1
|
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.
Collapse
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
| |
Collapse
|
2
|
Providência R, Aali G, Zhu F, Katairo T, Ahmad M, Bray JJH, Pelone F, Khanji MY, Marijon E, Cassandra M, Celermajer DS, Shokraneh F. Handheld echocardiography for the screening and diagnosis of rheumatic heart disease: a systematic review to inform WHO guidelines. Lancet Glob Health 2024; 12:e983-e994. [PMID: 38762298 DOI: 10.1016/s2214-109x(24)00127-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/29/2024] [Accepted: 03/08/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Early detection and diagnosis of acute rheumatic fever and rheumatic heart disease are key to preventing progression, and echocardiography has an important diagnostic role. Standard echocardiography might not be feasible in high-prevalence regions due to its high cost, complexity, and time requirement. Handheld echocardiography might be an easy-to-use, low-cost alternative, but its performance in screening for and diagnosing acute rheumatic fever and rheumatic heart disease needs further investigation. METHODS In this systematic review and meta-analysis, we searched Embase, MEDLINE, LILACS, and Conference Proceedings Citation Index-Science up to Feb 9, 2024, for studies on the screening and diagnosis of acute rheumatic fever and rheumatic heart disease using handheld echocardiography (index test) or standard echocardiography or auscultation (reference tests) in high-prevalence areas. We included all studies with useable data in which the diagnostic performance of the index test was assessed against a reference test. Data on test accuracy in diagnosing rheumatic heart disease, acute rheumatic fever, or carditis with acute rheumatic fever (primary outcomes) were extracted from published articles or calculated, with authors contacted as necessary. Quality of evidence was appraised using GRADE and QUADAS-2 criteria. We summarised diagnostic accuracy statistics (including sensitivity and specificity) and estimated 95% CIs using a bivariate random-effects model (or univariate random-effects models for analyses including three or fewer studies). Area under the curve (AUC) was calculated from summary receiver operating characteristic curves. Heterogeneity was assessed by visual inspection of plots. This study was registered with PROSPERO (CRD42022344081). FINDINGS Out of 4868 records we identified 11 studies, and two additional reports, comprising 15 578 unique participants. Pooled data showed that handheld echocardiography had high sensitivity (0·87 [95% CI 0·76-0·93]), specificity (0·98 [0·71-1·00]), and overall high accuracy (AUC 0·94 [0·84-1·00]) for diagnosing rheumatic heart disease when compared with standard echocardiography (two studies; moderate certainty of evidence), with better performance for diagnosing definite compared with borderline rheumatic heart disease. High sensitivity (0·79 [0·73-0·84]), specificity (0·85 [0·80-0·89]), and overall accuracy (AUC 0·90 [0·85-0·94]) for screening rheumatic heart disease was observed when pooling data of handheld echocardiography versus standard echocardiography (seven studies; high certainty of evidence). Most studies had a low risk of bias overall. Some heterogeneity was observed for sensitivity and specificity across studies, possibly driven by differences in the prevalence and severity of rheumatic heart disease, and level of training or expertise of non-expert operators. INTERPRETATION Handheld echocardiography has a high accuracy and diagnostic performance when compared with standard echocardiography for diagnosing and screening of rheumatic heart disease in high-prevalence areas. FUNDING World Health Organization. TRANSLATIONS For the Chinese, French, Italian, Persian, Portuguese, Spanish and Urdu translations of the abstract see Supplementary Materials section.
Collapse
Affiliation(s)
- Rui Providência
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK; Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK.
| | - Ghazaleh Aali
- Cochrane Heart, Institute of Health Informatics, University College London, London, UK
| | - Fang Zhu
- Systematic Review Consultants, Nottingham, UK
| | | | - Mahmood Ahmad
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK; Cardiology Department, Royal Free London NHS Foundation Trust, London, UK
| | - Jonathan J H Bray
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK; Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Ferruccio Pelone
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK
| | - Mohammed Y Khanji
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK; Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, London, UK
| | - Eloi Marijon
- Paris Cardiovascular Research Centre, INSERM U970, European Georges Pompidou Hospital, Paris, France
| | - Miryan Cassandra
- Cardiology Department, Hospital Dr Ayres de Menezes, São Tomé, São Tomé and Príncipe
| | - David S Celermajer
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Farhad Shokraneh
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK; Systematic Review Consultants, Nottingham, UK
| |
Collapse
|
3
|
Vervoort D, Yilgwan CS, Ansong A, Baumgartner JN, Bansal G, Bukhman G, Cannon JW, Cardarelli M, Cunningham MW, Fenton K, Green-Parker M, Karthikeyan G, Masterson M, Maswime S, Mensah GA, Mocumbi A, Kpodonu J, Okello E, Remenyi B, Williams M, Zühlke LJ, Sable C. Tertiary prevention and treatment of rheumatic heart disease: a National Heart, Lung, and Blood Institute working group summary. BMJ Glob Health 2023; 8:e012355. [PMID: 37914182 PMCID: PMC10619050 DOI: 10.1136/bmjgh-2023-012355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/14/2023] [Indexed: 11/03/2023] Open
Abstract
Although entirely preventable, rheumatic heart disease (RHD), a disease of poverty and social disadvantage resulting in high morbidity and mortality, remains an ever-present burden in low-income and middle-income countries (LMICs) and rural, remote, marginalised and disenfranchised populations within high-income countries. In late 2021, the National Heart, Lung, and Blood Institute convened a workshop to explore the current state of science, to identify basic science and clinical research priorities to support RHD eradication efforts worldwide. This was done through the inclusion of multidisciplinary global experts, including cardiovascular and non-cardiovascular specialists as well as health policy and health economics experts, many of whom also represented or closely worked with patient-family organisations and local governments. This report summarises findings from one of the four working groups, the Tertiary Prevention Working Group, that was charged with assessing the management of late complications of RHD, including surgical interventions for patients with RHD. Due to the high prevalence of RHD in LMICs, particular emphasis was made on gaining a better understanding of needs in the field from the perspectives of the patient, community, provider, health system and policy-maker. We outline priorities to support the development, and implementation of accessible, affordable and sustainable interventions in low-resource settings to manage RHD and related complications. These priorities and other interventions need to be adapted to and driven by local contexts and integrated into health systems to best meet the needs of local communities.
Collapse
Affiliation(s)
- Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Annette Ansong
- Outpatient Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | | | - Geetha Bansal
- Division of International Training and Research, John E Fogarty International Center, Bethesda, Maryland, USA
| | - Gene Bukhman
- Center for Integration Science, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Program in Global Noncommunicable Disease and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey W Cannon
- Department of Global Health and Population, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Marcelo Cardarelli
- Pediatric Heart Surgery, Inova Children Hospital, Falls Church, Virginia, USA
| | | | - Kathleen Fenton
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Melissa Green-Parker
- National Institutes of Health Office of Disease Prevention, Bethesda, Maryland, USA
| | | | - Mary Masterson
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Salome Maswime
- Global Surgery, University of Cape Town Faculty of Health Sciences, Observatory, Western Cape, South Africa
| | - George A Mensah
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Ana Mocumbi
- Non Communicable Diseases, Instituto Nacional de Saúde, Maputo, Mozambique
- Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Jacques Kpodonu
- Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Emmy Okello
- Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
| | - B Remenyi
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory of Australia, Australia
| | - Makeda Williams
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Liesl J Zühlke
- South African Medical Research Council, Tygerberg, South Africa
- Department of Medicine, Red Cross War Memorial Children's Hospital, Rondebosch, Western Cape, South Africa
| | - Craig Sable
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| |
Collapse
|
4
|
Namuyonga J, Ndagire E, Okumu D, Olugubuyi O, Lubega S, Omagino J, Lwabi P, Okello E. Positive impact of training rural health workers in identification and prevention of acute rheumatic fever in eastern Uganda. Cardiovasc J Afr 2023; 34:89-92. [PMID: 36162808 PMCID: PMC10512037 DOI: 10.5830/cvja-2022-029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 07/02/2022] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Diagnosis of acute rheumatic fever (ARF) is mainly clinical. Delayed or missed diagnosis and failure to administer appropriate and timely treatment of ARF leads to rheumatic heart disease (RHD), which could necessitate expensive treatments such as open-heart surgery. Implementation of preventative guidelines depends on availability of trained healthcare workers. As part of the routine support supervision, the Uganda Heart Institute sent out a team to rural eastern Uganda to evaluate health workers' knowledge level regarding management of ARF. METHODS Health workers from selected health facilities in Tororo district, eastern Uganda, were assessed for their knowledge on the clinical features and role of benzathine penicillin G (BPG) in the treatment and prevention of ARF recurrence. Using the RHD Action Needs assessment tool, we generated and administered a pre-test, then conducted training and re-administered a post-test. Eight months later, health workers were again assessed for knowledge retention and change in practices. Statistical analysis was done using Stata version 15. RESULTS During the initial phase, 34 of the 109 (31%) health workers passed the pre-test, indicating familiarity with clinical features of ARF. The level of knowledge of BPG use in ARF was very poor in all the health units [25/109 (22.6%)] but improved after training to 80%, as shown by the chi-squared test ( χ2 = 0.000). However, retention of this knowledge waned after eight months and was not significantly different compared to pre-training (χ2 ≥ 0.2). CONCLUSIONS A critical knowledge gap is evident among health workers, both in awareness and treatment of ARF, and calls for repetitive training as a priority strategy in prevention.
Collapse
Affiliation(s)
- Judith Namuyonga
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda.
- Department of Pediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Emma Ndagire
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - David Okumu
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
- Tororo District Local Government, Tororo, Uganda
| | - Oluwayomi Olugubuyi
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
- Department of Child and Adolescent Health, University of West Indies, Mona Jamaica
| | - Sulaiman Lubega
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - John Omagino
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Peter Lwabi
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Emmy Okello
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| |
Collapse
|
5
|
Mboweni N, Maseko M, Tsabedze N. Heart failure with reduced ejection fraction and atrial fibrillation: a Sub-Saharan African perspective. ESC Heart Fail 2023; 10:1580-1596. [PMID: 36934444 DOI: 10.1002/ehf2.14332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 01/06/2023] [Accepted: 02/07/2023] [Indexed: 03/20/2023] Open
Abstract
Cardiovascular diseases are a well-established cause of death in high-income countries. In the last 20 years, Sub-Saharan Africa (SSA) has seen one of the sharpest increases in cardiovascular disease-related mortality, superseding that of infectious diseases, including HIV/AIDS, in South Africa. This increase is evidenced by a growing burden of heart failure and atrial fibrillation (AF) risk factors. AF is a common comorbidity of heart failure with reduced ejection fraction (HFrEF), which predisposes to an increased risk of stroke, rehospitalizations, and mortality compared with patients in sinus rhythm. AF had the largest relative increase in cardiovascular disease burden between 1990 and 2010 in SSA and the second highest (106.4%) increase in disability-adjusted life-years (DALY) between 1990 and 2017. Over the last decade, significant advancements in the management of both HFrEF and AF have emerged. However, managing HFrEF/AF remains a clinical challenge for physicians, compounded by the suboptimal efficacy of guideline-mandated pharmacotherapy in this group of patients. There may be an essential role for racial differences and genetic influence on therapeutic outcomes of HFrEF/AF patients, further complicating our overall understanding of the disease and its pathophysiology. In SSA, the lack of accurate and up-to-date epidemiological data on this subgroup of patients presents a challenge in our quest to prevent and reduce adverse outcomes. This narrative review provides a contemporary overview of the epidemiology of HFrEF/AF in SSA. We highlight important differences in the demographic and aetiological profile and the management of this subpopulation, emphasizing what is currently known and, more importantly, what is still unknown about HFrEF/AF in SSA.
Collapse
Affiliation(s)
- Nonkanyiso Mboweni
- School of Physiology, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, Division of Cardiology, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Gauteng, Johannesburg, South Africa
| | - Muzi Maseko
- School of Physiology, University of the Witwatersrand, Johannesburg, South Africa
| | - Nqoba Tsabedze
- Department of Internal Medicine, Division of Cardiology, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Gauteng, Johannesburg, South Africa
| |
Collapse
|
6
|
Desta TT, Gezachew A, Eshetu K. Descriptive Analysis of Rheumatic Heart Disease Related Complications in Pediatric Patients at Tertiary Hospital, Addis Ababa, Ethiopia. Pediatric Health Med Ther 2023; 14:45-57. [PMID: 36817760 PMCID: PMC9930578 DOI: 10.2147/phmt.s396854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/31/2023] [Indexed: 02/13/2023] Open
Abstract
Introduction Rheumatic heart disease continues to be a public health problem worldwide. In developing countries such as Ethiopia where rheumatic heart disease is endemic, most of the patients present with complaints related to complications including heart failure, arrhythmias, pulmonary hypertension, stroke, systemic embolic events and infective endocarditis. Objective To identify the types and magnitude of complications in pediatric patients with rheumatic heart disease. Methodology Hospital-based cross-sectional study was conducted at Saint Paul Hospital Millennium Medical College, pediatric and child health department. All pediatric cardiac patients with rheumatic heart disease seen from January 1, 2018 to December 30, 2021 were included in the study. Conclusion The majority of patients presented to our health facility with complications which implies the need for action at the community level to detect the disease at early stage. Recommendations We recommend a similar large-scale study to be conducted at the national level and introduce a national RHD registry to better understand the magnitude of the problem, based on which necessary action will be undertaken. There is also a need to assess the proper implementation of screening and preventive RHD programmes.
