essential medicines, CVD preventive services, and skill shortages. Overall, the African continent progress toward a third reduction in premature mortality come 2030 is lagging behind. More can be done in the arena of effective policy implementation for risk factor reduction and CVD prevention, increasing health financing and focusing on strengthening primary health care services for prevention and treatment of CVDs, whilst ensuring availability and affordability of quality medicines. Further, investing in systematic country data collection and research outputs will improve the accuracy of the burden of disease data and inform policy adoption on interventions. This review summarizes the current CVD burden, important gaps in cardiovascular medicine in Africa, and further highlights priority areas where efforts could be intensified in the next decade with potential to improve the current rate of progress toward achieving a 33% reduction in CVD mortality.
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Affiliation(s)
- Neema W. Minja
- Rheumatic Heart Disease Research Collaborative, Uganda Heart Institute, Kampala, Uganda
- Kilimanjaro Clinical Research Institute (KCRI), Moshi, Tanzania
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Doreen Nakagaayi
- Department of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Twalib Aliku
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Wanzhu Zhang
- Department of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Isaac Ssinabulya
- Department of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Juliet Nabaale
- Department of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Willington Amutuhaire
- Department of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Sarah R. de Loizaga
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
| | - Emma Ndagire
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | | | - Emmy Okello
- Department of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - James Kayima
- Department of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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Hoosen EGM, Cilliers AM, Brown S, Mitchell B. Improving Access to Pediatric Cardiac Care in the Developing World: the South African Perspective. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2022; 8:141-150. [PMID: 37521172 PMCID: PMC9137262 DOI: 10.1007/s40746-022-00247-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 04/21/2022] [Indexed: 12/02/2022]
Abstract
Purpose of Review The paper outlines the current status of health care and pediatric cardiac services in South Africa and the challenges faced in providing pediatric cardiac care in the country. Recent Findings As infant and child mortality rates in South Africa and most of Sub-Saharan Africa continue to decline, establishing and improving the infrastructure to manage congenital heart disease increases in importance. Summary South Africa has well-established pediatric cardiac units in most major centers in the country. These have been able to train sufficient numbers of pediatric cardiologists to double the number in the country in just over a decade as well as train fellows from surrounding countries. A significant proportion of funding for this training comes from non-government sources. The number of pediatric cardiologists is however still far less than required with services spread unevenly throughout the country. Pediatric cardiac surgical services remain severely constrained with an urgent need to train more pediatric cardiac surgeons. Further progress depends not only on focussing resources on cardiac disease but also improvements in the health care systems and socioeconomic conditions in general.
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Affiliation(s)
- Ebrahim G. M. Hoosen
- Paediatric Cardiology, Inkosi Albert Luthuli Central Hospital, Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
| | - Antoinette M. Cilliers
- Paediatric Cardiology, C.H. Baragwanath Academic Hospital, Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
| | - Stephen Brown
- Division of Paediatric & Congenital Cardiology, University of the Free State, Bloemfontein, South Africa
| | - Belinda Mitchell
- Paediatric Cardiology, Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa
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13
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Zimmerman M, Kitooleko S, Okello E, Ollberding N, Sinha P, Mwambu T, Sable C, Beaton A, Longenecker C, Lwabi P. Clinical outcomes of children with rheumatic heart disease. Heart 2022; 108:633-638. [PMID: 35110387 PMCID: PMC9221000 DOI: 10.1136/heartjnl-2021-320356] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/19/2022] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To evaluate the long-term clinical outcomes of children with rheumatic heart disease (RHD) in Uganda, and determine characteristics that predict adverse outcomes. METHODS This retrospective cohort study evaluated the risk of death in Ugandan children with clinical RHD from 2010 to 2018; enrolling children aged 5-18 years old from an existing registry. Demographic data and clinical data (baseline complications, RHD severity, cardiac interventions) were collected. The primary outcome was survival. Univariable and multivariable hazard ratios (HR) were obtained from Cox proportional hazards regression. Survival probabilities were developed using Kaplan-Meier curves; log-rank tests compared survival based on cardiac interventions, disease severity and time of enrolment. RESULTS 612 cases met inclusion criteria; median age 12.8 years (IQR 5.3), 37% were male. Thirty-one per cent (187 of 612) died during the study period; median time to death 7.8 months (IQR 18.3). In univariable analysis, older age (HR 1.26, 95% CI=1.0 to 1.58), presence of baseline complications (HR 2.06, 95% CI=1.53 to 2.78) and severe RHD (HR 5.21, 95% CI=2.15 to 12.65) were associated with mortality. Cardiac intervention was associated with a lower risk of mortality (HR 0.06, 95% CI=0.02 to 0.24). In multivariable models, baseline complications (HR 1.78, 95% CI=1.31 to 2.41), severe RHD (HR 4.58, 95% CI=1.87 to 11.23) and having an intervention (HR 0.05, 95% CI=0.01 to 0.21) remained statistically significant. Kaplan-Meier survival curves demonstrated >25% mortality in the first 30 months, with significant differences in mortality based on intervention status and severity of disease. CONCLUSIONS The mortality rate of children with clinical RHD in Uganda exceeds 30%, over an 8-year time frame, despite in-country access to cardiac interventions. Children at highest risk were those with cardiac complications at baseline and severe RHD.
