Eliminating acute rheumatic fever and rheumatic heart disease

Temporal trend analysis of rheumatic heart disease burden in high-income countries between 1990 and 2019

AIMS

To assesses trends in rheumatic heart disease (RHD) burden in high-income, European Union 15+ (EU15+) countries between 1990 and 2019.

METHODS AND RESULTS

Cross-sectional analysis of the incidence and mortality of RHD was conducted using data from the Global Burden of Disease (GBD) Study database. Age-standardized incidence rates (ASIRs) and age-standardized mortality rates (ASMRs) were extracted for EU15+ countries per sex for each of the years from 1990 to 2019, inclusive, and mortality-to-incidence indices (MII) were computed. Joinpoint regression analysis was used for the description of trends. Over 29 years, an overall declining trend in RHD incidence and mortality across EU 15+ nations were observed. There was significant variability in RHD incidence and mortality rates across high-income countries. However, both RHD incidence and mortality were higher among females compared with males across EU15+ countries over the observed period. The most recent incidence trend, starting predominantly after 2014, demonstrated a rise in RHD incidence in most countries for both sexes. The timing of this RHD resurgence corresponds temporally with an influx of migrants and refugees into Europe. The recent increasing RHD incidence rates ranged from +0.4% to +24.7% for males, and +0.6% to +11.4% for females.

CONCLUSION

More than half of EU15+ nations display a recent increase in RHD incidence rate across both sexes. Possible factors associated with this rise are discussed and include increase in global migration from nations with higher RHD prevalence, host nation factors such as migrants' housing conditions, healthcare access, and migrant health status on arrival.

Innovation and disruptive science determine the future of cardiothoracic surgery

One of the currently most asked questions in the field of medicine is how any specialty in the future will evolve to ensure better health for the patients by using current, unparalleled developments in all areas of science. This article will give an overview of new and evolving strategies for cardiothoracic (CT) surgery that are available today and will become available in the future in order to achieve this goal. In the founding era of CT surgery in the 1950s and 1960s, there was tremendous excitement about innovation and disruptive science, which eventually resulted in a completely new medical specialty, i.e. CT surgery. Entirely new treatment strategies were introduced for many cardiovascular diseases that had been considered incurable until then. As expected, alternative techniques have evolved in all fields of science during the last few decades, allowing great improvements in diagnostics and treatment in all medical specialties. The future of CT surgery will be determined by an unrestricted and unconditional investment in innovation, disruptive science and our own transformation using current achievements from many other fields. From the multitude of current and future possibilities, I will highlight 4 in this review: improvements in our current techniques, bringing CT surgery to low- and middle-income countries, revolutionizing the perioperative period and treating as yet untreatable diseases. These developments will allow us a continuation of the previously unheard-of treatment possibilities provided by ingenious innovations based on the fundamentals of CT surgery.

Development of a core outcome set on Traditional Chinese Medicine and for rheumatic heart disease: a study protocol

INTRODUCTION

Globally, rheumatic heart disease (RHD) is an important cause of acquired heart disease in children and adolescents. Clinical trials on RHD treatment with Traditional Chinese Medicine (TCM) or integrated medicine are gradually increasing in China. However, because the outcomes of clinical trials are subject to heterogeneity and selective reporting, similar studies cannot be merged and compared, complicating assessing the effectiveness and safety of TCM, and diminishing the value of clinical trials. Therefore, there is an urgent need to design a TCM or integrated medicine core outcome set (COS) for RHD.

METHODS AND ANALYSIS

The development of this study will take place in four stages under the direction of a multidisciplinary advisory board. (1) Establishing a comprehensive outcomes checklist through a systematic review of previously published research, retrieval of clinical trial registration centres, patient's semistructured interviews, and clinician's questionnaire surveys; (2) Screen stakeholder groups from various fields to participate in the Delphi survey; (3) Two e-Delphi surveys will be conducted to determine the outcomes of various concerned stakeholder groups; (4) Hold a face-to-face consensus meeting to develop the COS-TCM-RHD.