Collapse
Affiliation(s)
- Temesgen Tsega Desta
- Department of Pediatrics and Child Health, Saint Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia,Correspondence: Temesgen Tsega Desta, Email
| | - Alem Gezachew
- Department of Pediatrics and Child Health, Saint Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Konjit Eshetu
- Department of Pediatrics and Child Health, Haramaya University College of Health and Medical Sciences, Harar, Ethiopia
| |
Collapse
|
7
|
Mapelli M, Zagni P, Calbi V, Fusini L, Twalib A, Ferrara R, Mattavelli I, Alberghina L, Salvioni E, Opira C, Kansiime J, Tamborini G, Pepi M, Agostoni P. Echocardiographic Screening for Rheumatic Heart Disease in a Ugandan Orphanage: Feasibility and Outcomes. CHILDREN 2022; 9:children9101451. [PMID: 36291389 PMCID: PMC9600298 DOI: 10.3390/children9101451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/10/2022] [Accepted: 09/19/2022] [Indexed: 11/16/2022]
Abstract
Background: Rheumatic heart disease (RHD) is a major cause of cardiovascular disease in developing nations, leading to more than 230,000 deaths annually. Most patients seek medical care only when long-term structural and hemodynamic complications have already occurred. Echocardiographic screenings ensure the early detection of asymptomatic subjects who could benefit from prophylaxis, monitoring and intervention, when appropriate. The aim of this study is to assess the feasibility of a screening program and the prevalence of RHD in a Ugandan orphanage. Methods: We performed an RHD-focused echocardiogram on all the children (5–14 years old) living in a north Ugandan orphanage. Exams were performed with a portable machine (GE Vivid-I). All the time intervals were recorded (minutes). Results: A total of 163 asymptomatic children were screened over 8 days (medium age 9.1; 46% male; 17% affected by severe motor impairment). The feasibility rate was 99.4%. An average of 20.4 exams were performed per day, with an average of 15.5 images collected per subject. Pathological mitral regurgitation (MR) was found in 5.5% of subjects, while at least two morphological features of RHD were found in 4.3%, leading to 1 “definite RHD” (0.6%) case and 13 “borderline RHD” cases (8.1%). Six congenital heart defects were also noted (3.7%): four atrial septal defects, one coronary artery fistula and one Patent Ductus Arteriosus. Conclusions: We demonstrated the feasibility of an echocardiographic screening for RHD in an orphanage in Uganda. A few factors, such as good clinical and hygienic care, the availability of antibiotics and closeness to a big hospital, may account for the low prevalence of the disease in our population.
Collapse
Affiliation(s)
- Massimo Mapelli
- Centro Cardiologico Monzino, IRCCs, Via Parea 4, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, 20122 Milan, Italy
- Correspondence: ; Tel.: +39-0258002930; Fax: +39-0258002266
| | - Paola Zagni
- Terapia Intensiva Neonatale, Ospedale Fatebenefratelli P.O. Macedonio Melloni, Via Macedonio Melloni 52, 20129 Milan, Italy
| | - Valeria Calbi
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132 Milan, Italy
- Pediatric Immunohematology Unit and BMT Program, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132 Milan, Italy
| | - Laura Fusini
- Centro Cardiologico Monzino, IRCCs, Via Parea 4, 20138 Milan, Italy
| | - Aliku Twalib
- Division of Paediatric Cardiology Uganda Heart Institute, Mulago Hospital and Complex, Kampala P.O. Box 37392, Uganda
| | - Roberto Ferrara
- Molecular Immunology Unit, Medical Oncology Department—Department of Research, Fondazione IRCCS Istituto Nazionale dei Tumori, 20132 Milan, Italy
| | - Irene Mattavelli
- Centro Cardiologico Monzino, IRCCs, Via Parea 4, 20138 Milan, Italy
| | - Laura Alberghina
- Department of Neurorehabilitation Sciences, Istituto Auxologico Italiano, IRCCS, 20132 Milan, Italy
- Hospital Lacor, Gulu P.O. Box 180, Uganda
| | | | | | | | - Gloria Tamborini
- Centro Cardiologico Monzino, IRCCs, Via Parea 4, 20138 Milan, Italy
| | - Mauro Pepi
- Centro Cardiologico Monzino, IRCCs, Via Parea 4, 20138 Milan, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCs, Via Parea 4, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, 20122 Milan, Italy
| |
Collapse
|
8
|
Scheel A, Miller KM, Beaton A, Katzenellenbogen J, Parks T, Cherian T, Van Beneden CA, Cannon JW, Moore HC, Bowen AC, Carapetis JR. Standardization of Epidemiological Surveillance of Rheumatic Heart Disease. Open Forum Infect Dis 2022; 9:S50-S56. [PMID: 36128407 PMCID: PMC9474940 DOI: 10.1093/ofid/ofac250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Rheumatic heart disease (RHD) is a long-term sequela of acute rheumatic fever (ARF), which classically begins after an untreated or undertreated infection caused by Streptococcus pyogenes (Strep A). RHD develops after the heart valves are permanently damaged due to ARF. RHD remains a leading cause of morbidity and mortality in young adults in resource-limited and low- and middle-income countries. This article presents case definitions for latent, suspected, and clinical RHD for persons with and without a history of ARF, and details case classifications, including differentiating between definite or borderline according to the 2012 World Heart Federation echocardiographic diagnostic criteria. This article also covers considerations specific to RHD surveillance methodology, including discussions on echocardiographic screening, where and how to conduct active or passive surveillance (eg, early childhood centers/schools, households, primary healthcare), participant eligibility, and the surveillance population. Additional considerations for RHD surveillance, including implications for secondary prophylaxis and follow-up, RHD registers, community engagement, and the negative impact of surveillance, are addressed. Finally, the core elements of case report forms for RHD, monitoring and audit requirements, quality control and assurance, and the ethics of conducting surveillance are discussed.
Collapse
Affiliation(s)
- Amy Scheel
- Emory University School of Medicine , Atlanta, Georgia , USA
| | - Kate M Miller
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, University of Western Australia , Nedlands, Western Australia , Australia
- Perth Children’s Hospital , Nedlands, Western Australia , Australia
| | - Andrea Beaton
- The Heart Institute, Cincinnati Children’s Hospital Medical Center , Cincinnati, Ohio , USA
- Department of Pediatrics, University of Cincinnati College of Medicine , Cincinnati, Ohio , USA
| | - Judith Katzenellenbogen
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, University of Western Australia , Nedlands, Western Australia , Australia
- School of Population and Global Health, University of Western Australia , Nedlands, Western Australia , Australia
| | - Tom Parks
- Department of Infectious Disease, Imperial College London, Hammersmith Hospital , London , United Kingdom
| | | | - Chris A Van Beneden
- CDC Foundation, Centers for Disease Control and Prevention , Atlanta, Georgia , USA
| | - Jeffrey W Cannon
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, University of Western Australia , Nedlands, Western Australia , Australia
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health , Boston, Massachusetts , USA
| | - Hannah C Moore
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, University of Western Australia , Nedlands, Western Australia , Australia
| | - Asha C Bowen
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, University of Western Australia , Nedlands, Western Australia , Australia
- Perth Children’s Hospital , Nedlands, Western Australia , Australia
| | - Jonathan R Carapetis
- Wesfarmers Centre of Vaccines and Telethon Kids Institute, University of Western Australia , Nedlands, Western Australia , Australia
- Perth Children’s Hospital , Nedlands, Western Australia , Australia
| | | |
Collapse
|
9
|
Salie MT, Yang J, Ramírez Medina CR, Zühlke LJ, Chishala C, Ntsekhe M, Gitura B, Ogendo S, Okello E, Lwabi P, Musuku J, Mtaja A, Hugo-Hamman C, El-Sayed A, Damasceno A, Mocumbi A, Bode-Thomas F, Yilgwan C, Amusa GA, Nkereuwem E, Shaboodien G, Da Silva R, Lee DCH, Frain S, Geifman N, Whetton AD, Keavney B, Engel ME. Data-independent acquisition mass spectrometry in severe rheumatic heart disease (RHD) identifies a proteomic signature showing ongoing inflammation and effectively classifying RHD cases. Clin Proteomics 2022; 19:7. [PMID: 35317720 PMCID: PMC8939134 DOI: 10.1186/s12014-022-09345-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 02/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rheumatic heart disease (RHD) remains a major source of morbidity and mortality in developing countries. A deeper insight into the pathogenetic mechanisms underlying RHD could provide opportunities for drug repurposing, guide recommendations for secondary penicillin prophylaxis, and/or inform development of near-patient diagnostics. METHODS We performed quantitative proteomics using Sequential Windowed Acquisition of All Theoretical Fragment Ion Mass Spectrometry (SWATH-MS) to screen protein expression in 215 African patients with severe RHD, and 230 controls. We applied a machine learning (ML) approach to feature selection among the 366 proteins quantifiable in at least 40% of samples, using the Boruta wrapper algorithm. The case-control differences and contribution to Area Under the Receiver Operating Curve (AUC) for each of the 56 proteins identified by the Boruta algorithm were calculated by Logistic Regression adjusted for age, sex and BMI. Biological pathways and functions enriched for proteins were identified using ClueGo pathway analyses. RESULTS Adiponectin, complement component C7 and fibulin-1, a component of heart valve matrix, were significantly higher in cases when compared with controls. Ficolin-3, a protein with calcium-independent lectin activity that activates the complement pathway, was lower in cases than controls. The top six biomarkers from the Boruta analyses conferred an AUC of 0.90 indicating excellent discriminatory capacity between RHD cases and controls. CONCLUSIONS These results support the presence of an ongoing inflammatory response in RHD, at a time when severe valve disease has developed, and distant from previous episodes of acute rheumatic fever. This biomarker signature could have potential utility in recognizing different degrees of ongoing inflammation in RHD patients, which may, in turn, be related to prognostic severity.
Collapse
Affiliation(s)
- M Taariq Salie
- AFROStrep Research Group, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jing Yang
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Carlos R Ramírez Medina
- Division of Informatics, Imaging, and Data Sciences, University of Manchester, Manchester , UK
| | - Liesl J Zühlke
- Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Chishala Chishala
- Division of Cardiology, University of Cape Town & Groote Schuur Hospital, Cape Town, South Africa
| | - Mpiko Ntsekhe
- Division of Cardiology, University of Cape Town & Groote Schuur Hospital, Cape Town, South Africa
| | - Bernard Gitura
- Cardiology Department of Medicine, Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Stephen Ogendo
- Department of Surgery, University of Nairobi, Nairobi, Kenya
| | - Emmy Okello
- Departments of Adult and Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Peter Lwabi
- Departments of Adult and Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - John Musuku
- University Teaching Hospital-Children's Hospital, University of Zambia, Lusaka, Zambia
| | - Agnes Mtaja
- University Teaching Hospital-Children's Hospital, University of Zambia, Lusaka, Zambia
| | - Christopher Hugo-Hamman
- Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
- Rheumatic Heart Disease Clinic, Windhoek Central Hospital, Windhoek, Namibia
| | - Ahmed El-Sayed
- Department of Cardiothoracic Surgery, Alshaab Teaching Hospital, Alazhari Health Research Center, Alzaiem Alazhari University, Khartoum, Sudan
| | - Albertino Damasceno
- Faculty of Medicine, Eduardo Mondlane University/Nucleo de Investigaçao, Departamento de Medicina, Hospital Central de Maputo, Maputo, Mozambique
| | - Ana Mocumbi
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
- Division of Non Communicable Diseases, Instituto Nacional de Saude, Vila de Marracuene, Mozambique
| | - Fidelia Bode-Thomas
- Departments of Paediatrics, Jos University Teaching Hospital, Jos, Plateau State, Nigeria
| | - Christopher Yilgwan
- Departments of Paediatrics, Jos University Teaching Hospital, Jos, Plateau State, Nigeria
| | - Ganiyu A Amusa
- Department of Medicine, University of Jos and Jos University Teaching Hospital, Jos, Nigeria
| | - Esin Nkereuwem
- Departments of Paediatrics, Jos University Teaching Hospital, Jos, Plateau State, Nigeria
| | - Gasnat Shaboodien
- Department of Medicine and Cape Heart Institute (CHI), University of Cape Town, Cape Town, South Africa
| | - Rachael Da Silva
- Stoller Biomarker Discovery Institute, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Dave Chi Hoo Lee
- Stoller Biomarker Discovery Institute, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Simon Frain
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Nophar Geifman
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Anthony D Whetton
- Faculty of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Bernard Keavney
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Manchester Heart Institute, Manchester University NHS Foundation Trust, Manchester, UK
| | - Mark E Engel
- AFROStrep Research Group, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| |
Collapse
|
10
|
Ndagire E, Ollberding N, Sarnacki R, Meghna M, Pulle J, Atala J, Agaba C, Kansiime R, Bowen A, Longenecker CT, Oyella L, Rwebembera J, Okello E, Parks T, Zang H, Carapetis J, Sable C, Beaton AZ. Modelling study of the ability to diagnose acute rheumatic fever at different levels of the Ugandan healthcare system. BMJ Open 2022; 12:e050478. [PMID: 35318227 PMCID: PMC8943770 DOI: 10.1136/bmjopen-2021-050478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 01/28/2022] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine the ability to accurately diagnose acute rheumatic fever (ARF) given the resources available at three levels of the Ugandan healthcare system. METHODS Using data obtained from a large epidemiological database on ARF conducted in three districts of Uganda, we selected variables that might positively or negatively predict rheumatic fever based on diagnostic capacity at three levels/tiers of the Ugandan healthcare system. Variables were put into three statistical models that were built sequentially. Multiple logistic regression was used to estimate ORs and 95% CI of predictors of ARF. Performance of the models was determined using Akaike information criterion, adjusted R2, concordance C statistic, Brier score and adequacy index. RESULTS A model with clinical predictor variables available at a lower-level health centre (tier 1) predicted ARF with an optimism corrected area under the curve (AUC) (c-statistic) of 0.69. Adding tests available at the district level (tier 2, ECG, complete blood count and malaria testing) increased the AUC to 0.76. A model that additionally included diagnostic tests available at the national referral hospital (tier 3, echocardiography, anti-streptolysin O titres, erythrocyte sedimentation rate/C-reactive protein) had the best performance with an AUC of 0.91. CONCLUSIONS Reducing the burden of rheumatic heart disease in low and middle-income countries requires overcoming challenges of ARF diagnosis. Ensuring that possible cases can be evaluated using electrocardiography and relatively simple blood tests will improve diagnostic accuracy somewhat, but access to echocardiography and tests to confirm recent streptococcal infection will have the greatest impact.
