Global burden of rheumatic heart disease: trends from 1990 to 2019

Acute rheumatic fever and Post-streptococcal reactive arthritis

Acute rheumatic fever (ARF) and poststreptococcal reactive arthritis (PSRA) represent two distinct but related poststreptococcal conditions, both arising from an autoimmune response following Group A streptococcal (GAS) infection, typically pharyngitis. Although both illnesses have a shared trigger, their clinical presentations and long-term consequences differ markedly. ARF, a systemic inflammatory disorder, can impact several organs, particularly the heart, potentially resulting in chronic rheumatic heart disease with irreversible valve damage. The cornerstone of ARF treatment includes Streptococcus eradication therapy, symptom management, and secondary prophylaxis to prevent recurrence. In contrast, PSRA primarily presents as non-infectious, nonmigratory, persistent arthritis without carditis and generally resolves without lasting sequelae. Distinguishing PSRA from ARF is crucial for appropriate management and to avoid unnecessary long-term antibiotic prophylaxis. This review focuses on the key clinical features and diagnostic approaches for ARF and PSRA, along with an overview of their management strategies.

Severe adverse reactions to benzathine penicillin G in rheumatic heart disease: A systematic review and meta-analysis

BACKGROUND

Fear of severe adverse reaction (SAR) and reluctance of health care providers to administer intramuscular injections are major contributing factors to poor adherence of benzathine penicillin G (BPG) in the management of rheumatic heart disease (RHD). However, data on the risk of SARs following BPG injections for RHD are relatively limited and inconclusive. Our systematic review and meta-analysis aimed to evaluate the incidence of SARs associated with BPG injections used for secondary prophylaxis of RHD.

METHODS

A systematic literature search of PubMed, Scopus and Web of Science databases was conducted to identify relevant studies reporting adverse reactions following BPG injections in patients with acute rheumatic fever (ARF) and/or RHD. A random effect meta-analysis was performed to estimate the pooled incidence of SARs.

RESULT

Nine studies (eight cohort and one randomized controlled trial), comprising 11,587 participants and > 154,760 BPG injections, were included in the analysis. The pooled incidence of SARs was 9.7 per 10,000 cases (95% CI: 0.1-29.2) and 1.1 per 10,000 BPG injections (95% CI: 0.4-2.2). Six fatal reactions were reported (0.05% of patients and 24% of SARs), all occurring in patients with severe RHD.

CONCLUSION

SARs following BPG injections in patients with ARF or RHD are rare. Our findings highlight the importance of balancing the low rate of SARs against the benefits of BPG in secondary prophylaxis for RHD, particularly in high-risk populations. High-quality longitudinal research and comprehensive adverse reaction reporting are essential to address safety concerns among healthcare providers and patients that impact BPG delivery.

Upstream and Downstream Cardiovascular Changes in Rheumatic Mitral Stenosis: An Update

Rheumatic heart disease (RHD) and its complications are major health problems worldwide, especially in developing countries, owing to their high prevalence. Mitral stenosis (MS) is one of the most common lesions in RHD, either isolated or in combination with mitral regurgitation, and eventually leads to atrial fibrillation (AF), congestive heart failure, pulmonary hypertension (PH), and other complications, including ischemic stroke or limb ischemia, if not promptly diagnosed and treated. Recent studies have suggested that MS affects the cardiovascular system beyond mere obstructions. The presence of MS in RHD causes significant changes in the cardiovascular system, both upstream and downstream, affecting both the left and right ventricles. Rheumatic MS causes significant structural changes through inflammatory pathways and hemodynamic changes, owing to its obstructive effects. This review aims to discuss the vast changes in the cardiovascular system caused by rheumatic MS.

Prevalence of Rheumatic Heart Disease in First-Degree Relatives of Index-Cases: A Systematic Review and Meta-Analysis

Background

Rheumatic heart disease (RHD) is the leading cause of cardiac death in children, with over 300,000 annual fatalities. Immunological, genetic, and environmental factors contribute to an increased risk of RHD. It remains unclear whether first-degree relatives have a higher prevalence of RHD compared to the general population in the same region.

Methods

We performed a systematic review and meta-analysis of echocardiographic screening studies reporting the prevalence of RHD in family members of individuals with RHD or acute rheumatic fever. PubMed, Embase, Cochrane, and Lilacs databases were searched. RHD was classified as per the 2012 World Heart Federation criteria. Random-effects models assessed definite RHD prevalence in study groups.

Results

Four of the 1,160 studies were included, with 776 first-degree relatives screened. Two studies were from Africa, one from South America, and one from Oceania. In the first-degree relatives of index cases, the prevalence of RHD was 7% (95% confidence interval [CI] 3.7-13). The control group, individuals screened with no known RHD cases in their family, had a lower prevalence than first-degree relatives (risk ratio [RR] 0.44, 95% CI 0.26-0.75). There was no difference in the prevalence of RHD among siblings and parents of cases.