ETHICS AND DISSEMINATION

The ethical approval for this study has been obtained from the Tianjin University of Traditional Chinese Medicine Ethics Committee (TJUTCM-EC20210008). The findings will be disseminated in peer-reviewed journals and meetings.

TRIAL REGISTRATION NUMBER

This study has been registered at the Core Outcome Measures in Effectiveness Trials (COMET) database (Registration #1743).

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

ABSTRACT

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

Expanding Valve Repair in Rheumatic Heart Disease

Rheumatic heart disease is a serious ailment with significant morbidity and mortality in endemic areas; yet, there is no agreement on indication, timing, and surgical modality for treating rheumatic valve affection. There is mounting evidence that rheumatic mitral valve repair is possible with good long-term results, less is the case with rheumatic aortic valve disease. We discuss the surgical approach for both valves emphasizing the role of multimodality imaging.

Aortic valve repair for the treatment of rheumatic aortic valve disease: a systematic review and meta-analysis

Valvuloplasty for rheumatic aortic valve disease remains controversial. We conducted this study to explore whether aortic valvuloplasty is appropriate for the rheumatic population. A comprehensive search was conducted, and 7 eligible retrospective studies were identified from PubMed, Embase, Medline and Cochrane (up to April 7, 2020) according to the inclusion and exclusion criteria. The data for hospital mortality, 5-year survival, 5-year reoperation, aortic insufficiency grade (AIG) and aortic valve gradient (AVG) were extracted by 2 independent reviewers and were analysed to evaluate the safety and availability of aortic valvuloplasty for rheumatic patients. The heterogeneity of the results was estimated using the Q test and I² statistics. The fixed pooling model was used when I² ≤ 50%; otherwise, the random pooling model was selected. 7 articles with 418 patients were included. The pooled hospital mortality, 5-year survival and 5-year reoperation rates were 3.2%, 94.5% and 9.9%, respectively. The heterogeneities of the weighted mean differences (WMD) values of the AIG and AVG between preoperation and postoperation were extremely high (I² = 81.5%, p < 0.001 in AIG, I² = 97.6%, p = 0.003 in AVG). Subgroup analysis suggested that the AIG and AVG were improved by 3.03 grades (I² = 0%, p < 0.001) and 3.16 mmHg (I² = 0%, p < 0.001) in the European group, respectively. In the Asian group, the AIG and AVG were improved by 2.57 grades (I² = 0%, p < 0.001) and 34.39 mmHg (I² = 0%, p < 0.001), respectively. Compared with the values at discharge, the AIG was increased by 0.15 grades (I² = 0%, p = 0.031) and the AVG was still decreased by 2.07 mmHg (I² = 0%, p = 0.031) at the time of follow up. Valvuloplasty is safe and effective to treat rheumatic aortic insufficiency and stenosis, and the duration of maintenance required to improve stenosis was longer than that of insufficiency.

Early outcomes of aortic valve repair versus replacement for aortic regurgitation: a single-center experience

Background

Aortic valve repair in rheumatic patients is not well-studied. We aimed to present our initial Egyptian experience in the aortic valve repair and compare it with the aortic valve replacement. The study included 85 patients who had an aortic valve surgery for aortic regurgitation (AR) in a single center from 2018 to 2020. We assigned the patients to either aortic valve repair (n= 39) or aortic valve replacement (n= 46). Fifty-nine patients (69.4%) had rheumatic heart disease. Study outcomes were hospital complications and the degree of aortic regurgitation after 6 months in patients who had aortic valve repair.