Collapse
Affiliation(s)
- Emma Ndagire
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Nicholas Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rachel Sarnacki
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Murali Meghna
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Jafesi Pulle
- Department of RHD Research, Uganda Heart Institute, Kampala, Uganda
| | - Jenifer Atala
- Department of RHD Research, Uganda Heart Institute, Kampala, Uganda
| | - Collins Agaba
- Department of RHD Research, Uganda Heart Institute, Kampala, Uganda
| | | | - Asha Bowen
- Telethon Kids Institute, Perth, Western Australia, Australia
| | | | - Linda Oyella
- Department of RHD Research, Uganda Heart Institute, Kampala, Uganda
| | | | - Emmy Okello
- Division of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Tom Parks
- London School of Hygiene & Tropical Medicine, London, UK
| | - Huaiyu Zang
- Division of Cardiology, The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | | | - Craig Sable
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Andrea Z Beaton
- Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Cardiology, The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| |
Collapse
|
11
|
Rwebembera J, Nascimento BR, Minja NW, de Loizaga S, Aliku T, dos Santos LPA, Galdino BF, Corte LS, Silva VR, Chang AY, Dutra WO, Nunes MCP, Beaton AZ. Recent Advances in the Rheumatic Fever and Rheumatic Heart Disease Continuum. Pathogens 2022; 11:pathogens11020179. [PMID: 35215123 PMCID: PMC8878614 DOI: 10.3390/pathogens11020179] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 12/13/2022] Open
Abstract
Nearly a century after rheumatic fever (RF) and rheumatic heart disease (RHD) was eradicated from the developed world, the disease remains endemic in many low- and middle-income countries (LMICs), with grim health and socioeconomic impacts. The neglect of RHD which persisted for a semi-centennial was further driven by competing infectious diseases, particularly the human immunodeficiency virus (HIV) pandemic. However, over the last two-decades, slowly at first but with building momentum, there has been a resurgence of interest in RF/RHD. In this narrative review, we present the advances that have been made in the RF/RHD continuum over the past two decades since the re-awakening of interest, with a more concise focus on the last decade’s achievements. Such primary advances include understanding the genetic predisposition to RHD, group A Streptococcus (GAS) vaccine development, and improved diagnostic strategies for GAS pharyngitis. Echocardiographic screening for RHD has been a major advance which has unearthed the prevailing high burden of RHD and the recent demonstration of benefit of secondary antibiotic prophylaxis on halting progression of latent RHD is a major step forward. Multiple befitting advances in tertiary management of RHD have also been realized. Finally, we summarize the research gaps and provide illumination on profitable future directions towards global eradication of RHD.
Collapse
Affiliation(s)
- Joselyn Rwebembera
- Department of Adult Cardiology (JR), Uganda Heart Institute, Kampala 37392, Uganda
- Correspondence: or ; Tel.: +256-779010527
| | - Bruno Ramos Nascimento
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
- Servico de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaude, Hospital das Clinicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena 110, 1st Floor, Belo Horizonte 30130-100, MG, Brazil
| | - Neema W. Minja
- Rheumatic Heart Disease Research Collaborative in Uganda, Uganda Heart Institute, Kampala 37392, Uganda;
| | - Sarah de Loizaga
- School of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA; (S.d.L.); (A.Z.B.)
| | - Twalib Aliku
- Department of Paediatric Cardiology (TA), Uganda Heart Institute, Kampala 37392, Uganda;
| | - Luiza Pereira Afonso dos Santos
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Bruno Fernandes Galdino
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Luiza Silame Corte
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Vicente Rezende Silva
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Andrew Young Chang
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Walderez Ornelas Dutra
- Laboratory of Cell-Cell Interactions, Institute of Biological Sciences, Department of Morphology, Federal University of Minas Gerais, Belo Horizonte 30130-100, MG, Brazil;
- National Institute of Science and Technology in Tropical Diseases (INCT-DT), Salvador 40170-970, BA, Brazil
| | - Maria Carmo Pereira Nunes
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
- Servico de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaude, Hospital das Clinicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena 110, 1st Floor, Belo Horizonte 30130-100, MG, Brazil
| | - Andrea Zawacki Beaton
- School of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA; (S.d.L.); (A.Z.B.)
- Cincinnati Children’s Hospital Medical Center, The Heart Institute, Cincinnati, OH 45229, USA
| |
Collapse
|
12
|
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.
Collapse
|
13
|
EVALUATION OF THE FUNCTIONAL STATE AND FEATURES OF LEFT VENTRICULAR REMODELING IN PATIENTS WITH ACUTE RHEUMATIC FEVER. WORLD OF MEDICINE AND BIOLOGY 2022. [DOI: 10.26724/2079-8334-2022-4-82-166-170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
14
|
Hearn J, Wali S, Birungi P, Cafazzo JA, Ssinabulya I, Akiteng AR, Ross HJ, Seto E, Schwartz JI. A digital self-care intervention for Ugandan patients with heart failure and their clinicians: User-centred design and usability study. Digit Health 2022; 8:20552076221129064. [PMID: 36185389 PMCID: PMC9520172 DOI: 10.1177/20552076221129064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background The prevalence of heart failure (HF) is increasing in Uganda. Ugandan patients with HF report receiving limited information about their illness and associated self-care behaviours. Interventions targeted at improving HF self-care have been shown to improve patient quality of life and reduce hospitalizations in high-income countries. However, such interventions remain underutilized in resource-limited settings like Uganda. This study aimed to develop a digital health intervention that enables improved self-care amongst HF patients in Uganda. Methods We implemented a user-centred design (UCD) process to develop a self-care intervention entitled Medly Uganda. The ideation phase comprised a scoping review and preliminary data collection amongst HF patients and clinicians in Uganda. An iterative design process was then used to advance an initial prototype into a functional digital health intervention. The evaluation phase involved usability testing of the intervention amongst Ugandan patients with HF and their clinicians. Results Medly Uganda is a digital health intervention that allows patients to report daily HF symptoms, receive tailored treatment advice and connect with a clinician when showing signs of decompensation. The system harnesses Unstructured Supplementary Service Data (USSD) technology that is already widely used in Uganda for mobile phone-based financial transactions. Usability testing showed Medly Uganda to be both acceptable and feasible amongst clinicians, patients and caregivers. Conclusions Medly Uganda is a functional digital health intervention with demonstrated acceptability and feasibility in enabling Ugandan HF patients to better care for themselves. We are hopeful that the system will improve self-care efficacy amongst HF patients in Uganda.
Collapse
Affiliation(s)
- Jason Hearn
- Institute of Biomedical Engineering, University of Toronto, Toronto, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, Canada
| | - Sahr Wali
- Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Patience Birungi
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Joseph A Cafazzo
- Institute of Biomedical Engineering, University of Toronto, Toronto, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Isaac Ssinabulya
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda.,Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | - Ann R Akiteng
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | - Heather J Ross
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Emily Seto
- Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Jeremy I Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda.,Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
15
|
Tadele H, Ahmed H, Mintesnot H, Gedlu E, Guteta S, Yadeta D. Subjective wellbeing among rheumatic heart disease patients at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia: observational cross-sectional study. BMC Health Serv Res 2021; 21:1354. [PMID: 34923975 PMCID: PMC8684619 DOI: 10.1186/s12913-021-07378-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background Subjective wellbeing (SWB) is a self-reported positive life judgment and good feeling. RHD, rheumatic heart disease, is a long-term sequel of single or recurrent acute rheumatic fever. There are no studies that assessed SWB in RHD patients. We aimed to assess SWB among RHD subjects enrolled in chronic care at Tikur Anbessa Specialized Hospital (TASH), Ethiopia. Methods This observational cross-sectional study employed a validated Amharic WHO-5 wellbeing index to assess SWB. Sociodemographic and clinical data were collected using structured questionnaire. RHD subjects aged 9 years and above were included. Factors associated with SWB were assessed using logistic regression models. Results The study included 384 subjects, females 68.2% (262). Children, < 18 years, constituted one third of study subjects, 32.8% (126). Moderate and severe echocardiographic RHD dominated, 85.9% (330) with no associated comorbidity, 84.4% (324). Only 17.2% (66) had surgical or device intervention. Poor SWB was documented in 9.6% of study subjects (95% CI: 6.88–13.04). On multivariable regression, those with younger age RHD diagnosis, < 20 years, had almost three times higher odds of poor SWB, adjusted odds ratio (aOR) 2.69(95% CI: 1.30–5.58, P 0.008). Those with monthly family income of < 1000 Ethiopian Birr had three times higher odds of poor SWB, aOR 2.97(95% CI: 1.24–7.1, P 0.014). Study subjects who had good medication adherence had reduced odds of poor SWB, aOR 0.37(95% CI: 0.18–0.77, P 0.028). Those who received psychologic support from their families also had reduced odds of poor SWB, aOR 0.26(95% CI: 0.11–0.64, P 0.003). Conclusion Poor SWB was documented in one-tenth of RHD patients. Family income, younger age at RHD diagnosis, medication adherence and psychological support predicted poor SWB. Poor SWB has to be considered and assessed among RHD patients particularly among those with younger age at RHD diagnosis and poor family income. Further mixed studies are recommended to assess how medication adherence and psychological supports associate with positive SWB among RHD patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07378-0.
Collapse
Affiliation(s)
- Henok Tadele
- Department of Pediatrics and Child Health, Cardiology Division, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Hayat Ahmed
- Department of Pediatrics and Child Health, Cardiology Division, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Helen Mintesnot
- Department of Pediatrics and Child Health, Cardiology Division, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Etsegenet Gedlu
- Department of Pediatrics and Child Health, Cardiology Division, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Senbeta Guteta
- Department of Internal Medicine, Cardiology Division, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Dejuma Yadeta
- Department of Internal Medicine, Cardiology Division, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| |
Collapse
|
16
|
Rheumatic heart disease in The Gambia: clinical and valvular aspects at presentation and evolution under penicillin prophylaxis. BMC Cardiovasc Disord 2021; 21:503. [PMID: 34663206 PMCID: PMC8525010 DOI: 10.1186/s12872-021-02308-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 09/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rheumatic heart disease (RHD) remains the leading cause of cardiac-related deaths and disability in children and young adults worldwide. In The Gambia, the RHD burden is thought to be high although no data are available and no control programme is yet implemented. We conducted a pilot study to generate baseline data on the clinical and valvular characteristics of RHD patients at first presentation, adherence to penicillin prophylaxis and the evolution of lesions over time. METHODS All patients registered with acute rheumatic fever (ARF) or RHD at two Gambian referral hospitals were invited for a clinical review that included echocardiography. In addition, patients were interviewed about potential risk factors, disease history, and treatment adherence. All clinical and echocardiography information at first presentation and during follow-up was retrieved from medical records. RESULTS Among 255 registered RHD patients, 35 had died, 127 were examined, and 111 confirmed RHD patients were enrolled, 64% of them females. The case fatality rate in 2017 was estimated at 19.6%. At first presentation, median age was 13 years (IQR [9; 18]), 57% patients had late stage heart failure, and 84.1% a pathological heart murmur. Although 53.2% of them reported history of recurrent sore throat, only 32.2% of them had sought medical treatment. A history suggestive of ARF was reported by 48.7% patients out of whom only 15.8% were adequately treated. Two third of the patients (65.5%) to whom it was prescribed were fully adherent to penicillin prophylaxis. Progressive worsening and repeated hospitalisation was experienced by 46.8% of the patients. 17 patients had cardiac surgery, but they represented only 18.1% of the 94 patients estimated eligible for cardiac surgery. CONCLUSION This study highlights for the first time in The Gambia the devastating consequences of RHD on the health of adolescents and young adults. Our findings suggest a high burden of disease that remains largely undetected and without appropriate secondary prophylaxis. There is a need for the urgent implementation of an effective national RHD control programto decrease the unacceptably high mortality rate, improve case detection and management, and increase community awareness of this disease.
Collapse
|
17
|
Asmare MH, Filtjens B, Woldehanna F, Janssens L, Vanrumste B. Rheumatic Heart Disease Screening Based on Phonocardiogram. SENSORS (BASEL, SWITZERLAND) 2021; 21:6558. [PMID: 34640876 PMCID: PMC8512197 DOI: 10.3390/s21196558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/24/2021] [Accepted: 09/26/2021] [Indexed: 01/31/2023]
Abstract
Rheumatic heart disease (RHD) is one of the most common causes of cardiovascular complications in developing countries. It is a heart valve disease that typically affects children. Impaired heart valves stop functioning properly, resulting in a turbulent blood flow within the heart known as a murmur. This murmur can be detected by cardiac auscultation. However, the specificity and sensitivity of manual auscultation were reported to be low. The other alternative is echocardiography, which is costly and requires a highly qualified physician. Given the disease's current high prevalence rate (the latest reported rate in the study area (Ethiopia) was 5.65%), there is a pressing need for early detection of the disease through mass screening programs. This paper proposes an automated RHD screening approach using machine learning that can be used by non-medically trained persons outside of a clinical setting. Heart sound data was collected from 124 persons with RHD (PwRHD) and 46 healthy controls (HC) in Ethiopia with an additional 81 HC records from an open-access dataset. Thirty-one distinct features were extracted to correctly represent RHD. A support vector machine (SVM) classifier was evaluated using two nested cross-validation approaches to quantitatively assess the generalization of the system to previously unseen subjects. For regular nested 10-fold cross-validation, an f1-score of 96.0 ± 0.9%, recall 95.8 ± 1.5%, precision 96.2 ± 0.6% and a specificity of 96.0 ± 0.6% were achieved. In the imbalanced nested cross-validation at a prevalence rate of 5%, it achieved an f1-score of 72.2 ± 0.8%, recall 92.3 ± 0.4%, precision 59.2 ± 3.6%, and a specificity of 94.8 ± 0.6%. In screening tasks where the prevalence of the disease is small, recall is more important than precision. The findings are encouraging, and the proposed screening tool can be inexpensive, easy to deploy, and has an excellent detection rate. As a result, it has the potential for mass screening and early detection of RHD in developing countries.