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Affiliation(s)
- Meghan Zimmerman
- Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | | | - Emmy Okello
- Cardiology, Uganda Heart Institute, Kampala, Uganda
- Makerere University, Kampala, Uganda
| | - Nicholas Ollberding
- Rehabilitation, Exercise, and Nutrition Sciences, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Pranava Sinha
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
- Pediatric Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Tom Mwambu
- Cardiology, Uganda Heart Institute, Kampala, Uganda
- Makerere University, Kampala, Uganda
| | - Craig Sable
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
- Pediatric Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Andrea Beaton
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Chris Longenecker
- Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Peter Lwabi
- Cardiology, Uganda Heart Institute, Kampala, Uganda
- Makerere University, Kampala, Uganda
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Impact of Technologic Innovation and COVID-19 Pandemic on Pediatric Cardiology Telehealth. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2022; 8:309-324. [PMID: 36479525 PMCID: PMC9510217 DOI: 10.1007/s40746-022-00258-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 12/14/2022]
Abstract
Purpose of Review Established telehealth practices in pediatrics and pediatric cardiology are evolving rapidly. This review examines several concepts in contemporary telemedicine in our field: recent changes in direct-to-consumer (DTC) pediatric telehealth (TH) and practice based on lessons learned from the pandemic, scientific data from newer technological innovations in pediatric cardiology, and how TH is shaping global pediatric cardiology practice. Recent Findings In 2020, the global pandemic of COVID-19 led to significant changes in healthcare delivery. The lockdown and social distancing guidelines accelerated smart adaptations and pivots to ensure continued pediatric care albeit in a virtual manner. Remote cardiac monitoring technology is continuing to advance at a rapid pace secondary to advances in the areas of Internet access, portable hand-held devices, and artificial intelligence. Summary TH should be approached programmatically by pediatric cardiac healthcare providers with careful selection of patients, technology platforms, infrastructure setup, documentation, and compliance. Payment parity with in-person visits should be advocated and legislated. Newer remote cardiac monitoring technology should be expanded for objective assessment and optimal outcomes. TH continues to be working beyond geographical boundaries in pediatric cardiology and should continue to expand and develop.
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15
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Pulmonary Hypertension in Children across Africa: The Silent Threat. Int J Pediatr 2021; 2021:9998070. [PMID: 34858504 PMCID: PMC8632426 DOI: 10.1155/2021/9998070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 10/23/2021] [Indexed: 11/22/2022] Open
Abstract
Pulmonary hypertension (PH) is a complex puzzle in Africa, especially among children who present with a cocktail of issues including recurrent pulmonary infections, unoperated congenital heart disease, and advanced rheumatic heart disease. Sickle cell anemia and neonatal complications of transiting from fetal circulation also contribute to the burden of pulmonary hypertension. Mortality from pulmonary arterial hypertension (PAH) remains high in Africa (18-21%), claiming sufferers in the first 6 months after diagnosis. Unfortunately, PH remains underreported in sub-Saharan Africa since many centers lack the capacity to diagnose and confirm it by the recommended gold standard, right heart catheterization. The unresolved burden of unoperated congenital heart lesions and rheumatic heart disease, among other preventable causes, stand out as major causes of PH in African children. This paper highlights pediatric PAH as a result of major gaps in care and illustrates the need for its prevention as well as for the promotion of research into the most important drivers, to prevent premature mortality in the continent.