Results

Patients who had replacement were significantly older (49.6± 7.2 vs. 43.8± 8.6 years: P= 0.002) and had more advanced New York Heart Association (P<0.001) and Canadian Cardiovascular Scoring (P= 0.03) classes. Hypertension (31 (67.4%) vs. 17 (43.6%); P= 0.03) and hypercholesteremia (18 (40%) vs. 17 (18.9%); P= 0.04) were more common in the replacement group. Patients who had replacement had a significantly higher percentage of valve retraction (P<0.001). Cardiopulmonary bypass (54.5 (49.5–60) vs. 45 (41–49) min; P<0.001) and ischemic times (36.5 (31–40) vs. 30 (28–33) min; P<0.001) were longer in patients who had an aortic valve replacement. Blood transfusion (28 (60.9%) vs. 11 (282%); P= 0.003) and ICU stay (24.5 (24–48) vs 23 (20–31) h; P= 0.01) were higher in the replacement group. Hospital mortality was non-significantly different between groups. Four patients had trivial AR (10.3%), and six had mild AR (15.4%) in the repair group. There was no difference in valve pathology or outcomes in aortic valve repair patients for degenerative versus rheumatic pathologies. After a 6-month follow-up, four patients had trivial AR (10.3%), and six patients had mild AR (15.4%) in the repair group.

Conclusions

Aortic valve repair could be an alternative to replacement in selected patients with rheumatic heart disease. Shorter cardiopulmonary bypass and ischemic times may improve repair outcomes compared to replacement.

When Aortic Stenosis Is Not Alone: Epidemiology, Pathophysiology, Diagnosis and Management in Mixed and Combined Valvular Disease

Aortic stenosis (AS) may present frequently combined with other valvular diseases or mixed with aortic regurgitation, with peculiar physio-pathological and clinical implications. The hemodynamic interactions between AS in mixed or combined valve disease depend on the specific combination of valve lesions and may result in diagnostic pitfalls at echocardiography; other imaging modalities may be helpful. Indeed, diagnosis is challenging because several echocardiographic methods commonly used to assess stenosis or regurgitation have been validated only in patients with the single-valve disease. Moreover, in the developed world, patients with multiple valve diseases tend to be older and more fragile over time; also, when more than one valvular lesion needs to address the surgical risk rises together with the long-term risk of morbidity and mortality associated with multiple valve prostheses, and the likelihood and risk of reoperation. Therefore, when AS presents mixed or combined valve disease, the heart valve team must integrate various parameters into the diagnosis and management strategy, including suitability for single or multiple transcatheter valve procedures. This review aims to summarize the most critical pathophysiological mechanisms underlying AS when associated with mitral regurgitation, mitral stenosis, aortic regurgitation, and tricuspid regurgitation. We will focus on echocardiography, clinical implications, and the most important treatment strategies.

Complex and multilevel left ventricular outflow tract obstruction: What can 3D echocardiography add?

Background

Subaortic obstruction by a membrane or systolic anterior motion of the mitral valve leaflets is usually suspected in young patients, especially if the anatomy of the aortic valve is not clearly stenotic and unexplained left ventricular hypertrophy exists in the context of high transaortic gradients.

Main body

In certain circumstances, some patients show both aortic and subaortic stenotic lesions of variable severity. Doppler echocardiography can help in grading severity in the case of single-level obstruction but not in patients with multilevel obstruction where the continuity equation is of no value. Three-dimensional (3D) echocardiography allows "en-face" visualization of each level of the aortic valve and subaortic tract; in addition, direct planimetry of the areas can be done using multiplanar reformatting.

Conclusions

Accordingly, 3D echocardiography plays a crucial role in the assessment in patients with multilevel left ventricular outflow tract obstruction as it can accurately delineate the location and size, and severity of the stenosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43044-021-00197-y.

The "Cairo Accord"- Towards the Eradication of RHD: An Update

Rheumatic heart disease (RHD) is the most common cause of acquired heart disease in children and young adults. It continues to be prevalent in many low- and middle-income countries where it causes significant morbidity and mortality. Following the 2017 Cairo conference "Rheumatic Heart Disease: from Molecules to the Global Community," experts from 21 countries formulated an approach for addressing the problem of RHD: "The Cairo Accord on Rheumatic Heart Disease." The Accord attempts to set policy priorities for the eradication of acute rheumatic fever (ARF) and RHD and builds on a recent series of policy initiatives and calls to action. We present an update on the recommendations of the Cairo Accord and discuss recent progress toward the eradication of RHD, including contributions from our own Aswan Rheumatic Heart Disease Registry (ARGI).