Collapse
Affiliation(s)
- Melkamu Hunegnaw Asmare
- eMedia Research Lab/STADIUS, Department of Electrical Engineering (ESAT), KU Leuven, Andreas Vesaliusstraat 13, 3000 Leuven, Belgium; (B.F.); (L.J.); (B.V.)
- Center of Biomedical Engineering, Addis Ababa Institute of Technology, Addis Ababa University, Addis Ababa P.O. Box 385, Ethiopia;
| | - Benjamin Filtjens
- eMedia Research Lab/STADIUS, Department of Electrical Engineering (ESAT), KU Leuven, Andreas Vesaliusstraat 13, 3000 Leuven, Belgium; (B.F.); (L.J.); (B.V.)
- Intelligent Mobile Platforms Research Group, Department of Mechanical Engineering, KU Leuven, Andreas Vesaliusstraat 13, 3000 Leuven, Belgium
| | - Frehiwot Woldehanna
- Center of Biomedical Engineering, Addis Ababa Institute of Technology, Addis Ababa University, Addis Ababa P.O. Box 385, Ethiopia;
| | - Luc Janssens
- eMedia Research Lab/STADIUS, Department of Electrical Engineering (ESAT), KU Leuven, Andreas Vesaliusstraat 13, 3000 Leuven, Belgium; (B.F.); (L.J.); (B.V.)
| | - Bart Vanrumste
- eMedia Research Lab/STADIUS, Department of Electrical Engineering (ESAT), KU Leuven, Andreas Vesaliusstraat 13, 3000 Leuven, Belgium; (B.F.); (L.J.); (B.V.)
| |
Collapse
|
18
|
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] [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.
Collapse
|
19
|
Martins JFBS, Nascimento ER, Nascimento BR, Sable CA, Beaton AZ, Ribeiro AL, Meira W, Pappa GL. Towards automatic diagnosis of rheumatic heart disease on echocardiographic exams through video-based deep learning. J Am Med Inform Assoc 2021; 28:1834-1842. [PMID: 34279636 DOI: 10.1093/jamia/ocab061] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/09/2021] [Accepted: 03/19/2021] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE Rheumatic heart disease (RHD) affects an estimated 39 million people worldwide and is the most common acquired heart disease in children and young adults. Echocardiograms are the gold standard for diagnosis of RHD, but there is a shortage of skilled experts to allow widespread screenings for early detection and prevention of the disease progress. We propose an automated RHD diagnosis system that can help bridge this gap. MATERIALS AND METHODS Experiments were conducted on a dataset with 11 646 echocardiography videos from 912 exams, obtained during screenings in underdeveloped areas of Brazil and Uganda. We address the challenges of RHD identification with a 3D convolutional neural network (C3D), comparing its performance with a 2D convolutional neural network (VGG16) that is commonly used in the echocardiogram literature. We also propose a supervised aggregation technique to combine video predictions into a single exam diagnosis. RESULTS The proposed approach obtained an accuracy of 72.77% for exam diagnosis. The results for the C3D were significantly better than the ones obtained by the VGG16 network for videos, showing the importance of considering the temporal information during the diagnostic. The proposed aggregation model showed significantly better accuracy than the majority voting strategy and also appears to be capable of capturing underlying biases in the neural network output distribution, balancing them for a more correct diagnosis. CONCLUSION Automatic diagnosis of echo-detected RHD is feasible and, with further research, has the potential to reduce the workload of experts, enabling the implementation of more widespread screening programs worldwide.
Collapse
Affiliation(s)
- João Francisco B S Martins
- Department of Computer Science, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Erickson R Nascimento
- Department of Computer Science, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Bruno R Nascimento
- Department of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Craig A Sable
- Children's National Medical Center, Washington, DC, USA
| | - Andrea Z Beaton
- Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, Ohio, USA
| | - Antônio L Ribeiro
- Department of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Wagner Meira
- Department of Computer Science, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Gisele L Pappa
- Department of Computer Science, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| |
Collapse
|
20
|
Pediatric rheumatic carditis in Italy and Rwanda: The same disease, different socio-economic settings. Int J Cardiol 2021; 338:154-160. [PMID: 34146584 DOI: 10.1016/j.ijcard.2021.06.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/23/2021] [Accepted: 06/14/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Acute Rheumatic Fever and Rheumatic Heart Disease are the leading cause of acquired heart disease in Low-Income Countries, and a common cause in High-Income Countries. We compared rheumatic carditis, its echocardiographic presentation at diagnosis and its progression in Italy and Rwanda. METHODS Retrospective study including all consecutive patients diagnosed with rheumatic carditis in an Italian (IT) and two Rwandan Hospitals (RW). Echocardiography was performed at diagnosis and three follow-up visits. Baseline characteristics, history of primary and secondary prophylaxis and cardiovascular complications data were collected. RESULTS Seventy-nine and 135 patients were enrolled in IT and RW, respectively. Mitral regurgitation was the most common lesion (IT: 70%, RW: 96%) in both cohorts; mixed valve lesions and severe lesions were more prevalent in RW. Age at diagnosis (IT: 8.4 ± 2.9 yrs.; RW: 11.1 ± 2.7 yrs.; P < 0.001), adherence to secondary prophylaxis (IT: 99%; RW: 48%; P < 0.001) and history of primary prophylaxis (IT: 65%; RW: 6%; P < 0.001) were different. During the follow-up, native valve lesions completely resolved in 38% of IT and in 2% of RW patients (P < 0.001). By contrast, cardiac surgery was performed in 31% of RW and 5% of IT patients (P < 0.001). Cardiovascular complications and death were only observed in RW. CONCLUSIONS The more severe cardiac involvement, the higher rate of valve surgery, CV complications and deaths in RW, could be due to delayed diagnosis and treatment, scarce adherence to secondary prophylaxis and differences in social determinants of health.
Collapse
|
21
|
Abstract
Rheumatic heart disease results in significant remodeling of the atria that provides the milieu for maintaining atrial fibrillation. Some electrical remodeling is reversible and hence early intervention may prove useful. Active screening for atrial fibrillation in high-risk subset and instituting anticoagulation may reduce the devastating complications that follow. Age older than 50 years, NYHA functional class II symptoms, left atrial dimension >4.0 cm on echocardiogram in parasternal long-axis view, and gradients across the mitral valve >10 mm Hg are clinical indicators that identify the high-risk subset. Ablation strategy in this population may differ compared with the nonvalvular group.
Collapse
Affiliation(s)
- Bobby John
- James Cook University, Townsville, Australia; Cardiology Unit, Townsville University Hospital, 100 Angus Smith Drive, Douglas, Queensland 4814, Australia; Christian Medical College, Vellore, India.
| | - Chu-Pak Lau
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Suite 1301-3, Central Building, 1 Pedder Street, Central, Hong Kong
| |
Collapse
|
22
|
Ndagire E, Kawakatsu Y, Nalubwama H, Atala J, Sarnacki R, Pulle J, Kyarimpa R, Mwima R, Kansiime R, Okello E, Lwabi P, Beaton A, Sable C, Watkins D. Examining the Ugandan health system's readiness to deliver rheumatic heart disease-related services. PLoS Negl Trop Dis 2021; 15:e0009164. [PMID: 33591974 PMCID: PMC7909659 DOI: 10.1371/journal.pntd.0009164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 02/26/2021] [Accepted: 01/20/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND In 2018, the World Health Assembly mandated Member States to take action on rheumatic heart disease (RHD), which persists in countries with weak health systems. We conducted an assessment of the current state of RHD-related healthcare in Uganda. METHODOLOGY/PRINCIPAL FINDINGS This was a mixed-methods, deductive simultaneous design study conducted in four districts of Uganda. Using census sampling, we surveyed health facilities in each district using an RHD survey instrument that was modeled after the WHO SARA tool. We interviewed health workers with experience managing RHD, purposively sampling to ensure a range of qualification and geographic variation. Our final sample included 402 facilities and 36 health workers. We found major gaps in knowledge of clinical guidelines and availability of diagnostic tests. Antibiotics used in RHD prevention were widely available, but cardiovascular medications were scarce. Higher levels of service readiness were found among facilities in the western region (Mbarara district) and private facilities. Level III health centers were the most prepared for delivering secondary prevention. Health worker interviews revealed that limited awareness of RHD at the district level, lack of diagnostic tests and case management registries, and absence of clearly articulated RHD policies and budget prioritization were the main barriers to providing RHD-related healthcare. CONCLUSIONS/SIGNIFICANCE Uganda's readiness to implement the World Health Assembly RHD Resolution is low. The forthcoming national RHD strategy must focus on decentralizing RHD diagnosis and prevention to the district level, emphasizing specialized training of the primary healthcare workforce and strengthening supply chains of diagnostics and essential medicines.
Collapse
Affiliation(s)
- Emma Ndagire
- Uganda Heart Institute, Kampala, Uganda
- Children’s National Hospital, Division of Cardiology, Washington, District of Columbia, United States of America
| | - Yoshito Kawakatsu
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | | | | | - Rachel Sarnacki
- Children’s National Hospital, Division of Cardiology, Washington, District of Columbia, United States of America
| | | | | | | | | | | | | | - Andrea Beaton
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Craig Sable
- Children’s National Hospital, Division of Cardiology, Washington, District of Columbia, United States of America
- George Washington University School of Medicine, Washington, District of Columbia, United States of America
| | - David Watkins
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Division of General Internal Medicine, University of Washington, Seattle, Washington, United States of America
| |
Collapse
|
23
|
Salie MT, Rampersadh K, Muhamed B, Engel KC, Zühlke LJ, Dale JB, Engel ME. Utility of Human Immune Responses to GAS Antigens as a Diagnostic Indicator for ARF: A Systematic Review. Front Cardiovasc Med 2021; 8:691646. [PMID: 34355030 PMCID: PMC8329041 DOI: 10.3389/fcvm.2021.691646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Previous studies have established that streptococcal antibody titer is correlated with a diagnosis of acute rheumatic fever (ARF). However, results vary in the usefulness of GAS antibodies, particularly anti-streptolysin-O (ASO) and anti-DNase B, in confirming a recent GAS infection. Therefore, we sought to provide, from published studies, an evidence-based synthesis of the correlation of streptococcal serology to establish the usefulness of immunological data in aiding the diagnosis of ARF. These findings are anticipated to have implications where echocardiography is not freely available, especially where ARF is rampant. Methods: We conducted a comprehensive search across a number of databases. Applying a priori criteria, we selected articles reporting on studies, regardless of study design, that evaluate the levels of antibodies against GAS-specific antigens in ARF subjects against control values or a published standard. Data were extracted onto data extraction forms, captured electronically, and analyzed using Stata software. Risk of bias was assessed in included studies using the Newcastle-Ottawa Scale (NOS). Results and Conclusion: The search strategy yielded 534 studies, from which 24 met the inclusion criteria, reporting on evaluation of titers for SLO (n = 10), DNase B (n = 9), anti-streptokinase (ASK) (n = 3) amongst others. Elevation in titers was determined by comparison with controls and upper limit of normal (ULN) antibody values as determined in healthy individuals. Meta-analysis of case-controlled studies revealed moderate odds ratio (OR) correlations between ARF diagnosis and elevated titers for SLO (OR = 10.57; 95% CI, 3.36-33.29; 10 studies) and DNAse B (OR = 6.97; 95% CI, 2.99-16.27; 7 studies). While providing support for incorporating SLO and DNase B in the diagnosis of ARF, we present the following reflections: an elevation in SLO and DNase B levels are not consistently associated with an ARF diagnosis; increasing the number of GAS proteins in the test is warranted to improve sensitivity; paired (acute and convalescent) samples could provide a more accurate indication of a rising titer. Use of community-based controls as a standard is not a reliable marker by which to gauge recent GAS infection.