Conclusion

There is an overall prevalence of non-relatives from the respective region, which suggests that genetic predisposition may play a role. In future studies of RHD, the systematic screening of first-degree relatives should be considered with a better control group-socioeconomic, region, age, and sex-matched.

Rheumatic heart disease burden and determinants in cardiac patients: A follow up care concern in Ethiopia

Rheumatic heart disease (RHD) is a neglected tropical disease and remains one of the leading causes of cardiovascular-related deaths in Ethiopia. This study aims to assess the burden of RHD and identify its determinants in the country. A hospital-based cross-sectional study was employed from January 5 to April 15, 2023, among cardiac patients attending Jimma Medical Center. Socio-demographic data were collected using a structured interviewer-administered questionnaire and echocardiographic patterns were taken by senior cardiologists. Data were entered into Epidata Version 4.6 and exported to SPSS version 25.0 for analysis. Bivariable and multivariable logistic regressions were performed. A p value < 0.05 was considered statistically significant. Accordingly, the most frequent morbidities were RHD (n = 95, 27.9 %), hypertensive heart disease (n = 92, 27.1 %), ischemic heart disease (n = 54, 15.9 %), and dilated cardiomyopathies (n = 54, 15.9 %). Further, female sex [AOR = 3.06: 95 % CI 1.73-5.47], using wood (biomass fuel) for cooking [AOR = 1.94: 95 % CI 1.10-3.42], history of malnutrition with follow-up at a health facility [AOR = 3.90: 95 % CI 2.22-6.86], dental caries [AOR = 2.09: 95 % CI 1.12-3.87], and living in crowded households [AOR = 2.02: 95 % CI 1.15-3.52] were identified as the determinants of RHD. This finding suggests that focusing on female healthcare, reducing biomass fuel exposure, improving nutritional status, providing regular dental care, and improving living conditions could help reduce the impacts of the disease. Moreover, conducting further research regularly will also benefit the community at large.

Recent Advances on the Prevention and Management of Rheumatic Heart Disease

The global burden of rheumatic heart disease (RHD) remains substantial, particularly in low-income countries, despite advancements in prevention and management strategies. This article emphasizes the strategies related to primordial prevention, primary prevention, and secondary prevention, including recent advancements in vaccine development, and discusses current challenges in management and future research directions. For treatment, it evaluates percutaneous mitral commissurotomy, mitral valve repair, and replacement, noting the advantages of individualized approaches based on patient conditions. Addressing RHD's global burden requires equitable access to surgical treatments, robust healthcare systems, and sustainable strategies for prevention and care.

Acceptability and Implementation Challenges of Benzathine Penicillin G Secondary Prophylaxis for Rheumatic Heart Disease in Ethiopia: A Qualitative Study

Background

Monthly intramuscular injections of benzathine penicillin G (BPG) remain the cornerstone of secondary prophylaxis for acute rheumatic fever and rheumatic heart disease (RHD). The barriers to successful delivery of BPG may be patient- or service-delivery-dependent.

Objective

The aim of the present study was to explore the perceived acceptability and implementation challenges of BPG treatment for RHD, from the perspective of healthcare providers (HCPs).

Methodology

A descriptive qualitative study using semi-structured interview guides was conducted in four public hospitals in Ethiopia. Physicians and nurses who had at least 1 year of experience in delivering RHD secondary prophylaxis were recruited. The interviews were audio recorded, transcribed verbatim, and translated into English for analysis using framework method thematic analysis. Identified behavioral factors were mapped onto a theoretical framework of acceptability (TFA), and the Capability, Opportunity, Motivation-Behavior (COM-B) model.

Result

Twenty-two interviews were conducted with HCPs (mean age 39 years, 55% nurses). Insights into BPG use and acceptability were categorized into four major themes related to: (1) individual factors (e.g., fear of anaphylactic reaction), (2) health system barriers (e.g., BPG shortage), (3) patient/caregiver perceptions (e.g., reliance on injectables, over expectation of treatment outcomes), and (4) product (e.g., injection pain, needle blockage).

Conclusions

HCPs identified facilitators and barriers which highlight the complexities associated with BPG as secondary prophylaxis for RHD in Ethiopia. Based on these data, we suggest RHD control programs should (1) provide cross-disciplinary training and education programs to support safe and context-appropriate delivery of BPG (2) improve resourcing of health facilities to facilitate safe drug delivery, (3) establish a comprehensive system for auditing severe adverse reactions post-BPG injection to generate robust pharmacovigilance data, and consider alternative approaches to BPG delivery including access to improved formulations (e.g., BPG suspension formulations in pre-filled syringes).