Rheumatic heart disease: The role of global cardiac surgery

Rheumatic heart disease (RHD) remains a neglected disease of poverty. While nearly eradicated in high-income countries due to timely detection and treatment of acute rheumatic fever, RHD remains highly prevalent in low- and middle-income countries (LMICs) and among indigenous and disenfranchised populations in high-income countries. As a result, over 30 million people in the world have RHD, of which approximately 300,000 die each year despite this being a preventable and treatable disease. In LMICs, such as in Latin America, sub-Saharan Africa, and Southeast Asia, access to cardiac surgical care for RHD remains limited, impacting countries' population health and resulting economic growth. Humanitarian missions play a role in this context but can only make a difference in the long term if they succeed in training and establishing autonomous local surgical teams. This is particularly difficult because these populations are typically young and largely noncompliant to therapy, especially anticoagulation required by mechanical valve prostheses, while bioprostheses have unacceptably high degeneration rates, and valve repair requires considerable experience. Devoted and sustained leadership and local government and public health cooperation and support with the clinical medical and surgical sectors are absolutely essential. In this review, we describe historical developments in the global response to RHD with a focus on regional, international, and political commitments to address the global burden of RHD. We discuss the surgical and clinical considerations to properly manage surgical RHD patients and describe the logistical needs to strengthen cardiac centers caring for RHD patients worldwide.

Paediatrics: how to manage pharyngitis in an era of increasing antimicrobial resistance

The goal of this narrative review of pharyngitis is to summarize the practical aspects of the management of sore throat in children in high- and middle-income countries. A traditional review of the literature was performed. Most cases of pharyngitis are viral and self-limited, although rarely viral pharyngitis due to Epstein–Barr leads to airway obstruction. Bacterial pharyngitis is usually due to group A streptococcus (GAS), occurs primarily in children aged 5–15 years, and presents as sore throat in the absence of rhinitis, laryngitis or cough. Again, most cases are self-limited; antibiotics hasten recovery by only 1–2 days. Guidelines vary by country, but antibiotics are commonly recommended for proven GAS pharyngitis as they may prevent rare but severe complications, in particular rheumatic fever (RF). In this era of antimicrobial stewardship, it should be extremely rare that antibiotics are prescribed for presumed GAS pharyngitis until GAS has been detected. Even with proven GAS pharyngitis, it is controversial whether children at low risk for RF should routinely be prescribed antibiotics as the number needed to treat to prevent one case of RF is undoubtedly very large. When treatment is offered, the antibiotics of choice are penicillin or amoxicillin as they are narrow spectrum and resistance resulting in clinical failure is yet to be documented. A 10-day oral course is recommended as shorter courses appear to be less likely to clear carriage of GAS. However, the evidence that one needs to clear carriage to prevent RF is low quality and indirect.

Transcatheter Aortic Valve Replacement in Rheumatic Aortic Stenosis: A Comprehensive Review

Rheumatic heart disease (RHD) mainly affects people in developing, low-income countries. However, due to globalization and migration, developed countries are now seeing more cases of RHD. In RHD patients who develop severe symptomatic aortic stenosis, surgical aortic valve replacement remains the treatment of choice. In the past decade, there has been an extension of transcatheter aortic valve replacement (TAVR) to intermediate-risk and lower-risk patients with aortic stenosis. This review suggests the possible utility of TAVR for the treatment of rheumatic aortic stenosis. Rheumatic aortic stenosis has been excluded from major TAVR studies due to the predominantly noncalcific pathology of the rheumatic aortic valve. However, there have been case reports and case series showing successful implantation of the valve even in patients with and without significant leaflet calcification. In this review article, we summarize the latest evidence of severe rheumatic aortic stenosis treated with TAVR and discuss the procedure's impact on patient care, safety, and efficacy.