Collapse
Affiliation(s)
- M Taariq Salie
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kimona Rampersadh
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Babu Muhamed
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Division of Cardiology, Children's National Health System, Washington, DC, United States
| | - Kélin C Engel
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Liesl J Zühlke
- Children's Heart Disease Research Unit, Department of Paediatrics, University of Cape Town, Cape Town, South Africa
| | - James B Dale
- Division of Infectious Diseases, University of Tennessee Health Science Center (UTHSC), Memphis, TN, United States
| | - Mark E Engel
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
24
|
Kumar RK, Antunes MJ, Beaton A, Mirabel M, Nkomo VT, Okello E, Regmi PR, Reményi B, Sliwa-Hähnle K, Zühlke LJ, Sable C. Contemporary Diagnosis and Management of Rheumatic Heart Disease: Implications for Closing the Gap: A Scientific Statement From the American Heart Association. Circulation 2020; 142:e337-e357. [PMID: 33073615 DOI: 10.1161/cir.0000000000000921] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The global burden of rheumatic heart disease continues to be significant although it is largely limited to poor and marginalized populations. In most endemic regions, affected patients present with heart failure. This statement will seek to examine the current state-of-the-art recommendations and to identify gaps in diagnosis and treatment globally that can inform strategies for reducing disease burden. Echocardiography screening based on World Heart Federation echocardiographic criteria holds promise to identify patients earlier, when prophylaxis is more likely to be effective; however, several important questions need to be answered before this can translate into public policy. Population-based registries effectively enable optimal care and secondary penicillin prophylaxis within available resources. Benzathine penicillin injections remain the cornerstone of secondary prevention. Challenges with penicillin procurement and concern with adverse reactions in patients with advanced disease remain important issues. Heart failure management, prevention, early diagnosis and treatment of endocarditis, oral anticoagulation for atrial fibrillation, and prosthetic valves are vital therapeutic adjuncts. Management of health of women with unoperated and operated rheumatic heart disease before, during, and after pregnancy is a significant challenge that requires a multidisciplinary team effort. Patients with isolated mitral stenosis often benefit from percutaneous balloon mitral valvuloplasty. Timely heart valve surgery can mitigate the progression to heart failure, disability, and death. Valve repair is preferable over replacement for rheumatic mitral regurgitation but is not available to the vast majority of patients in endemic regions. This body of work forms a foundation on which a companion document on advocacy for rheumatic heart disease has been developed. Ultimately, the combination of expanded treatment options, research, and advocacy built on existing knowledge and science provides the best opportunity to address the burden of rheumatic heart disease.
Collapse
|
25
|
Bansal A, Sarkar PG, Chaturvedi V. Atrial Fibrillation in Rheumatic Heart Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00845-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
26
|
Okello E, Murali M, Rwebembera J, Atala J, Bowen AC, Harik N, Kaudha G, Kitooleko S, Longenecker C, Ndagire E, Omara IO, Oyella LM, Parks T, Pulle J, Sable C, Sarnacki R, Stein E, Zimmerman M, de Klerk N, Carapetis J, Beaton A. Cross-sectional study of population-specific streptococcal antibody titres in Uganda. Arch Dis Child 2020; 105:825-829. [PMID: 32601082 PMCID: PMC11149943 DOI: 10.1136/archdischild-2020-318859] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/09/2020] [Accepted: 05/30/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Despite substantial variation of streptococcal antibody titres among global populations, there is no data on normal values in sub-Saharan Africa. The objective of this study was to establish normal values for antistreptolysin O (ASO) and antideoxyribonuclease B (ADB) antibodies in Uganda. DESIGN This was an observational cross-sectional study. SETTING This study was conducted at Mulago National Referral Hospital, which is located in the capital city, Kampala, and includes the Uganda Heart Institute. PATIENTS Participants (aged 0-50 years) were recruited. Of 428 participants, 22 were excluded from analysis, and 183 (44.4%) of the remaining were children aged 5-15 years. MAIN OUTCOME MEASURES ASO was measured in-country by nephelometric technique. ADB samples were sent to Australia (PathWest) for analysis by enzyme inhibition assay: 80% upper limit values were established. RESULTS The median ASO titre in this age group was 220 IU/mL, with the 80th percentile value of 389 IU/mL. The median ADB titre in this age group was 375 IU/mL, with the 80th percentile value of 568 IU/mL. CONCLUSIONS The estimated Ugandan paediatric population standardised 80% upper-limit-of-normal ASO and ADB titres is higher than many global populations. Appropriateness of using population-specific antibody cutoffs is yet to be determined and has important implications for the sensitivity and specificity of rheumatic fever diagnosis.
Collapse
Affiliation(s)
| | - Meghna Murali
- Children's National Health System, Washington, District of Columbia, USA
| | | | | | - Asha C Bowen
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
- University of Western Australia, Crawley, Western Australia, Australia
| | - Nada Harik
- Children's National Health System, Washington, District of Columbia, USA
| | | | | | - Chris Longenecker
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | | | | | | | - Tom Parks
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Craig Sable
- Children's National Health System, Washington, District of Columbia, USA
| | - Rachel Sarnacki
- Children's National Health System, Washington, District of Columbia, USA
| | - Elizabeth Stein
- University of Washington School of Medicine, Seattle, Washington, United States
| | - Meghan Zimmerman
- Dartmouth-Hitchcock School of Medicine, Dartmouth, New Hampshire, United States
| | - Nicholas de Klerk
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
| | - Jonathan Carapetis
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
| | - Andrea Beaton
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati School of Medicine, Cincinnati, Ohio, United States
| |
Collapse
|
27
|
Ghamrawy A, Ibrahim NN, Abd El-Wahab EW. How accurate is the diagnosis of rheumatic fever in Egypt? Data from the national rheumatic heart disease prevention and control program (2006-2018). PLoS Negl Trop Dis 2020; 14:e0008558. [PMID: 32804953 PMCID: PMC7451991 DOI: 10.1371/journal.pntd.0008558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 08/27/2020] [Accepted: 07/02/2020] [Indexed: 01/10/2023] Open
Abstract
Rheumatic heart disease (RHD) as a chronic sequela of repeated episodes of acute rheumatic fever (ARF), remains a cause of cardiac morbidity in Egypt although it is given full attention through a national RHD prevention and control program. The present report reviews our experience with subjects presenting with ARF or its sequelae in a single RHD centre and describes the disease pattern over the last decade. A cross-sectional study was conducted in El-Mahalla RHD centre between 2006 and 2018. A total of 17014 individual were enrolled and evaluated. Diagnosis ARF was based on the 2015 revised Jones criteria and RHD was ruled in by echocardiography. The majority of the screened subjects were female (63.2%), in the age group 5-15 years (64.6%), rural residents (61.2%), had primary education (43.0%), and of low socioeconomic standard (50.2%). The total percentage of cases presenting with ARF sequelae was 29.3% [carditis/RHD (10.8%), rheumatic arthritis (Rh.A) (14.9%), and Sydenham's chorea (0.05%)]. Noticeably, 72% were free of any cardiac insult, of which 37.7% were victims of misdiagnoses made elsewhere by untrained practitioners who prescribed for them long term injectable long-acting penicillin [Benzathine Penicillin G (BPG)] without need. About 54% of the study cohort reported the occurrence of recurrent attacks of tonsillitis of which 65.2% underwent tonsillectomy. Among those who experienced tonsillectomy and/or received BPG in the past, 14.5% and 22.3% respectively had eventually developed RHD. Screening of family members of some RHD cases who needed cardiac surgery revealed 20.7% with undiagnosed ARF sequalae [RHD (56.0%) and Rh.A (52.2%)]. Upon the follow-up of RHD cases, 1.2% had improved, 98.4% were stable and 0.4% had their heart condition deteriorated. Misdiagnosis of ARF or its sequelae and poor compliance with BPG use may affect efforts being exerted to curtail the disease. Updating national guidelines, capacity building, and reliance on appropriate investigations should be emphasized. Since the genetic basis of RHD is literally confirmed, a family history of RHD warrants screening of all family members for early detection of the disease.
Collapse
Affiliation(s)
- Alaa Ghamrawy
- Department of Non-Communicable Diseases, Ministry of Health and Population, Cairo, Egypt
| | - Nermeen N. Ibrahim
- Department of Epidemiology, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Ekram W. Abd El-Wahab
- Department of Tropical Health, High Institute of Public Health, Alexandria University, Alexandria, Egypt
- * E-mail:
| |
Collapse
|
28
|
Meta-Analysis of the Incidence, Prevalence, and Correlates of Atrial Fibrillation in Rheumatic Heart Disease. Glob Heart 2020; 15:38. [PMID: 32923332 PMCID: PMC7427678 DOI: 10.5334/gh.807] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective: To estimate the incidence, prevalence, and correlates of atrial fibrillation (AF) in a global population with rheumatic heart disease (RHD). Methods: Bibliographic databases were searched to identify all published studies providing data on AF in patients with RHD. Random-effects meta-analysis method was used to pool estimates. Results: Eighty-three studies were included, reporting data from 75,637 participants with RHD in 42 countries. The global prevalence of AF in RHD was 32.8% (range: 4.3%–79.9%). It was higher in severe valvular disease (30.8% vs 20.7%, p = 0.009), in severe mitral valve disease compared to severe aortic disease (30.4% vs 6.3%, p = 0.038). The global cumulative incidence of AF in patients with RHD was 4.8%, 11.4%, 13.2%, and 30.8% at 1, 2, 5, and 10 years of follow-up, respectively. From comparison between patients with and without AF, AF was associated with increased age (mean difference [MD]: 9.5 years; 95% CI: 7.8–1.3), advanced heart failure (odds ratio [OR]: 4.4; 95% CI 2.1–9.3), tricuspid valve involvement (OR: 4.0; 95% CI: 3.0–5.3), history of thromboembolism (OR: 6.2; 95% CI: 3.4–11.4), highly sensitive C-reactive protein (MD: 5.5 mg/dL; 95% CI: 1.2–9.8), systolic pulmonary arterial pressure (MD: 3.6 mmHg; 95% CI: 0.8–6.3), right atrium pressure (MD: 1.5 mmHg; 95% CI: 1.0–2.0), and left atrium diameter (MD: 8.1 mm; 95% CI: 5.5–10.7). Conclusions: About one-third of patients with RHD have AF, with an incidence which almost triples every five years after diagnosis. Factors associated with AF include age, advanced heart failure, thromboembolism, and few cardiac hemodynamics parameters.
Collapse
|
29
|
Idrees M, Butrous G, Mocumbi A, Sastry B, Ibrahim A, Alobaidallah K, Hassan A, Farghaly AA, Yacoub M. Pulmonary hypertension in the developing world: Local registries, challenges, and ways to move forward. Glob Cardiol Sci Pract 2020; 2020:e202014. [PMID: 33150158 PMCID: PMC7590932 DOI: 10.21542/gcsp.2020.14] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 05/30/2020] [Indexed: 12/11/2022] Open
Abstract
Pulmonary hypertension (PH) is a disease that can only be appropriately managed in the ‘rich’ developed countries, as both diagnostic and therapeutic interventions are extremely expensive and expectations for these to be adopted by the developing, economically-challenged countries are neither practical nor realistic. Furthermore, most of the enormous advances in understanding the pathobiology of PH and the subsequent evidence-based diagnostic and complex treatment algorithms came from the developed world.
Collapse
Affiliation(s)
- Majdy Idrees
- Division of Pulmonary Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | | | - Ana Mocumbi
- Instituto Nacional de Saúde Vila de Marracuene, Maputo, Mozambique
| | | | - Ahmed Ibrahim
- Division of Pulmonary Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Khalid Alobaidallah
- Division of Pulmonary Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ahmed Hassan
- Aswan Heart Center, Aswan, Egypt
- Cardiology Department, Cairo University, Cairo, Egypt
| | | | | |
Collapse
|
30
|
Peters F, Karthikeyan G, Abrams J, Muhwava L, Zühlke L. Rheumatic heart disease: current status of diagnosis and therapy. Cardiovasc Diagn Ther 2020; 10:305-315. [PMID: 32420113 DOI: 10.21037/cdt.2019.10.07] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Rheumatic heart disease (RHD) is the only preventable cardiovascular disease which causes significant morbidity and mortality particularly in low- and middle-income countries. Early clinical diagnosis is key, the updated Jones criteria increases the likelihood of diagnosis in endemic settings, including the echo diagnosis of sub-clinical carditis, polyarthralgia and monoarthritis as well as amended thresholds of minor criteria. The mainstay of rheumatic heart valve disease (RHVD) is a thorough clinical and echocardiographic investigation while severe disease is managed with medical, interventional and surgical treatment. In this report we detail some of the more recent epidemiological findings and focus on the diagnostic and interventional elements of the specific valve lesions. Finally, we discuss some of the recent efforts to improve medical and surgical management for this disease. As we are already more than a year from the historic 2018 World Heart Organization Resolution against Rheumatic Fever and Rheumatic Heart Disease, we advocate strongly for renewed efforts to prioritize this disease across the endemic regions of the world.
Collapse
Affiliation(s)
- Ferande Peters
- Cardiovascular pathophysiology and Genomic Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Ganesan Karthikeyan
- Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Jessica Abrams
- Division of Paediatric Cardiology, Department of Paediatrics, Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Lorrein Muhwava
- Division of Paediatric Cardiology, Department of Paediatrics, Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Liesl Zühlke
- Division of Paediatric Cardiology, Department of Paediatrics, Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa.,Division of Cardiology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
31
|
Ganapathi S, Jeemon P, Krishnasankar R, Kochumoni R, Vineeth P, Mohanan Nair KK, Valaparambil AK, Harikrishnan S. Early and long-term outcomes of decompensated heart failure patients in a tertiary-care centre in India. ESC Heart Fail 2020; 7:467-473. [PMID: 32012491 PMCID: PMC7160472 DOI: 10.1002/ehf2.12600] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 12/28/2022] Open
Abstract
AIM Long-term outcome data of acute decompensated heart failure (HF) are scarce from India. The aim of the study was to collect in-hospital and long-term outcome data of HF patients admitted during 2001-2010 in a tertiary-care centre in South India. METHODS AND RESULTS Consecutive patients admitted with first episode of decompensated HF were part of the registry. Data regarding diagnosis, risk factors, treatment, early (in-hospital), and late (5 and 10year) mortality outcomes were captured. During this period, 1502 patients were admitted with first episode of decompensated HF [37.7% of women, mean age of 51.1 (SD = 14.3) years]. Common causes were ischaemic heart disease (36.2%), rheumatic heart disease (34.3%), and cardiomyopathies (9.9%). HF with reduced ejection fraction (HFrEF) was present in 26.9% of patients, and 33.8% had atrial arrhythmias. Diabetes, hypertension, and renal dysfunction were prevalent in 27.4%, 28.6%, and 37.4%, respectively. Median duration of hospitalization was 6 days (interquartile range: 3-10), and 247 patients (16.4%) died during index admission. The total time at risk was 6248 person years, and 1051 patients died during the study period with a median survival time of 3.7 years. Overall mortality rate was 16.8 per 100 person years (95% CI: 15.8-17.9 per 100 person years). Older age [hazard ratio (HR) = 1.08, 95% CI: 1.02-1.14, P = 0.007], anaemia (HR = 1.34, 95% CI: 1.08-1.65, P = 0.007), renal dysfunction (HR = 1.38, 95% CI: 1.20-1.59, P < 0.001), HFpEF (HR = 0.61, 95% CI: 0.52-0.73, P < 0.001 against HFrEF), and the use of guideline-directed therapies (GDT; beta blockers: HR = 0.57, 95% CI: 0.49-0.66, P < 0.0001; and angiotensin converting enzyme inhibitor/angiotensin receptor blocker: HR = 0.59, 95% CI: 0.51-0.69, P < 0.001) were important predictors of mortality. Patients with HF and mid-range EF also benefited from GDT. CONCLUSION In our cohort, ischaemic and rheumatic heart diseases were the leading contributors for HF. Anaemia, renal dysfunction, poor ejection fraction, and suboptimal prescriptions of GDT were the main predictors of long-term mortality. Both patients with HFrEF and mid-range EF benefited from GDT.