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DeWyer A, Scheel A, Kamarembo J, Akech R, Asiimwe A, Beaton A, Bobson B, Canales L, DeStigter K, Kazi DS, Kwan GF, Longenecker CT, Lwabi P, Murali M, Ndagire E, Namuyonga J, Sarnacki R, Ssinabulya I, Okello E, Aliku T, Sable C. Establishment of a cardiac telehealth program to support cardiovascular diagnosis and care in a remote, resource-poor setting in Uganda. PLoS One 2021; 16:e0255918. [PMID: 34358281 PMCID: PMC8345851 DOI: 10.1371/journal.pone.0255918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/26/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION To address workforce shortages and expand access to care, we developed a telemedicine program incorporating existing infrastructure for delivery of cardiovascular care in Gulu, Northern Uganda. Our study had three objectives: 1) assess feasibility and clinical impact 2) evaluate patient/parent satisfaction and 3) estimate costs. METHODS All cardiology clinic visits during a two-year study period were included. All patients received an electrocardiogram and echocardiogram performed by a local nurse in Gulu which were stored and transmitted to the Uganda Heart Institute in the capital of Kampala for remote consultation by a cardiologist. Results were relayed to patients/families following cardiologist interpretation. The following telemedicine process was utilized: 1) clinical intake by nurse in Gulu; 2) ECG and echocardiography acquisition in Gulu; 3) echocardiography transmission to the Uganda Heart Institute in Kampala, Uganda; 4) remote telemedicine consultation by cardiologists in Kampala; and 5) communication of results to patients/families in Gulu. Clinical care and technical aspects were tracked. Diagnoses and recommendations were analyzed by age groups (0-5 years, 6-21 years, 22-50 years and > 50 years). A mixed methods approach involving interviews and surveys was used to assess patient satisfaction. Healthcare sector costs of telemedicine-based cardiovascular care were estimated using time-driven activity-based costing. RESULTS Normal studies made up 47%, 55%, 76% and 45% of 1,324 patients in the four age groups from youngest to oldest. Valvular heart disease (predominantly rheumatic heart disease) was the most common diagnosis in the older three age groups. Medications were prescribed to 31%, 31%, 24%, and 48% of patients in the four age groups. The median time for consultation was 7 days. A thematic analysis of focus group transcripts displayed an overall acceptance and appreciation for telemedicine, citing cost- and time-saving benefits. The cost of telemedicine was $29.48/visit. CONCLUSIONS Our data show that transmission and interpretation of echocardiograms from a remote clinic in northern Uganda is feasible, serves a population with a high burden of heart disease, has a significant impact on patient care, is favorably received by patients, and can be delivered at low cost. Further study is needed to better assess the impact relative to existing standards of care and cost effectiveness.
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Affiliation(s)
- Alyssa DeWyer
- Virginia Tech Carilion School of Medicine, Roanoke, VA, United States of America
| | - Amy Scheel
- Emory University School of Medicine, Atlanta, GA, United States of America
| | | | - Rose Akech
- Gulu Regional Referral Hospital, Gulu, Uganda
| | | | - Andrea Beaton
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States of America
- The University of Cincinnati School of Medicine, Cincinnati, OH, United States of America
| | | | - Lesley Canales
- Children’s National Hospital, Washington, DC, United States of America
| | - Kristen DeStigter
- University of Vermont Medical Center, Burlington, VT, United States of America
| | - Dhruv S. Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
- Cardiovascular Medicine Section, Department of Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Gene F. Kwan
- Boston University School of Medicine, Boston, MA, United States of America
| | - Chris T. Longenecker
- Case Western Reserve University School of Medicine, Cleveland, OH, United States of America
- University Hospitals Harrington Heart & Vascular Institute, Cleveland, OH, United States of America
| | | | - Meghna Murali
- Children’s National Hospital, Washington, DC, United States of America
| | | | | | - Rachel Sarnacki
- Children’s National Hospital, Washington, DC, United States of America
| | | | | | | | - Craig Sable
- Children’s National Hospital, Washington, DC, United States of America
- George Washington School of Medicine, Washington, DC, United States of America
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Aliku T, Beaton A, Lubega S, Dewyer A, Scheel A, Kamarembo J, Akech R, Sable C, Lwabi P. Profile of congenital heart disease and access to definitive care among children seen at Gulu Regional Referral Hospital in Northern Uganda: a four-year experience. JOURNAL OF CONGENITAL CARDIOLOGY 2021. [DOI: 10.1186/s40949-021-00064-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objectives
The aim of this study was to describe the profile of Congenital Heart Disease [CHD] and access to definitive surgical or catheter-based care among children attending a regional referral hospital in Northern Uganda.
Methods
This was a retrospective chart review of all children aged less than 17 years attending Gulu Regional Referral Hospital Cardiac clinic from November 2013 to July 2017.
Results
A total of 295 children were diagnosed with CHD during the study period. The median age at initial diagnosis was 12 months [IQR: 4–48]. Females comprised 59.3% [n = 175] of cases. Diagnosis in the neonatal period accounted for only 7.5 % [n = 22] of cases. The commonest CHD seen was ventricular septal defect [VSD] in 19.7 % [n = 58] of cases, followed by atrioventricular septal defect (AVSD) in 17.3 % [n = 51] and patent ductus arteriosus (PDA) in 15.9 % [n = 47]. The commonest cyanotic CHD seen was tetralogy of Fallot [TOF] in 5.1 % [n = 15], followed by double outlet right ventricle [DORV] in 4.1 % [n = 12] and truncus arteriosus in 3.4% [n = 10]. Dextro-transposition of the great arteries [D-TGA] was seen in 1.3 % [n = 4]. At initial evaluation, 76 % [n = 224] of all CHD cases needed definitive intervention and 14 % of these children [n = 32] had accessed surgical or catheter-based therapy within 2 years of diagnosis. Three quarters of the cases who had intervention [n = 24] had definitive care at the Uganda Heart Institute (UHI), including all 12 cases who underwent catheter-based interventions. No mortalities were reported in the immediate post-operative period and in the first annual follow up in all cases who had intervention.