Highlights

- Key barriers included (a) resistance from healthcare providers to administer benzathine penicillin G (BPG) due to their concerns about injection-related severe adverse events, and potential repercussions should an event occur, (b) poor community and healthcare provider awareness of the disease and its treatment, (c) lack of resources to manage adverse events, and (d) injection pain.- Key enablers included (a) perceived superior treatment benefits of BPG and (b) co-administration of lidocaine/analgesics to reduce injection pain.- Recommendations to address identified challenges include (a) improved training/education on RHD diagnosis, disease progression, and treatment, (b) improved access to supportive resources, (c) active adverse reaction monitoring and reporting, and (d) encouraging the provision/access of globally subsidized BPG suspension formulations in pre-filled syringes.

Prevalence of pulmonary hypertension and associated factors among rheumatic heart disease patients in Ethiopia

BACKGROUND

In developing countries evidences regarding pulmonary hypertension (PH) in rheumatic heart disease (RHD) patients are lacking, despite being responsible for significant morbidity and mortality. As a result, identifying the factors that influence PH is crucial to improve the quality of care.

OBJECTIVE

To determine prevalence of pulmonary hypertension and its associated factors among rheumatic heart disease patients at the public hospitals of Bahir Dar city, Ethiopia.

METHODS

An institution based prospective cross-sectional study was conducted among RHD patients who had follow up at the two public hospitals of Bahir Dar city from January 2022 to December 2023. It involved 310 patients selected by systematic random sampling technique. Pretested, structured, and interviewer-administered questionnaires were used to collect sociodemographic and diseases related parameters.Transthoracic echocardiography by cardiologist was used to assess PH. Data were entered using Epidata Manager version 4.6 and analyzed using SPSS version 27. Multivariate logistic regression analysis was used to identify determinants of PH, considering with a p-value of < 0.05 as statically significant, with a 95% confidence interval.

RESULTS

The mean systolic pulmonary arterial pressure (sPAP) of the participants was 50.2 mmHg [SD ± 25.0 mmHg]. The prevalence of PH among RHD patients was 56.5% (95% CI 50.9 - 61.9) from which 51.4% had severe PH. Severe mitral valve stenosis (AOR 7.8, 95% CI 2.4-25.7), duration of illness ≥ 3 years (AOR 7.7, 95% CI 2.1-28.5), and diuretics use (AOR 5.6, 95% CI 2.2-14.3) were factors associated with PH. In contrast, valvular intervention (AOR 0.06, 95% CI 0.01-0.29) and LVEF ≥ 50% (AOR 0.14, 95% CI 0.02-0.81) were found to be protective factors.

CONCLUSIONS

The prevalence of PH among RHD patients in Ethiopia is high and it's associated with delayed presentation & complications. Special attention should be paid to early surgical or percutaneous valvular intervention for those who have indication, before they develop permanent cardiac remodeling and LVFE become reduced. As a result, access to valvular intervention need to be addressed to improve PH related morbidity & mortality among RHD patients in Ethiopia.

Unveiling End-of-Life Disparities in Chronic Rheumatic Heart Disease: A 22-Year Analysis of the CDC-WONDER Database

Background This research examines mortality patterns and the place of death in individuals with chronic rheumatic heart disease (RHD) in the United States, aiming to identify demographic predictors for home or hospice death. Additionally, the study aims to uncover trends in mortality due to RHD and provide a predictive forecast. Methods The study utilized data from the Centers for Disease Control and Prevention (CDC)-Wide-Ranging Online Data for Epidemiologic Research (WONDER) database, which spans 22 years (1999-2020), and was categorized based on place of death, including home or hospice care, inpatient, outpatient, or emergency room deaths, and nursing home facility deaths. The data was further analyzed by age, gender, race, and region. The Autoregressive Integrated Moving Average (ARIMA) model was used for statistical analysis and forecasting. Results A total of 73,673 deaths were analyzed, and age was found to be a significant predictor of place of death. The highest number of deaths was in the 85+ age group, followed by a decrease in likelihood with decreasing age. Individuals residing in the West were more likely to die at home or in hospice compared to those in other regions. White individuals had a higher likelihood of dying at home or in hospice compared to other racial groups. Conclusions The findings emphasize the importance of considering patients' preferences and ensuring equitable access to end-of-life care services, regardless of their demographic background. The study highlights the need for further research to improve access to palliative care, reduce disparities in end-of-life care, and enhance the quality of life for individuals with chronic RHD and their families.

Rheumatic Heart Disease Burden: A Comparative Analysis between the United States and the European Union

Background

Rheumatic heart disease (RHD) is a major challenge to global health, primarily in low- and middle-income countries. Even though RHD is rare in high-income countries, it still poses a health challenge, yet there is a lack of data on its impact within the highest-income regions.