Collapse
Affiliation(s)
- Sanjay Ganapathi
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695011, Kerala, India
| | - Panniyammakal Jeemon
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695011, Kerala, India
| | | | - Rajamoni Kochumoni
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695011, Kerala, India
| | - Purushothaman Vineeth
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695011, Kerala, India
| | | | - Ajit Kumar Valaparambil
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695011, Kerala, India
| | | |
Collapse
|
32
|
Coronary Embolism and Myocardial Infarction: A Scoping Study. AMERICAN JOURNAL OF MEDICAL CASE REPORTS 2020; 8:31-43. [PMID: 32775621 PMCID: PMC7410523 DOI: 10.12691/ajmcr-8-2-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Coronary embolism is a cause of acute myocardial infarction (AMI)in which obstructive foci enter the coronary circulation, block normal blood flow and precipitate ischemia. Precise studies focusing on patient population affected, pathophysiological mechanisms, and treatment strategies are scanty, in spite of a reported prevalence estimated at 2.9%. As the understanding of myocardial infarction without evidence of coronary artery disease continues to grow, an in-depth review of this previously seldomly reported subtype of coronary ischemia was in order. Patients suffering coronary embolism are 15 to 20 years younger than traditional AMI patients with a slight predominance towards male sex, which resembles the gender data of the populations affected by non-traditional myocardial infarction in published reports. While the expected prevalence rate of cardiovascular disease risk factors such as hypertension and hyperlipidemia are present, this population also has a relatively high prevalence of atrial fibrillation and valve pathology, especially endocarditis. Initial presentation is indistinguishable from other causes of myocardial infarction however fever is commonly present, when endocarditis with valvular involvement is the primary cause of the coronary embolism. Mechanical thrombectomy is the mainstay of treatment, followed by percutaneous coronary intervention. Mortality is the highest in patients who do not receive targeted treatment for the coronary embolism, particularly if only antimicrobial agents or anticoagulation without thrombolytic agents are employed. The unique features of coronary embolism highlighted in this historical study justify further examination in contemporary patient populations.
Collapse
|
33
|
Noubiap JJ, Nyaga UF. A review of the epidemiology of atrial fibrillation in sub-Saharan Africa. J Cardiovasc Electrophysiol 2019; 30:3006-3016. [PMID: 31596016 DOI: 10.1111/jce.14222] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/05/2019] [Accepted: 09/09/2019] [Indexed: 01/05/2023]
Abstract
This systematic review summarizes the data on the prevalence, risk factors, complications, and management of atrial fibrillation (AF) in sub-Saharan Africa (SSA). Bibliographic databases were searched from inception to 31 May 2019, to identify all published studies providing data on AF in populations living in SSA. A total of 72 studies were included. The community-based prevalence of AF was 4.3% and 0.7% in individuals aged ≥40 years and aged ≥70 years, respectively. The prevalence of AF ranged between 6.7% and 34.8% in patients with ischemic stroke, between 9.5% and 46.8% in those with rheumatic heart disease (RHD), between 5% and 31.5% in patients with dilated cardiomyopathy. The main risk factors for AF were hypertension, affecting at least one-third of patients with AF, and valvular heart disease (12.3%-44.4%) and cardiomyopathy (~20%). Complications of AF included heart failure in about two thirds and stroke in 10% to 15% of cases. The use of anticoagulation for stroke prevention was suboptimal. Rate control was the most frequent therapeutic strategy, used in approximately 65% to 95% of AF patients, with approximately 80% of them achieving rate control. The management of AF was associated with exorbitant cost. In conclusion, AF seems to have a higher prevalence in the general population than previously thought and is mostly associated with hypertension, cardiomyopathy, and RHD in SSA. It is associated with a high incidence of heart failure and stroke. The management of AF is suboptimal in SSA, especially with a low uptake of oral anticoagulation.
Collapse
Affiliation(s)
- Jean Jacques Noubiap
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Ulrich Flore Nyaga
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, Yaoundé, Cameroon
| |
Collapse
|
34
|
Beaton A, Okello E, Engelman D, Grobler A, Scheel A, DeWyer A, Sarnacki R, Omara IO, Rwebembera J, Sable C, Steer A. Determining the impact of Benzathine penicillin G prophylaxis in children with latent rheumatic heart disease (GOAL trial): Study protocol for a randomized controlled trial. Am Heart J 2019; 215:95-105. [PMID: 31301533 DOI: 10.1016/j.ahj.2019.06.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 06/01/2019] [Indexed: 11/15/2022]
Abstract
Rheumatic heart disease (RHD) remains a high prevalence condition in low- and middle-income countries. Most individuals with RHD present late, missing the opportunity to benefit from secondary antibiotic prophylaxis. Echocardiographic screening can detect latent RHD, but the impact of secondary prophylaxis in screen-detected individuals is not known. METHODS/DESIGN This trial aims to determine if secondary prophylaxis with every-4-week injectable Benzathine penicillin G (BPG) improves outcomes for children diagnosed with latent RHD. This is a randomized controlled trial in consenting children, aged 5 to 17 years in Northern Uganda, confirmed to have borderline RHD or mild definite RHD on echocardiography, according to the 2012 World Heart Federation criteria. Qualifying children will be randomized to every-4-week injectable intramuscular BPG or no medical intervention and followed for a period of 2 years. Ongoing intervention adherence and retention in the trial will be supported through the establishment of peer support groups for participants in the intervention and control arms. A blinded echocardiography adjudication panel consisting of four independent experts will determine the echocardiographic classification at enrollment and trajectory through consensus review. The primary outcome is the proportion of children in the BPG-arm who demonstrate echocardiographic progression of latent RHD compared to those in the control arm. The secondary outcome is the proportion of children in the BPG-arm who demonstrate echocardiographic regression of latent RHD compared to those in the control arm. A sample size of 916 participants will provide 90% power to detect a 50% relative risk reduction assuming a 15% progression in the control group. The planned study duration is from 2018-2021. DISCUSSION Policy decisions on the role of echocardiographic screening for RHD have stalled because of the lack of evidence of the benefit of secondary prophylaxis. The results of our study will immediately inform the standard of care for children diagnosed with latent RHD and will shape, over 2-3 years, practical and scalable programs that could substantially decrease the burden of RHD in our lifetime. TRIAL REGISTRATION ClinicalTrials.gov: NCT03346525. Date Registered: November 17, 2017.
Collapse
Affiliation(s)
- Andrea Beaton
- Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
| | | | - Daniel Engelman
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Anneke Grobler
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Amy Scheel
- Emory School of Medicine, Atlanta, GA, USA
| | - Alyssa DeWyer
- Children's National Medical Center, Washington, DC, USA
| | | | | | | | - Craig Sable
- Children's National Medical Center, Washington, DC, USA
| | - Andrew Steer
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Royal Children's Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
35
|
Jacobs MS, Van Hulst M, Adeoye AM, Tieleman RG, Postma MJ, Owolabi MO. Atrial Fibrillation in Africa—An Under-Reported and Unrecognized Risk
Factor for Stroke: A Systematic Review. Glob Heart 2019; 14:269-279. [DOI: 10.1016/j.gheart.2019.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/17/2019] [Accepted: 04/07/2019] [Indexed: 12/31/2022] Open
|
36
|
Effect of anaemia on the diagnosis of rheumatic heart disease using World Heart Federation criteria. Cardiol Young 2019; 29:862-868. [PMID: 31218969 DOI: 10.1017/s1047951119000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND There is overlap between pathological mitral regurgitation seen in borderline rheumatic heart disease using World Heart Federation echocardiography criteria and physiologic regurgitation found in normal children. One possible contributing factor is higher rates of anaemia in endemic countries. OBJECTIVE To investigate the contribution of anaemia as a potential confounder in the diagnosis of rheumatic heart disease detected in echocardiographic screening. METHOD/DESIGN A novel Server 2012 data warehouse tool was used to incorporate haematology and echocardiography databases. The study included a convenience sample of patients from 5 to 18 years old without structural or functional heart disease that had a haemoglobin value within 1 month prior to an echocardiogram. Echocardiogram images were reviewed to determine presence or absence of World Heart Federation criteria for rheumatic heart disease. The rate of rheumatic heart disease among anaemic and non-anaemic children according to gender- and age-based norms groups was compared. RESULTS Of the 935 patients who met the study inclusion criteria, 406 were classified as anaemic. There was no difference in the rate of echocardiograms meeting criteria for borderline rheumatic heart disease in anaemic (2.0%, 95% CI 0.6-3.3%) and non-anaemic children (1.3%, 95% CI 0.3-2.3%). However, there was a statistically significant increase in rates of mitral regurgitation of unclear significance among anaemic versus non-anaemic patients (8.6 versus 3.6%; p = 0.0012). CONCLUSION Anaemia does not increase the likelihood of meeting echocardiographic criteria for borderline rheumatic heart disease. Future studies should evaluate for the correlation between anaemia and mitral regurgitation in endemic settings.
Collapse
|
37
|
Morberg D, Alzate López Y, Moreira S, Prata N, Riley L, Burroughs Peña M. The rheumatic heart disease healthcare paradox: disease persistence in slums despite universal healthcare coverage—a provider perspective qualitative study. Public Health 2019; 171:15-23. [DOI: 10.1016/j.puhe.2019.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 03/16/2019] [Accepted: 03/20/2019] [Indexed: 01/19/2023]
|
38
|
Sanyahumbi A, Beaton A, Guffey D, Hosseinipour MC, Karlsten M, Minard CG, Penny DJ, Sable CA, Kazembe PN. Two-year evolution of latent rheumatic heart disease in Malawi. CONGENIT HEART DIS 2019; 14:614-618. [PMID: 30706669 DOI: 10.1111/chd.12756] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/03/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND In asymptomatic children, screening echocardiography has been used to attempt to diagnose rheumatic heart disease (RHD) at an early stage (latent RHD). World Heart Federation guidelines have standardized categorization of "definite," "borderline," or no RHD by echo findings. The progression of RHD diagnosed through echo screening is not known. In 2014, we screened 1450 schoolchildren in Malawi. OBJECTIVE Our objective was to evaluate 2-year RHD evolution among those diagnosed through screening. METHODS Two-year follow-up echocardiograms of those diagnosed with latent RHD were read by a primary, secondary, then third reader if there was disagreement. Progression or regression of both definite and borderline groups were tabulated. Penicillin adherence, age, gender, number in home, and household income were compared between those with definite RHD who regressed to borderline and those that stayed definite. We utilized the local system used to track HIV defaulters in order to bring participants back into care. Comparisons were made using Fisher's exact and Wilcoxon rank-sum tests. RESULTS Of the 39 with borderline RHD, 1 was lost to follow-up (2.6%), 1 progressed to definite (2.6%), 19 remained borderline (48.7%), 17 (43.6%) regressed to normal, and 1 was reclassified as mitral valve prolapse (2.6%). Of the 11 with definite RHD, 6 (54.5%) remained definite, 4 regressed to borderline (36.4%), and 1 regressed to normal (9.1%). Two of 11 with definite RHD had penicillin adherence above 80% for the 2-year follow-up period. There were no differences in adherence, gender, age, household income, or number in household between those with definite RHD that regressed to borderline and those who did not (P > .19). CONCLUSIONS Borderlines had a very low progression rate to definite RHD. A strength of our study was a high retention rate (98%). Longer follow-up is needed to determine expected disease evolution.