Conclusions
There is delayed diagnosis of most rural Ugandan Children with CHD and access to definitive care is severely limited. The commonest CHD seen was VSD followed by AVSD. The majority of patients who had definitive surgery or transcatheter intervention received care in Uganda.
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Starting and Operating a Public Cardiac Catheterization Laboratory in a Low Resource Setting: The Eight-Year Story of the Uganda Heart Institute Catheter Laboratory. Glob Heart 2021; 16:11. [PMID: 33598391 PMCID: PMC7879993 DOI: 10.5334/gh.859] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Low- and-middle-income-countries (LMICs) currently bear 80% of the world’s cardiovascular disease (CVD) mortality burden. The same countries are underequipped to handle the disease burden due to critical shortage of resources. Functional cardiac catheterization laboratories (cath labs) are central in the diagnosis and management of CVDs. Yet, most LMICs, including Uganda, fall remarkably below the minimum recommended standards of cath lab:population ratio due to a host of factors including the start-up and recurring costs. Objectives: To review the performance, challenges and solutions employed, lessons learned, and projections for the future for a single cath lab that has been serving the Ugandan population of 40 million people in the past eight years. Methods: A retrospective review of the Uganda Heart Institute cath lab clinical database from 15 February 2012 to 31 December 2019 was performed. Results: In the initial two years, this cath lab was dependent on skills transfer camps by visiting expert teams, but currently, Ugandan resident specialists independently operate this lab. 3,542 adult and pediatric procedures were conducted in 8 years, including coronary angiograms and percutaneous coronary interventions, device implantations, valvuloplasties, and cardiac defect closures, among others. There was a consistent expansion of the spectrum of procedures conducted in this cath lab each year. The initial lack of technical expertise and sourcing for equipment, as well as the continual need for sundries present(ed) major roadblocks. Government support and leveraging existing multi-level collaborations has provided a platform for several solutions. Sustainability of cath lab services remains a significant challenge especially in relation to the high cost of sundries and other consumables amidst a limited budget. Conclusion: A practical example of how centers in LMIC can set up and sustain a public cardiac catheterization laboratory is presented. Government support, research, and training collaborations, if present, become invaluable leverage opportunities.
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Obongonyinge B, Namuyonga J, Tumwebaze H, Aliku T, Lwabi P, Lubega S. Congenitally corrected transposition of great arteries: a case series of five unoperated African children. JOURNAL OF CONGENITAL CARDIOLOGY 2020. [DOI: 10.1186/s40949-020-00038-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Congenitally corrected transposition of great arteries (ccTGA) is rare. It is commonly associated with ventricular septal defect (VSD), pulmonary stenosis and heart block. Early anatomic repair is recommended between 3 and 6 months of age to prevent development of tricuspid valve regurgitation and systemic right ventricular failure.
Case presentation
We retrospectively identified five cases of ccTGA. Cases were between one and 13 years of age. All the cases were unoperated. Four of the five cases had associated intracardiac defects/complications. These included: VSD, pulmonary stenosis, tricuspid valve regurgitation, right ventricular systolic dysfunction and heart block.
Conclusion
These cases demonstrate the challenges of access to early diagnosis and surgery in a low resource setting. This delay in anatomic repair leads to complications of tricuspid valve regurgitation and systemic right ventricular failure.