Objectives

The purpose of this study was to compare the epidemiology of RHD in the United States of America (USA) and the European Union (EU).

Methods

Data on RHD burden were collected using the Global Disease Burden Study 2021 using the Global Health Data Exchange query tool. Age-standardized rates of incidence (ASIR), prevalence (ASPR), death (ASDR), disability-adjusted life years (ASDALY), years lived with disability (ASYLD), and years of life lost (ASYLL) were collected. Estimated annual percentage change (EAPC) was calculated.

Results

In USA in 2021, the ASPR was 123.4/100,000 with a decreasing annual trend of 0.32% since 1993. Between 2021 and 1993, the ASIR decreased from 10.6 to 10.0/100,000 cases. In the EU in 2021, the ASPR was 49.7/100,000 cases, with an annual decreasing trend of 1.6% between 2021 and 1993. Between 2021 and 1993, the ASIR decreased from 7.43 to 4.6/100,000 cases. The changing prevalence and incidence in the US was primarily driven by Florida, Nevada, and Tennessee. There has been a reversal in the burden of RHD since 2007 in the USA. In both regions, there was a significant gender disparity with female predominance. The EU reported higher age-standardized disability-adjusted life years and age-standardized years of life losts than the USA.

Conclusions

The varied trends underscore the complexity of RHD epidemiology and the need for region-specific strategies to address this persistent health challenge.

Invasive group A Streptococcus infection (Streptococcus pyogenes): Current situation in Spain

Group A ß-hemolytic Streptococcus (S. pyogenes), also known as GAS, is a Gram-positive bacterium. It can be easily identified in the microbiology laboratory by its ability to hemolyse blood in culture media. This bacterium is highly virulent due to its production of enzymes and toxins, and its ability to cause immunologically mediated diseases such as rheumatic fever and post-streptococcal glomerulonephritis. GAS is the primary cause of bacterial pharyngotonsillitis, although it is typically a benign and non-invasive disease. However, it also has the potential to cause severe skin and soft tissue infections, necrotising fasciitis, bacteraemia and endocarditis, pneumonia and empyema, and streptococcal toxic shock syndrome, without any age or predisposition limits. The term invasive GAS disease (iGAS) is used to refer to this group of conditions. In more developed countries, iGAS disease has declined thanks to improved hygiene and the availability of antibiotics. For example, rheumatic fever has practically disappeared in countries such as Spain. However, recent data suggests a potential increase in some iGAS diseases, although the accuracy of this data is not consistent. Because of this, the COVID and Emerging Pathogens Committee of the Illustrious Official College of Physicians of Madrid (ICOMEM) has posed several questions about invasive GAS infection, especially its current situation in Spain. The committee has enlisted the help of several experts in the field to answer these questions. The following lines contain the answers that we have collaboratively produced, aiming to assist not only the members of ICOMEM but also anyone interested in this topic.

Global Disparities in Outcomes of Pregnant Individuals With Rheumatic Heart Disease: A Scoping Review

Background

Rheumatic heart disease (RHD) remains as 1 of the major contributors to indirect pregnancy-related mortality and morbidity worldwide and disproportionately affects marginalized populations.

Objectives

In this scoping review, the authors sought to explore the socioeconomic, cultural, and health care access-related causes of global disparities in outcomes of pregnancy among individuals with RHD.

Methods

We performed a literature search of all studies published between January 1, 1990, and January 1, 2022, that investigated causes for disparate outcomes in pregnant individuals with RHD.

Results

Of the 3,544 articles identified, 16 were included in the final analysis. The key reasons for disparate outcomes included lack of secondary antibiotic RHD prophylaxis; late and more severe RHD diagnosis, differences in management and antenatal care access; lack of expert and coordinated multidisciplinary care; suboptimal patient health education; inadequate access to RHD medication, intervention and surgery in pregnancy; and limited financial and economic resources.

Conclusions

These findings illustrated using a life-course approach demonstrate opportunities for clinical and public health interventions to improve outcomes in this population.

Valvular Heart Disease-Related Mortality Between Middle- and High-Income Countries During 2000 to 2019

Background

Valvular heart disease (VHD) management has evolved rapidly in recent decades, but disparities in health care access persist among countries with varying socioeconomic backgrounds.

Objectives

The purpose of this study was to investigate global mortality trends from VHD and assess the difference between middle- and high-income countries.

Methods

We obtained mortality data from the World Health Organization Mortality Database for VHD and its subgroups (rheumatic valvular disease [RVD], infective endocarditis [IE], aortic stenosis [AS], and mitral regurgitation [MR]) from 2000 to 2019. Age-specific and age-standardized mortality rates per 100,000 persons in middle- and high-income countries were calculated, and trends were analyzed using joinpoint regression.