Collapse
Affiliation(s)
- Amy Sanyahumbi
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Andrea Beaton
- Department of Pediatric Cardiology, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Danielle Guffey
- Dan L Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Mina C Hosseinipour
- Department of Infectious Disease, University of North Carolina Project, University of North Carolina, Lilongwe, Malawi
| | - Melissa Karlsten
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Charles G Minard
- Dan L Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Daniel J Penny
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Craig A Sable
- Department of Pediatric Cardiology, Children's National Heart Institute, Children's National Medical Center, Washington, District of Columbia
| | - Peter N Kazembe
- Department of Pediatrics, Baylor College of Medicine Clinical Center of Excellence, Lilongwe, Malawi
| |
Collapse
|
39
|
Negi PC, Sondhi S, Rana V, Rathoure S, Kumar R, Kolte N, Kumar R, Rao S, Diman A, Mahajan K, Dev M, Kandoria A, Ganju N, Bhardwaj R, Merwaha R, Sharma R, Asotra S. Prevalence, risk determinants and consequences of atrial fibrillation in rheumatic heart disease: 6 years hospital based-Himachal Pradesh- Rheumatic Fever/Rheumatic Heart Disease (HP-RF/RHD) Registry. Indian Heart J 2018; 70 Suppl 3:S68-S73. [PMID: 30595324 PMCID: PMC6309149 DOI: 10.1016/j.ihj.2018.05.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/27/2018] [Accepted: 05/11/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To report the prevalence, risk factors and consequences of atrial fibrillation (AF) in patients of rheumatic heart disease (RHD). METHODS The Himachal Pradesh- Rheumatic Fever/Rheumatic Heart Disease (HP-RF/RHD) Registry database of 1918 patients was analyzed. AF was diagnosed with 12-lead ECG recording at entry in to the registry. The association of AF with nature and severity of valvular dysfunction was analyzed, adjusted for age, left atrial (LA) dimension and pulmonary arterial hypertension using multivariable logistic regression model and strength of association was reported as odds ratio (OR) with 95% confidence intervals (C. I.). RESULTS The study population consisted of young (40.2 ± 14.3 years), predominantly females (72.3%) from rural area (94.1%). Prevalence of AF was 23.9% (95% C. I. 22.1%-25.8%). The independent determinants AF were age (OR 1.04, 95% C.I. 1.03-1.06), LA size (OR 1.10, 95% C.I. 1.08-1.11). The association of AF with age, New York Heart Association functional class, mitral stenosis severity and tricuspid regurgitation was statistically significant and graded. Mitral regurgitation and aortic valve disease had no significant independent association with AF. The prevalence of heart failure, stroke, peripheral embolism and mortality was significantly higher among patients with AF (p < .01). CONCLUSION AF is common in RHD patients and is significantly associated with heart failure and systemic thromboembolism. Age, mitral stenosis severity, tricuspid regurgitation and LA size were independently associated with AF.
Collapse
|
40
|
Zilla P, Yacoub M, Zühlke L, Beyersdorf F, Sliwa K, Khubulava G, Bouzid A, Mocumbi AO, Velayoudam D, Shetty D, Ofoegbu C, Geldenhuys A, Brink J, Scherman J, du Toit H, Hosseini S, Zhang H, Luo XJ, Wang W, Mejia J, Kofidis T, Higgins RS, Pomar J, Bolman RM, Mayosi BM, Madansein R, Bavaria J, Yanes-Quintana AA, Kumar AS, Adeoye O, Chauke RF, Williams DF. Global Unmet Needs in Cardiac Surgery. Glob Heart 2018; 13:293-303. [DOI: 10.1016/j.gheart.2018.08.002] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 08/08/2018] [Indexed: 11/24/2022] Open
|
41
|
Scheel A, Ssinabulya I, Aliku T, Bradley-Hewitt T, Clauss A, Clauss S, Crawford L, DeWyer A, Donofrio MT, Jacobs M, Klein J, Moore TE, Okello E, Scheel J, Shaw R, Sable C, Lwabi P, Watkins DA, Beaton A. Community study to uncover the full spectrum of rheumatic heart disease in Uganda. Heart 2018; 105:60-66. [DOI: 10.1136/heartjnl-2018-313171] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/29/2018] [Accepted: 07/03/2018] [Indexed: 11/04/2022] Open
Abstract
ObjectiveEstimates of the prevalence of rheumatic heart disease (RHD) in many endemic countries are limited to samples of children attending schools, which generate an incomplete picture of disease burden in communities. The present study conducted household-based RHD screening in a representative community in Gulu district, Uganda.MethodsMembers of households identified through a two-stage cluster-sampling approach between the ages of 5 years and 50 years were invited to undergo limited cardiac testing with a handheld echocardiogram to assess for the presence of RHD. Suspicious cases underwent confirmatory echocardiogram with a fully functional machine.ResultsOf the 2453 community members screened, 2.45% (95% CI 1.87% to 3.14%) showed echocardiographic evidence of RHD with 1.26% (95% CI 0.860% to 1.79%) having definite RHD. The overall prevalence of RHD among participants <20 years was 2.52% (95% CI 1.78% to 3.45%), with a borderline prevalence of 1.97% (95% CI 1.33% to 2.82%) and a definite prevalence of 0.544% (95% CI 0.235% to 1.07%). Prevalence rates among youth increased with age and peaked in the age group of 16–20 years. The overall adult prevalence (>20 years) of RHD was 2.34% (95% CI 1.49% to 3.49%). The majority of definite cases were mild (81%) and marked by mitral regurgitation and associated morphological valve changes (71%).ConclusionOur data reveal a high prevalence of undiagnosed RHD within an endemic community and fill a critical gap in RHD epidemiology in African adults.
Collapse
|
42
|
Rwebembera J, Manyilirah W, Zhu ZW, Nabbaale J, Namuyonga J, Ssinabulya I, Lubega S, Lwabi P, Omagino J, Okello E. Prevalence and characteristics of primary left-sided valve disease in a cohort of 15,000 patients undergoing echocardiography studies in a tertiary hospital in Uganda. BMC Cardiovasc Disord 2018; 18:82. [PMID: 29728065 PMCID: PMC5935941 DOI: 10.1186/s12872-018-0813-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 04/20/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Although rheumatic heart disease remains the leading cause of valve heart disease (VHD) in developing countries, other forms of valve disease have been over shadowed and not regarded as a public health problem. However, several facts suggest that the role of non-rheumatic VHD as a significant cardiovascular disease should be reconsidered. We aimed to assess the prevalence and characteristics of different forms of primary left sided valve diseases from a series of 15,009 echocardiographic studies. METHODS This was a retrospective review of echocardiographic reports for studies performed between January 2012 and December 2013 (24 months) at Uganda Heart Institute. All patients with primary left-sided valve disease were classified into one of five major diagnostic categories and in each diagnostic category; patients were sub-classified into stages A-D of primary valve disease as defined by the American College of Cardiology. RESULTS Three thousand five hundred eighty-two echocardiography reports qualified for final data analysis. The "sclerotic valve changes with normal valve function", a Stage A sub-class of "degenerative valve disease" overwhelmingly overshadowed all the other diagnostic categories in this stage. "Rheumatic Heart Disease", "Degenerative Valve Disease", "Bicuspid Aortic Valve", "Mitral Valve Prolapse" and "Endomyocardial Fibrosis" diagnostic categories accounted for 53.0%, 41.8%, 2.2%, 1.4% and 1.7% respectively in stages B-D of primary VHD. Rheumatic heart disease disproportionately affected the young, productive age groups. It was the major risk factor for infective endocarditis; and was the indication for valve surgery in 44 of 50 patients who had undergone valve replacement procedures. CONCLUSIONS We acknowledge that rheumatic heart disease remains a leading cause of progressive and severe primary left-sided valve disease among young adults in Uganda. But we bring to light the contemporary footprints of other forms of primary valve disease that require coordinated multidisciplinary approach to research, education and clinical management to ensure improved patient outcomes.
Collapse
Affiliation(s)
| | | | | | | | - Judith Namuyonga
- Uganda Heart Institute, Kampala, Uganda
- School of Medicine Makerere University, Kampala, Uganda
| | - Isaac Ssinabulya
- Uganda Heart Institute, Kampala, Uganda
- School of Medicine Makerere University, Kampala, Uganda
| | | | - Peter Lwabi
- Uganda Heart Institute, Kampala, Uganda
- School of Medicine Makerere University, Kampala, Uganda
| | | | - Emmy Okello
- Uganda Heart Institute, Kampala, Uganda
- School of Medicine Makerere University, Kampala, Uganda
| |
Collapse
|
43
|
Wu X, Yue Q, Jia W, Zhang J, Ouyang H, Xin D, Xiao Y. A novel approach for characterizing variations in serum peptides in rheumatic heart disease. Indian J Med Res 2018; 145:365-372. [PMID: 28749400 PMCID: PMC5555066 DOI: 10.4103/ijmr.ijmr_1581_14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background & objectives: Acute rheumatic fever and rheumatic heart disease (RHD) are important public health problems in developing countries. In this study, peptidomic analyses on RHD patients and healthy individuals were performed to characterize variations in serum peptide levels using label-free quantitation approaches. Methods: Blood samples were obtained from 160 healthy controls and 160 RHD patients. Of the 448 identified peptides, 272 were analyzed by two label-free mass spectrometry methods, the spectral count and spectral index. Results: There were 38 proteins and 95 peptides with significant (adjusted P<0.001) differences in the abundance of peptides between healthy controls and RHD patients, including multiple peptides derived from histone H2B, villin-like protein, complement C4-B and motile sperm domain containing protein-2. The levels of 10 peptides were upregulated, and 85 peptides were downregulated in patients compared to controls. In addition, in patients, the levels of four proteins were upregulated and 34 were downregulated compared to controls. Interpretation & conclusions: This study shows that detection of significant changes in serum peptides reflects the difference between RHD patients and healthy controls. This label-free method may be helpful for clinicians to treat RHD patients during the perioperative period.
Collapse
Affiliation(s)
- Xiaochen Wu
- Department of Cardiovascular Surgery, Chengdu Military General Hospital, Chengdu, PR, China
| | - Qin Yue
- Department of Cardiovascular Surgery, Chengdu Military General Hospital, Chengdu, PR, China
| | - Weikun Jia
- Department of Cardiovascular Surgery, Xinqiao Hospital, The Third Military Medical University, Chongqing, PR, China
| | - Jinbao Zhang
- Department of Cardiovascular Surgery, Chengdu Military General Hospital, Chengdu, PR, China
| | - Hui Ouyang
- Department of Cardiovascular Surgery, Chengdu Military General Hospital, Chengdu, PR, China
| | - Dong Xin
- Department of Cardiovascular Surgery, Chengdu Military General Hospital, Chengdu, PR, China
| | - Yingbin Xiao
- Department of Cardiovascular Surgery, Xinqiao Hospital, The Third Military Medical University, Chongqing, PR, China
| |
Collapse
|
44
|
Prendergast EA, Perkins S, Engel ME, Cupido B, Francis V, Joachim A, Al Kebsi M, Bode-Thomas F, Damasceno A, Abul Fadl A, El Sayed A, Gitura B, Kennedy N, Ibrahim A, Mucumbitsi J, Adeoye AM, Musuku J, Okello E, Olunuga T, Sheta S, Mayosi BM, Zühlke LJ. Participation in research improves overall patient management: insights from the Global Rheumatic Heart Disease registry (REMEDY). Cardiovasc J Afr 2018; 29:98-105. [PMID: 29570206 PMCID: PMC6008904 DOI: 10.5830/cvja-2017-054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 11/19/2017] [Indexed: 12/28/2022] Open
Abstract
Background Rheumatic heart disease (RHD) is a major public health problem in low– and middle–income countries (LMICs), with a paucity of high–quality trial data to improve patient outcomes. Investigators felt that involvement in a recent large, observational RHD study impacted positively on their practice, but this was poorly defined. Aim The purpose of this study was to document the experience of investigators and research team members from LMICs who participated in a prospective, multi–centre study, the global Rheumatic Heart Disease Registry (REMEDY), conducted in 25 centres in 14 countries from 2010 to 2012. Methods We conducted an online survey of site personnel to identify and quantify their experiences. Telephone interviews were conducted with a subset of respondents to gather additional qualitative data. We asked about their experiences, positive and negative, and about any changes in RHD management practices resulting from their participation in REMEDY as a registry site. Results The majority of respondents in both the survey and telephone interviews indicated that participation as a registry site improved their management of RHD patients. Administrative changes included increased attention to follow–up appointments and details in patient records. Clinical changes included increased use of penicillin prophylaxis, and more frequent INR monitoring and contraceptive counselling. Conclusions Our study demonstrates that participation in clinical research on RHD can have a positive impact on patient management. Furthermore, REMEDY has led to increased patient awareness and improved healthcare workers’ knowledge and efficiency in caring for RHD patients.