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Namuyonga J, Lubega S, Aliku T, Omagino J, Sable C, Lwabi P. Pattern of congenital heart disease among children presenting to the Uganda Heart Institute, Mulago Hospital: a 7-year review. Afr Health Sci 2020; 20:745-752. [PMID: 33163039 PMCID: PMC7609125 DOI: 10.4314/ahs.v20i2.26] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Congenital heart disease (CHD) is the most common congenital anomaly in children. Over half of the deaths due to CHD occur in the neonatal period. Most children with unrepaired complex heart lesions do not live to celebrate their first birthday. We describe the spectrum of congenital heart disease in Uganda. METHODS We retrospectively reviewed the data of children with CHD who presented to the Uganda Heart Institute (UHI), Mulago Hospital Complex from 2007 to 2014. RESULTS A total of 4621 children were seen at the UHI during the study period. Of these, 3526 (76.3%) had CHD; 1941(55%) were females. Isolated ventricular septal defect (VSD) was the most common CHD seen in 923 (27.2%) children followed by Patent ductus arteriosus (PDA) 760 (22%) and atrial septal defects (ASD) 332 (9.4%). Tetralogy of Fallot (TOF) and Truncus arteriosus were the most common cyanotic heart defects (7% and 5% respectively). Dysmorphic features were diagnosed in 185 children, of which 61 underwent genetic testing (Down syndrome=24, 22q11.2 deletion syndrome n=10). Children with confirmed 22q11.2 deletion had conotruncal abnormalities. CONCLUSION Isolated VSD and Tetralogy of Fallot are the most common acyanotic and cyanotic congenital heart defects. We report an unusually high occurrence of Truncus arteriosus.
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MESH Headings
- Adolescent
- Child
- Child, Preschool
- Ductus Arteriosus, Patent/diagnostic imaging
- Ductus Arteriosus, Patent/epidemiology
- Echocardiography
- Female
- Heart Defects, Congenital/diagnostic imaging
- Heart Defects, Congenital/epidemiology
- Heart Septal Defects, Atrial/diagnostic imaging
- Heart Septal Defects, Atrial/epidemiology
- Heart Septal Defects, Ventricular/diagnostic imaging
- Heart Septal Defects, Ventricular/epidemiology
- Humans
- Infant
- Infant, Newborn
- Male
- Prevalence
- Retrospective Studies
- Rubella Syndrome, Congenital
- Sex Distribution
- Tetralogy of Fallot/epidemiology
- Truncus Arteriosus/diagnostic imaging
- Uganda/epidemiology
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Affiliation(s)
- Judith Namuyonga
- Uganda Heart Institute
- Makerere University College of Health Sciences
| | | | | | | | - Craig Sable
- Children's National Medical Center, Washington DC
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DeWyer A, Scheel A, Otim IO, Longenecker CT, Okello E, Ssinabulya I, Morris S, Okwir M, Oyang W, Joyce E, Nabongo B, Sable C, Alencherry B, Tompsett A, Aliku T, Beaton A. Improving the accuracy of heart failure diagnosis in low-resource settings through task sharing and decentralization. Glob Health Action 2020; 12:1684070. [PMID: 31694487 PMCID: PMC6844369 DOI: 10.1080/16549716.2019.1684070] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Task sharing of TTE may improve capacity for heart failure diagnosis and management in patients in remote, low-resource settings but the impact on diagnostic accuracy and patient outcomes has not been studied. Objectives: Determine feasibility and impact of non-expert training in transthoracic echocardiography (TTE) to improve the diagnosis and outcomes of patients with suspected heart failure in Uganda. Methods: This two-part study examined an innovative training program to develop TTE competency among non-experts and used a pre-post design to determine the impact of decentralized TTE. Four of 8 non-experts (50%) passed a three-part training course. The training comprised of distance learning through a web-based curriculum, a 2-day hands-on workshop with cardiologists, and independent practice with remote mentorship. Continuous measures were compared (pre- vs. post-TTE) using t-tests or Wilcoxon rank-sum tests as distributionally appropriate and categorical variables assessed through chi-square testing. Sensitivity and specificity were calculated according to standard methodology comparing diagnosis pre- and post-TTE during phase 2. Results: Performance in the post-training phase showed good agreement with expert categorization (κ = 0.80) with diagnostic concordance in 421 of 454 studies (92.7%). TTE changed the preliminary diagnosis in 81% of patients, showing low specificity of clinical decision-making alone (14.2%; 95% CI 10.1–19.2%). Dilated cardiomyopathy, hypertensive heart disease with preserved systolic function, and right heart failure were the most underdiagnosed conditions prior to TTE while hypertensive heart disease with decreased systolic function was the most over-diagnosed condition. Conclusions: In conclusion, non-expert providers can achieve a high level of proficiency for the categorization of heart failure using handheld TTE in low-resource settings and use of telemedicine and remote mentorship may improve performance and feasibility. The addition of TTE resulted in substantial improvement in etiological specificity. Further study is needed to understand implications of this strategy on healthcare utilization, long-term patient outcomes, and cost.