Results

A total of 93 countries (42 middle-income and 51 high-income) were included in the analysis. Both middle- and high-income countries showed an increasing trend in crude VHD mortality rate. In middle-income countries, the age-standardized VHD-related mortality rate was constant (0.0%/year), with decreasing RVD (-2.7%/year) and increasing IE, AS, and MR (0.8%/year, 2.0%/year, and 2.2%/year, respectively). In high-income countries, the age-standardized VHD-related mortality rate was decreasing (-0.6%/year). However, there was a rapid increase in mortality rate from IE in age ≤39 years after 2009 (7.0%/year). Moreover, there was a decreasing mortality rate from AS after 2015 but an increasing rate from MR after 2013, particularly in age ≥80 years.

Conclusions

Our study identified a rising burden of VHD-related mortality worldwide. The distribution and trends of VHD mortality differed between middle- and high-income countries. Further investigation is needed to understand the underlying etiology of these varying mortality trends in VHD and its subgroups.

HUSM endocarditis team's approach to acute ruptured chordae tendineae in chronic rheumatic heart disease

Neglected rheumatic heart disease (RHD) can lead to severe complications and change patients' quality of life, particularly that of young patients. This report highlights the importance of public health education for patients and families in preventing RHD complications. In RHD management, prevention is better than cure.

European Society of Cardiology: the 2023 Atlas of Cardiovascular Disease Statistics

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the 2021 report in presenting cardiovascular disease (CVD) statistics for the ESC member countries. This paper examines inequalities in cardiovascular healthcare and outcomes in ESC member countries utilizing mortality and risk factor data from the World Health Organization and the Global Burden of Disease study with additional economic data from the World Bank. Cardiovascular healthcare data were collected by questionnaire circulated to the national cardiac societies of ESC member countries. Statistics pertaining to 2022, or latest available year, are presented. New material in this report includes contemporary estimates of the economic burden of CVD and mortality statistics for a range of CVD phenotypes. CVD accounts for 11% of the EU's total healthcare expenditure. It remains the most common cause of death in ESC member countries with over 3 million deaths per year. Proportionately more deaths from CVD occur in middle-income compared with high-income countries in both females (53% vs. 34%) and males (46% vs. 30%). Between 1990 and 2021, median age-standardized mortality rates (ASMRs) for CVD decreased by median >50% in high-income ESC member countries but in middle-income countries the median decrease was <12%. These inequalities between middle- and high-income ESC member countries likely reflect heterogeneous exposures to a range of environmental, socioeconomic, and clinical risk factors. The 2023 survey suggests that treatment factors may also contribute with middle-income countries reporting lower rates per million of percutaneous coronary intervention (1355 vs. 2330), transcatheter aortic valve implantation (4.0 vs. 153.4) and pacemaker implantation (147.0 vs. 831.9) compared with high-income countries. The ESC Atlas 2023 report shows continuing inequalities in the epidemiology and management of CVD between middle-income and high-income ESC member countries. These inequalities are exemplified by the changes in CVD ASMRs during the last 30 years. In the high-income ESC member countries, ASMRs have been in steep decline during this period but in the middle-income countries declines have been very small. There is now an important need for targeted action to reduce the burden of CVD, particularly in those countries where the burden is greatest.

Spatiotemporal patterns of rheumatic heart disease burden attributable to high systolic blood pressure, high sodium diet, and lead exposure (1990 to 2019): a longitudinal observational study

Background

Rheumatic heart disease (RHD) continues to be a significant global health concern, exhibiting unique regional disparities. Although there is a noted decline in the burden of RHD, the specific causatives for this decrease remain unclear. This study aims to identify and quantify the spatiotemporal patterns related to the RHD-attributable risk burden.

Methods

The data pertaining to deaths and disability-adjusted life years (DALYs) attributable to RHD risk were drawn from the Global Burden of Disease (GBD) study conducted from 1990 to 2019. These data, categorized by age, gender, and geographical location, highlighted risk factors including diets high in sodium, elevated systolic blood pressure (SBP), and lead exposure. To examine the long-term trends in RHD changes due to these specific risk factors, the average annual percentage change (AAPC) method was used.

Results

During the past 30 years, the highest decrease in RHD burden was attributed to high SBP. An AAPC of -2.73 [95% confidence interval (CI): -2.82 to -2.65] and - 2.45 (95% CI: -2.55 to -2.36) in deaths and DALYs was attributable to high SBP, while an AAPC of -3.99 (95% CI: -4.14 to -3.85) and - 3.74 (95% CI: -3.89 to -3.6) in deaths and DALYs was attributed to a diet high in sodium. Moreover, the trends in deaths and DALYs due to lead exposure also showed decreases with an AAPC of -2.94 (95% CI: -3 to -2.89) and - 3.46 (95% CI: -3.58 to -3.34) from 1990 to 2019. Oceania showed an upward trend of the RHD DALYs due to high SBP, with an AAPC of 0.23 (95% CI: 0.13 to 0.33). In general, countries in Oceania, East Asia, and South Asia had higher age-standard deaths and DALY rates of RHD due to diets high in sodium.