Save a Child's Heart: We Can and We Should-A Generation Later

The Annals of Thoracic Surgery published a seminal article by the late Dr Amram ("Ami") Cohen and his associates entitled "Save a Child's Heart: We Can and We Should" in 2001. It stressed the moral imperative and challenge of pediatric heart care in the developing world. The current article presents an update of the past 25 years of the history, experience, and international ramifications of 1 institution and 1 UN-recognized Israeli organization.

Previous Traditional Medicine Use for Sore Throat among Children Evaluated for Rheumatic Fever in Northern Uganda

Timely diagnosis of group A streptococcal (GAS) sore throat coupled with appropriate antibiotic treatment is necessary to prevent serious post-streptococcal complications, including rheumatic fever (RF) and rheumatic heart disease (RHD). Traditional medicine (TM) is a known common adjunct to formal medical care in sub-Saharan Africa. A better understanding of health-seeking behavior for sore throat both within and outside the formal medical system is critical to improving primary prevention efforts of RF and RHD. A prospective mixed-methods study on the use of TM for sore throat was embedded within a larger epidemiological study of RF in Northern Uganda. Children presenting with symptoms of RF were interviewed about recent TM use as well as health services use for sore throat. One hundred children with a median age of 10 years (interquartile range: 6.8-13 years) completed the TM interview with their parent/guardian as part of a research study of RF. Seventeen, or 17%, accessed a TM provider for sore throat as part of the current illness, and 70% accessed TM for sore throat in the past (73% current or past use). Of the 20 parents who witnessed the TM visit, 100% reported use of crude tonsillectomy. Penicillin was the most frequently prescribed medication by TM providers in 52% of participants who were seen by a TM provider. The use of TM among children presenting with symptoms of sore throat in northern Uganda is common and frequently used in tandem with diagnostic services offered through the formal healthcare system. Engagement with TM practitioners may provide an important avenue for designing effective primary prevention and management strategies of RF and reduce the global burden of RHD.

A questionnaire survey for improving awareness of rheumatic heart disease among school-aged children in India

Objectives

We examined the level of awareness about Rheumatic Heart Disease (RHD) among school-aged children in a rural district of India and evaluated the effects of a questionnaire-based survey in improving the level of awareness.

Methods

The study involved 8,646 students aged 10–16 years from 20 schools in West Midnapore, India which was conducted in August 2017. We examined changes in the level of awareness of RHD using a 29-point scoring system in seven domains. The baseline questionnaire survey assessed students’ knowledge and was followed by a multimedia presentation about RHD and a post-intervention survey using the same questionnaire. The questionnaire included 9 questions on different aspects of RHD including prevalence, nature of disease, symptoms, determinants, treatment options, impact of the disease and diagnosis.

Results

The mean age of the study population was 13 years and 46% were boys. At baseline, the mean level of knowledge about RHD was 42% (12.2 out of 29 points). After the school-based presentation, the score improved to a mean of 55% (15.9 points on the 29-point scale), a 31% relative improvement. Improvement in students' knowledge was noted across all seven domains, individually and combined (p < 0.001).

Conclusions

Awareness among children in rural India about RHD is modest. A school-based intervention could help in improving awareness about this chronic condition and may promote secondary prophylaxis to reduce the morbidity and mortality from RHD.

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

Background:

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

Methods:

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

Findings:

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

Interpretation:

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

Funding:

National Research Foundation of South Africa.

Rheumatic heart disease: current status of diagnosis and therapy

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.