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Affiliation(s)
- Alyssa DeWyer
- Department of Cardiology, Children's National Health System, Washington, DC, USA
| | - Amy Scheel
- Department of Cardiology, Children's National Health System, Washington, DC, USA.,School of Medicine, Emory University, Atlanta, GA, USA
| | - Isaac Omara Otim
- Department of Medicine, Lira Regional Referral Hospital, Cardiac Clinic, Lira, Uganda
| | - Christopher T Longenecker
- Department of Cardiology, University Hospitals Harrington Heart & Vascular Institute, Case Western Reserve University, Cleveland, OH, USA
| | - Emmy Okello
- Department of Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Isaac Ssinabulya
- Department of Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Stephen Morris
- Department of Cardiology, University Hospitals Harrington Heart & Vascular Institute, Case Western Reserve University, Cleveland, OH, USA
| | - Mark Okwir
- Department of Medicine, Lira Regional Referral Hospital, Cardiac Clinic, Lira, Uganda
| | - William Oyang
- Department of Medicine, Lira Regional Referral Hospital, Cardiac Clinic, Lira, Uganda
| | - Erine Joyce
- Department of Medicine, Lira Regional Referral Hospital, Cardiac Clinic, Lira, Uganda
| | - Betty Nabongo
- Department of Medicine, Lira Regional Referral Hospital, Cardiac Clinic, Lira, Uganda
| | - Craig Sable
- Department of Cardiology, Children's National Health System, Washington, DC, USA
| | - Ben Alencherry
- Department of Cardiology, University Hospitals Harrington Heart & Vascular Institute, Case Western Reserve University, Cleveland, OH, USA
| | - Alison Tompsett
- Department of Cardiology, University Hospitals Harrington Heart & Vascular Institute, Case Western Reserve University, Cleveland, OH, USA
| | - Twalib Aliku
- Department of Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Andrea Beaton
- Department of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Tefera E, Qureshi SA, Gezmu AM, Mazhani L. Radiation protection knowledge and practices in interventional cardiologists practicing in Africa: a cross sectional survey. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2020; 40:311-318. [PMID: 31731286 DOI: 10.1088/1361-6498/ab5840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
We conducted a survey of doctors working in the cardiac catheterisation laboratories in Africa on their knowledge, attitude and practice with respect to radiation protection. Of seventy-two respondents contacted, 61 (84.7%) completed the questionnaire. Twenty-eight, (45.9%) were younger than 45 years. Thirty-seven, (60.6%) had less than 10 years of experience in the laboratory. Only 28 (45.9%) had undertaken radiation protection training. Fifty-eight, (95.1%) consistently used lead aprons. Forty-seven, (77%) reported consistently using thyroid shields. Ten (16.4%) consistently used radiation protection eyeglasses, whilst 36 (59%) never used them. Thermoluminescent Dosimeter badges were consistently used in 23 (37.7%). Forty-two, (68.9%) reported having ceiling mounted lead/acrylic shields. Level of radiation exposure in the most recent one year was ≤2 mSv in 14, between 2 and 20 mSv in 8 and between 20 and 30 mSv in 2, whilst 33 did not know their dose readings. The use of basic radiation protection tools as well as the knowledge and measurement of radiation exposure among interventional cardiologists working in Africa is low. The unavailability of some of the protective tools and a knowledge gap in terms of radiation protection and monitoring of self-exposure were some of the reasons for suboptimal self-protection against ionising radiation among our respondents. We suggest that initiatives be taken by all stakeholders to train this group of medical professionals in basic radiation protection to avoid unnecessary exposure to themselves, co-workers and patients.
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Affiliation(s)
- Endale Tefera
- Department of Paediatrics & Adolescent Health, division of Cardiology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
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Zimmerman M, Sable C. Congenital heart disease in low-and-middle-income countries: Focus on sub-Saharan Africa. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2020; 184:36-46. [PMID: 32026623 DOI: 10.1002/ajmg.c.31769] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/15/2020] [Accepted: 01/16/2020] [Indexed: 02/06/2023]
Abstract
The etiology of congenital heart disease (CHD) is multifactorial. The birth prevalence of CHD is shaped by a wide variety of maternal, fetal, and neonatal risk factors, along with the rates of prenatal diagnosis and terminations of pregnancy, all of which have geographic variability Epidemiology data availability from low-and-middle-income countries (LMIC) on CHD prevalence, morbidity, and mortality are far more limited than from high income countries. Data on specific genetic, environmental, and prenatal risk associated with CHD are almost nonexistent. In this article, we will focus on defining what data are available, genetic risk factors, birth and overall prevalence, morbidity, and the impact of limited access to interventions, both surgery and cardiac catheterizations. We will highlight CHD in sub-Saharan Africa to detail epidemiology studies in the poorest regions of the world. Existing literature as well as estimates from the Global Burden of Disease Study (http://ghdx.healthdata.org) form the basis for this review. The intersection of poverty, high fertility rates, and limited access to care results in a unique profile of CHD in LMIC. CHD is not a preventable disease (by most standards), so early detection and access are our key interventions to improve the dire outcomes for children in low-resources settings of the world.