Conclusion

Our study has revealed that high SBP remains the prime risk factor contributing to the RHD burden. There are decreasing spatiotemporal patterns in RHD-related deaths and burdens. Gaining this knowledge is fundamental to making informed public health strategies and clinical decisions, especially concerning risk assessment, screening, and prevention initiatives.

Cost and cost-effectiveness of treatments for rheumatic heart disease in low- and middle-income countries: a systematic review protocol

OBJECTIVE

This review will synthesize studies on costs, the impact of these costs, and the cost-effectiveness of treatments for rheumatic heart disease (RHD) in low- and middle-income countries.

INTRODUCTION

RHD incurs high costs owing to its clinical complexity, surgical treatments, and prolonged hospital stays. Thus, the disease has a substantial economic impact on the health system, patients, and their families. No systematic review on economic evidence of treatments for RHD has been published to date.

INCLUSION CRITERIA

This review will consider all cost and cost-effectiveness studies on RHD treatments for children and young adults (5─30 years) residing in low- and middle-income countries.

METHODS

The review will follow the JBI methodology for systematic reviews of economic evaluation evidence. The search strategy will locate published and unpublished studies in English. Systematic searches will be conducted in MEDLINE (PubMed), MEDLINE (Ovid), Embase (Ovid), Scopus, CINAHL (EBSCOhost), National Health Service Economic Evaluation Databases, Pediatric Economic Database Evaluation, and Cost-Effectiveness Analysis Registry. Two independent reviewers will screen titles and abstracts, followed by a full-text review based on the inclusion criteria. Data will be extracted using a modified JBI data extraction form for economic evaluations. JBI's Dominance Ranking Matrix for economic evaluations will be used to summarize and compare the results of cost and cost-effectiveness studies. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach will be used to assess the certainty of economic evidence for outcomes related to resource use.

REVIEW REGISTRATION

PROSPERO CRD42023425850.

Intramuscular versus enteral penicillin prophylaxis to prevent progression of rheumatic heart disease: Study protocol for a noninferiority randomized trial (the GOALIE trial)

BACKGROUND

Rheumatic Heart Disease (RHD) persists as a major cardiovascular driver of mortality and morbidity among young people in low-and middle-income countries. Secondary antibiotic prophylaxis (SAP) with penicillin remains the cornerstone of RHD control, however, suboptimal treatment adherence undermines most secondary prevention programs. Many of the barriers to optimal SAP adherence are specific to the intramuscular form of penicillin and may potentially be overcome by use of oral penicillin. This noninferiority trial is comparing the efficacy of intramuscular to oral penicillin SAP to prevent progression of mild RHD at 2 years.

METHODS/DESIGN

The Intramuscular vs Enteral Penicillin Prophylaxis to Prevent Progression of Rheumatic Heart Disease (GOALIE) trial is randomizing Ugandan children aged 5 to 17 years identified by echocardiographic screening with mild RHD (Stage A or B as defined by 2023 World Heart Federation criteria) to Benzathine Benzyl Penicillin G (BPG arm, every-28-day intramuscular penicillin) or Phenoxymethyl Penicillin (Pen V arm, twice daily oral penicillin) for a period of 2 years. A blinded echocardiography adjudication panel of 3 RHD experts and 2 cardiologists is determining the echocardiographic stage of RHD at enrollment and will do the same at study completion by consensus review. Treatment adherence and study retention are supported through peer support groups and case management strategies. The primary outcome is the proportion of children in the Pen V arm who progress to more advanced RHD compared to those in the BPG arm. Secondary outcomes are patient-reported outcomes (treatment acceptance, satisfaction, and health related quality of life), costs, and cost-effectiveness of oral compared to intramuscular penicillin prophylaxis for RHD. A total sample size of 1,004 participants will provide 90% power to demonstrate noninferiority using a margin of 4% with allowance for 7% loss to follow-up. Participant enrollment commenced in October 2023 and final participant follow-up is expected in December 2026. The graphical abstract (Fig. 1) summarizes the flow of echocardiographic screening, participant enrollment and follow-up.

DISCUSSION

The GOALIE trial is critical in global efforts to refine a pragmatic approach to secondary prevention for RHD control. GOALIE insists that the inferiority of oral penicillin be proven contemporarily and against the most important near-term clinical outcome of progression of RHD severity. This work also considers other factors that could influence the adoption of oral prophylaxis and change the calculus for acceptable efficacy including patient-reported outcomes and costs.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05693545.