Collapse
Affiliation(s)
- E A Prendergast
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - S Perkins
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - M E Engel
- Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - B Cupido
- Division of Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - V Francis
- Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - A Joachim
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - M Al Kebsi
- Faculty of Medicine and Surgery, University of Sana'a, Al-Thawrah, Cardiac Centre, Sana'a, Yemen
| | - F Bode-Thomas
- Departments of Paediatrics, University of Jos and Jos University Teaching Hospital, Jos, Nigeria
| | - A Damasceno
- Department of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - A Abul Fadl
- Faculty of Medicine, Benha University, Cairo, Egypt
| | - A El Sayed
- Cardiothoracic Surgery Department, Al Shaab Teaching Hospital and Faculty of Medicine, Alzaiem Alazhari University, Khartoum, Sudan
| | - B Gitura
- Cardiology Unit, Department of Medicine, Kenyatta National Teaching and Referral Hospital, Nairobi, Kenya
| | - N Kennedy
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi; Centre for Medical Education, Queen's University, Belfast; Royal Belfast Hospital for Sick Children, Belfast, Ireland
| | - A Ibrahim
- Cardiothoracic Surgery Department, Al Shaab Teaching Hospital and Faculty of Medicine, Alzaiem Alazhari University, Khartoum, Sudan
| | - J Mucumbitsi
- Paediatric Cardiology Unit, Department of Paediatrics, King Faisal Hospital, Kigali, Rwanda
| | - A M Adeoye
- Division of Cardiology, Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - J Musuku
- University Teaching Hospital, Department of Paediatrics and Child Health, University of Zambia, Lusaka, Zambia
| | - E Okello
- Uganda Heart Institute, Kampala, Uganda
| | - T Olunuga
- Department of Medicine, Federal Medical Centre, Abeokuta, Nigeria
| | - S Sheta
- Department of Paediatrics, Division of Paediatric Cardiology, Faculty of Medicine, Cairo University Children's Hospital, Cairo, Egypt
| | - B M Mayosi
- Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Division of Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Dean of Faculty of Health Sciences, University of Cape Town, South Africa
| | - L J Zühlke
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Division of Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | | |
Collapse
|
45
|
Okello E, Longenecker CT, Scheel A, Aliku T, Rwebembera J, Mirembe G, Sable C, Lwabi P, Beaton A. Impact of regionalisation of a national rheumatic heart disease registry: the Ugandan experience. HEART ASIA 2018; 10:e010981. [PMID: 29422951 DOI: 10.1136/heartasia-2017-010981] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 12/20/2017] [Accepted: 12/21/2017] [Indexed: 12/14/2022]
Abstract
Objectives Rheumatic heart disease (RHD) remains a major driver of cardiovascular morbidity and mortality in low-resource settings. Registry-based care for RHD has been advocated as a powerful tool to improve clinical care and track quality metrics. Data collected through an RHD registry may also reveal epidemiological and geospatial trends, as well as insight into care utilisation. Uganda established a central RHD registry at the country's only tertiary cardiac centre in 2010. In 2014 RHD care and registry enrolment expanded to the Western region and in 2015 to the North. Here, we examine the geographical distribution of RHD cases in Uganda and the impact of registry expansion. Methods A retrospective search of the Ugandan national RHD registry was preformed to capture all cases of acute rheumatic fever or clinical RHD from January 2010 through July 2016. A geospatial analysis revealed that the density of detected cases (cases/100 000 district residents) reflected proximity to an RHD registry enrolment centre. Regionalisation improved the number of cases detected in the regions of expansion and improved retention of patients in care. Results and conclusions RHD appears to have uniform distribution throughout Uganda with geographical clustering surrounding RHD registry enrolment centres reflecting access to care, rather than differences in prevalence. Higher rates of case detection and improved retention in care with regionalisation highlight the urgent need for decentralisation of cardiovascular services. Future studies should examine sustainable models for cardiovascular care delivery, including task shifting of clinical care and echocardiography and use of telemedicine.
Collapse
Affiliation(s)
- Emmy Okello
- Uganda Heart Institute, Kampala, Uganda.,School of Medicine, Makerere University, Kampala, Uganda
| | - Chris T Longenecker
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Division of Cardiology, University Hospitals of Cleveland, Cleveland, Ohio, USA
| | - Amy Scheel
- Division of Cardiology, Children's National Health System, Washington DC, USA
| | - Twalib Aliku
- School of Medicine, Gulu University, Gulu, Uganda
| | - Joselyn Rwebembera
- Uganda Heart Institute, Kampala, Uganda.,Mbarara University of Sciences and Technology, Mbarara, Uganda
| | | | - Craig Sable
- Division of Cardiology, Children's National Health System, Washington DC, USA
| | | | - Andrea Beaton
- Division of Cardiology, Children's National Health System, Washington DC, USA
| |
Collapse
|
46
|
Curry C, Zuhlke L, Mocumbi A, Kennedy N. Acquired heart disease in low-income and middle-income countries. Arch Dis Child 2018; 103:73-77. [PMID: 28838969 DOI: 10.1136/archdischild-2016-312521] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 08/05/2017] [Accepted: 08/13/2017] [Indexed: 11/04/2022]
Abstract
The burden of illness associated with acquired cardiac disease in children in low-income and middle-income countries (LMIC) is significant and may be equivalent to that of congenital heart disease. Rheumatic heart disease, endomyocardial fibrosis, cardiomyopathy (including HIV cardiomyopathy) and tuberculosis are the most important causes. All are associated with poverty with the neediest children having the least access to care. The associated mortality and morbidity is high. There is an urgent need to improve cardiac care in LMIC, particularly in sub-Saharan Africa and parts of Southeast Asia where the burden is highest.
Collapse
Affiliation(s)
- Chris Curry
- Centre for Medical Education, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - Liesl Zuhlke
- Cardiology, University of Cape Town, Cape Town, South Africa
| | - Ana Mocumbi
- Cardiology, University Eduardo Mondlane, Maputo, Mozambique
| | - Neil Kennedy
- Centre for Medical Education, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| |
Collapse
|
47
|
Bigna JJ, Noubiap JJ, Nansseu JR, Aminde LN. Prevalence and etiologies of pulmonary hypertension in Africa: a systematic review and meta-analysis. BMC Pulm Med 2017; 17:183. [PMID: 29221480 PMCID: PMC5723068 DOI: 10.1186/s12890-017-0549-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 11/30/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Despite the recent increasing worldwide attention towards pulmonary hypertension (PH), its epidemiology remains poorly described in Africa. Accordingly, we performed a systematic review and meta-analysis of PH prevalence, incidence and etiologies in Africa. METHODS We searched PubMed, EMBASE, African Journals Online, and Africa Index Medicus. Published observational studies until September 20, 2017, including adult participants residing in Africa were considered. Two review authors independently selected studies, assessed included studies for methodological quality, and extracted data. A random-effects model was used for meta-analysis. Heterogeneity was evaluated by the χ 2 test on Cochrane's Q statistic which is quantified by I2 values. Using Newcastle-Ottawa Scale, we considered a score of 0-4, 5-7, and 8-10 as indicative of high, moderate, and low risk of bias in included studies, respectively. RESULTS Of 1611 entries, 25 studies were retained. Twelve (48%), seven (28%), and six (24%) papers had respectively a low, moderate and high risk of bias. The prevalence of PH widely varied across different populations: 9.8% (95% confidence interval: 3.2-19.3; I2 = 99.4%; 6 studies) in 11,163 people presenting with cardiac complaints; 10.6% (4.3-19.1; I2 = 90.3%; 4 studies) in 937 HIV-infected people; 32.9% (17.6-50.4; I2 = 97.2%; 3 studies) in 2077 patients with heart failure; 23.2% (15.2-32.2; I2 = 59.4%; 3 studies) in 248 patients on hemodialysis; 12.9% (11.8-14.0; I2 = 79.7%; 2 studies) in 3750 patients with rheumatic heart disease; 36.9% (29.7-44.3; I2 = 79.7; 2 studies) in 79 patients with sickle cell disease; 62.7% (49.0-74.7; 1 study) in 51 patients with chronic obstructive pulmonary disease; 25.4% (16.3-37.3; 1 study) in 63 patients with systemic lupus erythematous; 68.7% (62.8-74.1; 1 study) in 259 patients with cardiac surgery; and 7.4% (4.6-11.9; 1 study) in 202 patients with systemic sclerosis. No study reported PH incidence. From one international study (n = 209), PH etiologies were: left heart disease (68.9%), pulmonary arterial hypertension (15.8%), lung disease and/or hypoxia (12.0%), chronic thromboembolic PH (1.9%) and unclear/multifactorial PH (15.8%). CONCLUSION The prevalence of PH is relatively high in some populations in Africa, perhaps mainly driven by left heart diseases, highlighting the need for context-specific interventions.
Collapse
Affiliation(s)
- Jean Joel Bigna
- Department of Epidemiology and Public Health, Centre Pasteur of Cameroon, Yaoundé, Cameroon
- Faculty of Medicine, University of Paris Sud XI, Le Kremlin Bicêtre, France
| | - Jean Jacques Noubiap
- Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Jobert Richie Nansseu
- Department of Public Health, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
- Sickle Cell Disease Unit, Mother and Child Centre of the Chantal Biya Foundation, Yaoundé, Cameroon
- Department of Disease, Epidemics and Pandemics Control, Ministry of Public Health, Yaoundé, Cameroon
| | - Leopold Ndemnge Aminde
- Clinical Research Education, Networking and Consultancy (CRENC), Douala, Cameroon
- School of Public Health, Faculty of Medicine & Biomedical Sciences, University of Queensland, Brisbane, Australia
| |
Collapse
|
48
|
Beaton A, Aliku T, Dewyer A, Jacobs M, Jiang J, Longenecker CT, Lubega S, McCarter R, Mirabel M, Mirembe G, Namuyonga J, Okello E, Scheel A, Tenywa E, Sable C, Lwabi P. Latent Rheumatic Heart Disease: Identifying the Children at Highest Risk of Unfavorable Outcome. Circulation 2017; 136:2233-2244. [PMID: 28972003 PMCID: PMC5716883 DOI: 10.1161/circulationaha.117.029936] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 09/12/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Screening echocardiography has emerged as a potentially powerful tool for early diagnosis of rheumatic heart disease (RHD). The utility of screening echocardiography hinges on the rate of RHD progression and the ability of penicillin prophylaxis to improve outcome. We report the longitudinal outcomes of a cohort of children with latent RHD and identify risk factors for unfavorable outcomes. METHODS This was a prospective natural history study conducted under the Ugandan RHD registry. Children with latent RHD and ≥1 year of follow-up were included. All echocardiograms were re-reviewed by experts (2012 World Heart Federation criteria) for inclusion and evidence of change. Bi- and multivariable logistic regression, Kaplan-Meier analysis, and Cox proportional hazards models, as well, were developed to search for risk factors for unfavorable outcome and compare progression-free survival between those treated and not treated with penicillin. Propensity and other matching methods with sensitivity analysis were implemented for the evaluation of the penicillin effect. RESULTS Blinded review confirmed 227 cases of latent RHD: 164 borderline and 63 definite (42 mild, 21 moderate/severe). Median age at diagnosis was 12 years and median follow-up was 2.3 years (interquartile range, 2.0-2.9). Penicillin prophylaxis was prescribed in 49.3% with overall adherence of 84.7%. Of children with moderate-to-severe definite RHD, 47.6% had echocardiographic progression (including 2 deaths), and 9.5% had echocardiographic regression. Children with mild definite and borderline RHD showed 26% and 9.8% echocardiographic progression and 45.2% and 46.3% echocardiographic improvement, respectively. Of those with mild definite RHD or borderline RHD, more advanced disease category, younger age, and morphological mitral valve features were risk factors for an unfavorable outcome. CONCLUSIONS Latent RHD is a heterogeneous diagnosis with variable disease outcomes. Children with moderate to severe latent RHD have poor outcomes. Children with both borderline and mild definite RHD are at substantial risk of progression. Although long-term outcome remains unclear, the initial change in latent RHD may be evident during the first 1 to 2 years following diagnosis. Natural history data are inherently limited, and a randomized clinical trial is needed to definitively determine the impact of penicillin prophylaxis on the trajectory of latent RHD.
Collapse
Affiliation(s)
- Andrea Beaton
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.).
| | - Twalib Aliku
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Alyssa Dewyer
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Marni Jacobs
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Jiji Jiang
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Chris T Longenecker
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Sulaiman Lubega
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Robert McCarter
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Mariana Mirabel
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Grace Mirembe
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Judith Namuyonga
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Emmy Okello
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Amy Scheel
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Emmanuel Tenywa
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Craig Sable
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Peter Lwabi
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| |
Collapse
|
49
|
Namukwaya E, Murray SA, Downing J, Leng M, Grant L. 'I think my body has become addicted to those tablets'. Chronic heart failure patients' understanding of and beliefs about their illness and its treatment: A qualitative longitudinal study from Uganda. PLoS One 2017; 12:e0182876. [PMID: 28957338 PMCID: PMC5619713 DOI: 10.1371/journal.pone.0182876] [Citation(s) in RCA: 14] [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: 03/15/2017] [Accepted: 07/26/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Patients with heart failure in Uganda present for health care with advanced structural heart disease, have repeated hospitalizations and poorly controlled disease symptoms. The reasons for these are unclear. Literature from other settings shows that patients' understanding of their illness and their beliefs influence their health related behaviour. The study aimed to explore the beliefs of patients with heart failure, their understanding of their illness and its treatment, and how this influenced their health related behaviour to inform future health education programs, information and palliative care services. METHODS Serial qualitative in-depth interviews were conducted with Heart Failure patients who were purposively sampled and recruited in Mulago National Referral Hospital until thematic saturation was reached. In-depth interviews were conducted at three time points over the course of their illness with intervals of 3 months between interviews. A grounded theory approach was used in data analysis. The University of Edinburgh ethics committee, Mulago Hospital Research Ethics committee and the Uganda National Council of Science and Technology (Reference numbers D/GC/178; MREC 33, SS 3083 respectively) approved the research. RESULTS A total of 40 face to face qualitative longitudinal interviews (36-patient alone, 4 paired-patient and family carer), were conducted with 21 patients. The findings revealed that heart failure patients were unaware of the symptoms of the illness and their definition of illness differed from that of health professionals. Patients understood their diagnosis, cause of illness, prognosis and the importance of the medicines differently from health professionals, and had insufficient information on self-care. Lay beliefs were used to explain many aspects of the illness and treatments. All these influenced where patients sought care and their adherence to treatment, self-care and follow up leading to uncontrolled disease. CONCLUSION There is a high level of health illiteracy among heart failure patients in Uganda. Patients rely on lay beliefs to make health decisions and medical information is often miscomprehended. There is an urgent need for health education using culturally appropriate information.
Collapse
Affiliation(s)
- Elizabeth Namukwaya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Scott A. Murray
- Primary Palliative Care Research Group, The Usher Institute of Population Health Sciences & Informatics, The University of Edinburgh, Medical School, Edinburgh, United Kingdom
| | - Julia Downing
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Mhoira Leng
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Liz Grant
- Global Health Academy, The Usher Institute of Population Health Sciences & Informatics, The University of Edinburgh, Medical School, Edinburgh, United Kingdom
| |
Collapse
|
50
|
Stroke characterization in Sun Saharan Africa: Congolese population. Int J Cardiol 2017; 240:392-397. [DOI: 10.1016/j.ijcard.2017.04.063] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/26/2017] [Accepted: 04/19/2017] [Indexed: 11/15/2022]
|