Looking back and thinking forwards - 15 years of cardiology and cardiovascular research

The first issue of Nature Reviews Cardiology was published in November 2004 under the name Nature Clinical Practice Cardiovascular Medicine. To celebrate our 15th anniversary in 2019, we invited six of our Advisory Board members to discuss what they considered the most important advances in their field of cardiovascular research or clinical practice in the past 15 years and what changes they envision for cardiovascular medicine in the next 15 years. Several practice-changing breakthroughs are described, including advances in procedural techniques to treat arrhythmias and hypertension and the development of novel therapeutic strategies to treat heart failure and pulmonary arterial hypertension, as well as those that target risk factors such as inflammation and elevated LDL-cholesterol levels. Furthermore, these key opinion leaders predict that machine learning technology and data derived from wearable devices will pave the way towards the coveted goal of personalized medicine.

Scolopendra subspinipes mutilans L. Koch Ameliorates Rheumatic Heart Disease by Affecting Relative Percentages of CD4+CD25+FoxP3 Treg and CD4+IL17 T Cells

(Scolopendra subspinipes mutilans L. Koch. (SSLK) helps reduce the risk of coronary heart disease (CHD) but its effects on rheumatic heart disease (RHD) patients remain unclear. 80 RHD patients were recruited and randomly assigned into SG (to receive SSLK treatment) and CG (to receive placebo) groups, and the intervention lasted for 3 months. The following cardiac indexes were measured, including mean arterial pressure (MAP), heart rate (HR), central venous pressure (CVP), blood lactate, fatigue, shortness of breath, palpitation, and chest pain. ELISA kits were used to analyze creatine kinase isoenzyme (CK-MB), serum troponin T (cTnT), CRP, IL-1β, IL-6, and TNF-α, malondialdehyde (MDA), and superoxide dismutase (SOD). Relative percentages of CD4⁺CD25⁺FoxP3 regulatory (Treg) and CD4⁺IL-17 T cells were measured using flow cytometry. After 3-month therapy, SSLK intervention improved MAP, HR, CVP, fatigue, palpitation, and shortness breath of CHD patients, reduced the levels of blood lactate, CK-MB, cTnT, CRP, IL-1β, IL-6, TNF-α, MDA, and increased SOD level (p < 0.05). Meanwhile, SSLK treatment increased the percentages of CD4⁺CD25⁺FoxP3 Treg cells and reduced relative percentages of CD4⁺IL-17 T cells in a dose-dependent way (p < 0.05). Relative percentage of CD4⁺CD25⁺FoxP3 Treg cells had negative relationship while CD4⁺IL17 T cells had positive relationship with CK-MB, cTnT, CRP, and TNF-a (p < 0.01). SSLK ameliorated RHD by affecting the balance of CD4⁺CD25⁺FoxP3 Treg and CD4⁺IL17 T cells.

Infections: a double-edge sword in autoimmunity

PURPOSE OF REVIEW

Infections play a role in the pathogenesis of autoimmune diseases (AID). Several bacterial and viral pathogens play a double role, as both inducers and inhibitors of AID. In this review, we will present current evidence and discuss different aspects of this notion.

RECENT FINDINGS

Infectors that both inhibit and induce AID include Helicobacter pylori, Klebsiella pneumoniae, hepatitis B virus, group B Coxsackieviruses, Epstein-Barr virus and Lymphocytic choriomeningitis virus. Numerous AID are affected by infections, including polyarteritis nodosa, inflammatory bowel disease, and type 1 diabetes. Some pathogens, such as group B Coxsackieviruses, may induce and inhibit the development of the same AID. This reveals a complex role of infections in autoimmunity pathogenesis.

SUMMARY

Elucidating the exact role of each pathogen on each specific AID is important, as this will enable evaluating the manipulation of these infections in the treatment of AID.

Rheumatic aortic valve disease-when and who to repair?

Rheumatic valve disease is an endemic problem that is responsible for substantial morbidity and mortality in many countries. Unlike the rheumatic mitral valve, aortic repair continues to be challenging. A thorough understanding of the underlying mechanisms; structural and functional, is essential for repair. We here describe various methods of repair and outline our favoured techniques.