BASELINE CLINICAL CHARACTERISTICS OF CONTEMPORARY ADULT CHRONIC RHEUMATIC HEART DISEASE IN IBADAN, NIGERIA

Introduction

Introduction: Rheumatic heart disease (RHD) is a major public health issue, especially in developing countries. Globally, the largest increase in RHD incidence over 30 years was seen in sub-Saharan Africa, further contributing to the burden of cardiovascular disease in a region with high rates of hypertensive heart disease and cardiomyopathies. There are few reports describing the contemporary clinical profile of RHD in Nigeria.

Objective

The objective of the study is to describe the profile of RHD at the University College Hospital Ibadan.

Methodology

This is an analysis of data collected on adult patients aged 18 years and above attending the cardiology service of the University College Hospital, Ibadan, Nigeria between September 1, 2016, and August 31, 2021. We collected information on the bio-data, clinical features, and echocardiographic diagnoses.

Results

During this period, 92 cases of RHD were diagnosed and 24 (26.1%) were male. The mean age of the study population was 49.67 ± 17.54 years, with ages ranging from 16 to 86 years. Most participants (45.7%) were within the age group of 30-49 years. Most (70.8%) of the participants presented in NYHA Class II heart failure. The most common presentation mode was dyspnea on exertion and nocturnal cough (64.1%). Mitral regurgitation was the commonest lesion (65.4%).

Conclusion

Rheumatic heart disease is still a common cause of adult heart disease in Ibadan. There is a need for concerted efforts to tackle the burden of this disease by increasing screening among high-risk groups, improving access to healthcare, and increasing the uptake of secondary prophylaxis in those with a previous history of rheumatic fever.

Incidence and predictors of adverse outcomes in patients with rheumatic mitral stenosis following percutaneous balloon mitral valvuloplasty: a study from a tertiary center in Thailand

BACKGROUND

Rheumatic mitral stenosis (MS) remains a common and concerning health problem in Asia. Percutaneous balloon mitral valvuloplasty (PBMV) is the standard treatment for patients with symptomatic severe MS and favorable valve morphology. However, studies on the incidence and predictors of adverse cardiac outcomes following PBMV in Asia have been limited. This study aims to evaluate the incidence and predictors of adverse outcomes in patients with rheumatic MS following PBMV.

METHODS

A retrospective cohort study was conducted on patients with symptomatic severe MS who underwent successful PBMV between 2002 and 2020 at a tertiary academic institute in Thailand. Patients were followed up to assess adverse outcomes, defined as a composite of cardiac death, heart failure hospitalization, repeat PBMV, or mitral valve surgery. Univariable and multivariable analyses were performed to identify predictors of adverse outcomes. A p-value of < 0.05 was considered statistically significant.

RESULTS

A total of 379 patients were included in the study (mean age 43 ± 11 years, 80% female). During a median follow-up of 5.9 years (IQR 1.7-11.7), 74 patients (19.5%) experienced adverse outcomes, with an annualized event rate of 2.7%. Multivariable analysis showed that age (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.008-1.05, p = 0.006), significant tricuspid regurgitation (HR 2.17, 95% CI 1.33-3.56, p = 0.002), immediate post-PBMV mitral valve area (HR 0.39, 95% CI 0.25-0.64, p = 0.01), and immediate post-PBMV mitral regurgitation (HR 1.91, 95% CI 1.18-3.07, p = 0.008) were independent predictors of adverse outcomes.

CONCLUSIONS

In patients with symptomatic severe rheumatic MS, the incidence of adverse outcomes following PBMV was 2.7% per year. Age, significant tricuspid regurgitation, immediate post-PBMV mitral valve area, and immediate post-PBMV mitral regurgitation were identified as independent predictors of these adverse outcomes.

Assessment of suitability for percutaneous mitral commissurotomy: a contemporary review of key anatomical criteria and predictive models

The immediate result of percutaneous balloon mitral commissurotomy is largely determined by the anatomy of the mitral valve complex. Several scores and models have been developed to assess anatomical suitability for percutaneous balloon mitral commissurotomy. Although none has an optimal predictive power, these models look at the valvular apparatus from different perspectives bearing the potential for a complementary role.

The Echocardiographic Diagnosis of Rheumatic Heart Disease: A Review of the Performance of the World Heart Federation Criteria 2012-2023

Background

The World Heart Federation (WHF) published the first evidence-based guidelines on the echocardiographic diagnosis of rheumatic heart disease (RHD) in 2012. These guidelines have since been applied internationally in research and clinical practice. Substantial research has assessed the utility of the 2012 WHF criteria, including its applicability in low-resource settings. This article summarises the evidence regarding the performance of the guidelines.