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Affiliation(s)
| | - Craig Sable
- Children's National Health System, Washington, District of Columbia
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24
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Zühlke L, Lawrenson J, Comitis G, De Decker R, Brooks A, Fourie B, Swanson L, Hugo-Hamman C. Congenital Heart Disease in Low- and Lower-Middle-Income Countries: Current Status and New Opportunities. Curr Cardiol Rep 2019; 21:163. [PMID: 31784844 DOI: 10.1007/s11886-019-1248-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW The paper summarises the most recent data on congenital heart disease (CHD) in low- and lower-middle-income countries (LLMICs). In addition, we present an approach to diagnosis, management and interventions in these regions and present innovations, research priorities and opportunities to improve outcomes and develop new programs. RECENT FINDINGS The reported birth prevalence of CHD in LLMICs is increasing, with clear evidence of the impact of surgical intervention on the burden of disease. New methods of teaching and training are demonstrating improved outcomes. Local capacity building remains the key. There is a significant gap in epidemiological and outcomes data in CHD in LLMICs. Although the global agenda still does not address the needs of children with CHD adequately, regional initiatives are focusing on quality improvement and context-specific interventions. Future research should focus on epidemiology and the use of innovative thinking and partnerships to provide low-cost, high-impact solutions.
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Affiliation(s)
- Liesl Zühlke
- Western Cape Paediatric Cardiology Services, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and University of Cape Town, 2.17 Institute of Child Health Building, Klipfontein Rd Mowbray, 7700, South Africa.
- Division of Cardiology, Department of Medicine, Groote Schur Hospital and University of Cape Town, Cape Town, South Africa.
| | - John Lawrenson
- Western Cape Paediatric Cardiology Services, and Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, 7925, South Africa
| | - George Comitis
- Western Cape Paediatric Cardiology Services, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and University of Cape Town, 2.17 Institute of Child Health Building, Klipfontein Rd Mowbray, 7700, South Africa
| | - Rik De Decker
- Western Cape Paediatric Cardiology Services, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and University of Cape Town, 2.17 Institute of Child Health Building, Klipfontein Rd Mowbray, 7700, South Africa
| | - Andre Brooks
- Chris Barnard Division of Cardiac Surgery, University of Cape Town, Cape Town, South Africa
| | - Barend Fourie
- Western Cape Paediatric Cardiology Services, and Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, 7925, South Africa
| | - Lenise Swanson
- Western Cape Paediatric Cardiology Services, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and University of Cape Town, 2.17 Institute of Child Health Building, Klipfontein Rd Mowbray, 7700, South Africa
| | - Christopher Hugo-Hamman
- Western Cape Paediatric Cardiology Services, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and University of Cape Town, 2.17 Institute of Child Health Building, Klipfontein Rd Mowbray, 7700, South Africa
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Namuyonga J, Lwabi PS, Omagino J, Yacoub M, Mocumbi AO. Feasibility of south-south collaboration in Africa: the Uganda-Mozambique perspective. Cardiovasc J Afr 2019; 29:262-263. [PMID: 30204223 PMCID: PMC6421556 DOI: 10.5830/cvja-2018-030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
| | | | | | - Magdi Yacoub
- Imperial College of London, UK; Aswan Heart Centre, Cairo, Egypt
| | - Ana Olga Mocumbi
- Mozambique Institute of Health Education and Research (MIHER); Instituto Nacional de Saúde; Universidade Eduardo Mondlane, Maputo, Mozambique
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26
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Namuyonga J, Lubega S, Aliku T, Omagino J, Sable C, Lwabi P. High prevalence of truncus arteriosus in pediatric congenital heart disease in Uganda. Ann Pediatr Cardiol 2019; 12:186-188. [PMID: 31143055 PMCID: PMC6521674 DOI: 10.4103/apc.apc_161_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Judith Namuyonga
- Department of Paediatric Cardiology, Uganda Heart Institute, Kampala, Uganda. E-mail: .,Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Sulaiman Lubega
- Department of Paediatric Cardiology, Uganda Heart Institute, Kampala, Uganda. E-mail:
| | - Twalib Aliku
- Department of Paediatric Cardiology, Uganda Heart Institute, Kampala, Uganda. E-mail:
| | - John Omagino
- Department of Paediatric Cardiology, Uganda Heart Institute, Kampala, Uganda. E-mail:
| | - Craig Sable
- Children's National Medical Center, Washington, DC, USA
| | - Peter Lwabi
- Department of Paediatric Cardiology, Uganda Heart Institute, Kampala, Uganda. E-mail:
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Ekure EN, Kalu N, Sokunbi OJ, Kruszka P, Olusegun-Joseph AD, Ikebudu D, Bala D, Muenke M, Adeyemo A. Clinical epidemiology of congenital heart disease in Nigerian children, 2012-2017. Birth Defects Res 2018; 110:1233-1240. [PMID: 30230273 DOI: 10.1002/bdr2.1361] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 05/24/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Congenital heart diseases (CHDs) affect ~1% of newborns and are a significant cause of morbidity and mortality in children. We present the clinical epidemiology of CHD as seen in a large university medical center in Nigeria. METHODS Participants were 767 children with echocardiographically confirmed CHD seen over a 5-year period at the Lagos University Teaching Hospital, Nigeria. RESULTS Clinical presentation was often late with just over half (58.1%) presenting in infancy. The male:female distribution was 1:1. The predominant types of cardiac lesion seen were septal defects (43%), conotruncal defects (23.7%), atrioventricular septal defects (9.8%), and right ventricular outflow tract obstruction (7.3%). Cyanotic CHD was seen in 28.4% of cases and the single most common cyanotic CHD was Tetralogy of Fallot (13.4%). Children with cyanotic CHD were older (p = .002), had more severe lesions (p < .0001) and were more likely to have cardiac intervention (p < .0001). Extracardiac malformations were present in nearly one-third of the children. Syndromes associated with CHD were identified in 15.5% of the children and included Down syndrome (11.9%), congenital rubella syndrome (1.0%), and Marfan syndrome (0.7%). CONCLUSIONS This study is a large case series of CHD from a single site in sub-Saharan Africa utilizing clinical, epidemiological, and developmental considerations. It provides a rich and up-to-date description of the clinical epidemiology of CHD in Nigerian children while yielding data that could be useful for designing genetic, molecular, and biomarker studies.
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Affiliation(s)
- Ekanem N Ekure
- Department of Pediatrics, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
| | - Nnenna Kalu
- Department of Pediatrics, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Ogochukwu J Sokunbi
- Department of Pediatrics, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Paul Kruszka
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Akinsanya D Olusegun-Joseph
- Department of Medicine, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
| | - Desmond Ikebudu
- Central Research Laboratory, College of Medicine, University of Lagos, Lagos, Nigeria
| | - David Bala
- Central Research Laboratory, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Maximilian Muenke
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Adebowale Adeyemo
- Center for Research on Genomics and Global Health, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
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Longenecker CT, Kalra A, Okello E, Lwabi P, Omagino JO, Kityo C, Kamya MR, Webel AR, Simon DI, Salata RA, Costa MA. A Human-Centered Approach to CV Care: Infrastructure Development in Uganda. Glob Heart 2018; 13:347-354. [PMID: 29685638 PMCID: PMC6258347 DOI: 10.1016/j.gheart.2018.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/19/2018] [Accepted: 02/20/2018] [Indexed: 12/28/2022] Open
Abstract
In this case study, we describe an ongoing approach to develop sustainable acute and chronic cardiovascular care infrastructure in Uganda that involves patient and provider participation. Leveraging strong infrastructure for HIV/AIDS care delivery, University Hospitals Harrington Heart and Vascular Institute and Case Western Reserve University have partnered with U.S. and Ugandan collaborators to improve cardiovascular capabilities. The collaboration has solicited innovative solutions from patients and providers focusing on education and advanced training, penicillin supply, diagnostic strategy (e.g., hand-held ultrasound), maternal health, and community awareness. Key outcomes of this approach have been the completion of formal training of the first interventional cardiologists and heart failure specialists in the country, establishment of 4 integrated regional centers of excellence in rheumatic heart disease care with a national rheumatic heart disease registry, a penicillin distribution and adherence support program focused on retention in care, access to imaging technology, and in-country capabilities to treat advanced rheumatic heart valve disease.
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Affiliation(s)
- Christopher T Longenecker
- Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Ankur Kalra
- Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | | | | | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Moses R Kamya
- Department of Medicine, Makerere University School of Medicine, Mulago Hill, Kampala, Uganda
| | - Allison R Webel
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Daniel I Simon
- Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Robert A Salata
- Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Marco A Costa
- Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Abstract
An estimated 15 million children die or are crippled annually by treatable or preventable heart disease in low- and middle-income countries. Global efforts to reduce under-5 mortality have focused on reducing death from communicable diseases in low- and middle-income countries with little to no attention focusing on paediatric CHD and acquired heart disease. Lack of awareness of CHD and acquired heart disease, access to care, poor healthcare infrastructure, competing health priorities, and a critical shortage of specialists are important reasons why paediatric heart disease has not been addressed in low resourced settings. Non-governmental organisations have taken the lead to address these challenges. This review describes the global burden of paediatric heart disease and strategies to improve the quality of care for paediatric heart disease. These strategies would improve outcomes for children with heart disease.
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