Time to tackle rheumatic heart disease: Data needed to drive global policy dialogues

Rheumatic heart disease (RHD) is an avoidable disease of poverty that persists predominantly in low resource settings and among Indigenous and other high-risk populations in some high-income nations. Following a period of relative global policy inertia on RHD, recent years have seen a resurgence of research, policy and civil society activity to tackle RHD; this has culminated in growing momentum at the highest levels of global health diplomacy to definitively address this disease of disadvantage. RHD is inextricably entangled with the global development agenda, and effective RHD action requires concerted efforts both within and beyond the health policy sphere. This report provides an update on the contemporary global and regional policy landscapes relevant to RHD, and highlights the fundamental importance of good data to inform these policy dialogues, monitor systems responses and ensure that no one is left behind.

The Cape Town Declaration on Access to Cardiac Surgery in the Developing World

Mission

to urge all relevant entities within the international cardiac surgery, industry and government sectors to commit to develop and implement an effective strategy to address the scourge of rheumatic heart disease in the developing world through increased access to life-saving cardiac surgery.

The role of social determinants of health in the risk and prevention of group A streptococcal infection, acute rheumatic fever and rheumatic heart disease: A systematic review

Background

Rheumatic heart disease (RHD) poses a major disease burden among disadvantaged populations globally. It results from acute rheumatic fever (ARF), a complication of Group A Streptococcal (GAS) infection. These conditions are acknowledged as diseases of poverty, however the role of specific social and environmental factors in GAS infection and progression to ARF/RHD is not well understood. The aim of this systematic review was to determine the association between social determinants of health and GAS infection, ARF and RHD, and the effect of interventions targeting these.

Methodology

We conducted a systematic literature review using PubMed, the Cochrane Library and Embase. Observational and experimental studies that measured: crowding, dwelling characteristics, education, employment, income, nutrition, or socioeconomic status and the relationship with GAS infection, ARF or RHD were included. Findings for each factor were assessed against the Bradford Hill criteria for evidence of causation. Study quality was assessed using a standardised tool.

Principle findings

1,164 publications were identified. 90 met inclusion criteria, comprising 91 individual studies. 49 (50.5%) were poor quality in relation to the specific study question. The proportion of studies reporting significant associations between socioeconomic determinants and risk of GAS infection was 57.1%, and with ARF/RHD was 50%. Crowding was the most assessed factor (14 studies with GAS infection, 36 studies with ARF/RHD) followed by socioeconomic status (6 and 36 respectively). The majority of studies assessing crowding, dwelling characteristics, education and employment status of parents or cases, and nutrition, reported a positive association with risk of GAS infection, ARF or RHD. Crowding and socioeconomic status satisfactorily met the criteria of a causal association. There was substantial heterogeneity across all key study aspects.

Conclusion

The extensive literature examining the role of social determinants in GAS infection, ARF and RHD risk lacks quality. Most were observational, not interventional. Crowding as a cause of GAS infection and ARF/RHD presents a practical target for prevention actions.

Rates of rheumatic heart disease (RHD) are high in disadvantaged populations globally. It results from acute rheumatic fever (ARF), a complication of Group A Streptococcal (GAS) infection. These are described as diseases of poverty, but exactly what components of poverty promote them has been unclear. The aim of this review was to find what specific social and environmental factors are associated with GAS infection, ARF and RHD, and if actions targeting these can reduce disease rates. We did a search of published literature and found 90 relevant articles. Many supported an association between GAS infection, ARF or RHD and crowding, dwelling characteristics, low education level and employment status, poor nutrition and low social class. There was enough evidence to show that crowding and socioeconomic disadvantage increase the risk of GAS infection and ARF/RHD. However, most studies were of fair to poor quality in their ability to answer the research question, and there was little interventional research. This may relate to challenges inherent in intervening to change social determinants of health, but may also suggest lesser research attention to health issues affecting disadvantaged populations. The association between crowding and disease risk strongly supports initiatives to reduce crowding. This should become a key target for ARF and RHD prevention.