Methods

A scoping review assessing the performance of the guidelines was performed. Cochrane, Embase, Medline, PubMed Lilacs, Sielo, and Portal BVS databases were searched for studies on the performance of the guidelines between January 2012-March 2023, and 4047 manuscripts met the search criteria, of which 34 were included. This included papers assessing the specificity, inter-rater reliability, application using hand-carried ultrasound, and modification of the criteria for simplicity. The review followed the PRISMA Extension for Scoping Reviews guideline.

Results

The WHF 2012 criteria were 100% specific for definite RHD when applied in low-prevalence populations. The criteria demonstrated substantial and moderate inter-rater reliability for detecting definite and borderline RHD, respectively. The inter-rater reliability for morphological features was lower than for valvular regurgitation. When applied to hand-carried ultrasound performed by an expert, modified versions of the criteria demonstrated a sensitivity and specificity range of 79-90% and 87-93% respectively for detecting any RHD, performing best for definite RHD. The sensitivity and the specificity were reduced when performed in task-sharing but remains moderately accurate.

Conclusion

The WHF 2012 criteria provide clear guidance for the echocardiographic diagnosis of RHD that is reproducible and applicable to a range of echocardiographic technology. Furthermore, the criteria are highly specific and particularly accurate for detecting definite RHD. There are limitations in applying all aspects of the criteria in specific settings, including task-sharing. This summary of evidence can inform the updated version of the WHF guidelines to ensure improved applicability in all RHD endemic regions.

A Rare Case of Severe Mitral Stenosis Presenting As Cardiogenic Shock

We report a case of severe mitral stenosis (MS) in a 58-year-old female from Guyana. Though rheumatic MS continues to be less prevalent in third-world countries, it poses a significant threat as far as morbidity and mortality are concerned. The modern definition of "Third World" is used to classify countries that are poor or developing. Countries that are part of the "third world" are generally characterized by (1) high rates of poverty, (2) economic and/or political instability, and (3) high mortality. The standard method of diagnosing MS in patients has been established as transthoracic echocardiograms (TTE), along with pertinent historical and physical exam findings. Specifically, with TTE, criteria include a mitral valve area ≤1.5 cm2, severe left atrial enlargement, and elevated pulmonary artery systolic pressure >50 millimeters of mercury (mmHg). Once diagnosed with severe MS, treatment options for patients range from non-surgical percutaneous mitral balloon valvuloplasty to surgical mitral valve commissurotomy. In our case, she was a 58-year-old female with a past medical history of seizures of unknown etiology, not on any home medication regimen, presenting to the emergency department with shortness of breath, malaise, weight loss, and bilateral lower leg edema. Vitals were significant for tachycardia at 153 bpm, tachypnea at 24 breaths per minute, and saturating at 96% on room air. On the physical exam, there was an irregularly irregular rhythm, bilateral crackles at the bases, right upper quadrant tenderness to palpation, bilateral pitting edema, and no calf tenderness. Lab findings were significant for elevated brain natriuretic peptide, but three electrocardiograms were performed in the emergency department, all confirming the new onset of atrial fibrillation. A CT angiogram of the chest was performed, which ruled out pulmonary embolus but additionally found marked reflux of contrast noted within the inferior vena cava and hepatic veins, along with right atrial dilation reflective of right heart strain; additionally, mitral valve calcifications were noted. The cardiologist on duty confirmed the diagnosis using point-of-care ultrasound (POCUS) followed by TTE; the patient was rapidly transferred to a hospital with appropriate services for surgical management within the same day of arrival at the emergency department. This case highlights the importance of bedside POCUS as an additional diagnostic tool for cardiologists, along with pertinent history, physical examination findings, and laboratory findings. Proper utilization of POCUS can allow for the immediate diagnosis of severe pathologies and prevent the delay of appropriate treatment, as seen in our case. Wider adoption of POCUS practices as a part of the general initial evaluation of patients has not yet been recommended by the American Heart Association but can offer clinical benefit in morbidity/mortality with expedited progression to appropriate treatment.

Left Ventricle Myocardial Work Correlated with Functional Capacity in Severe Rheumatic Mitral Stenosis with Preserved Left Ventricular Ejection Fraction

Background and Aims

Functional capacity is reduced in mitral stenosis (MS) patients. Previous studies showed a correlation between left atrial strain and functional capacity in this population. However, currently, no left ventricle (LV) echocardiographic parameters were associated with functional capacity in patients with MS. Noninvasive LV pressure-strain loop analysis is a new echocardiographic method for evaluating LV function, integrating longitudinal strain from speckle-tracking analysis and noninvasively measured blood pressure to estimate myocardial work (MW) that overcomes the preload-dependent characteristics conventional parameters by integrating afterload. This study aimed to evaluate the association between MW and functional capacity measured using exercise tests in patients with severe MS and preserved LV ejection fraction (LVEF).

Methods

Adult patients with symptomatic severe rheumatic MS (mitral valve area <1.5 cm2), and preserved LVEF (>50%) and sinus rhythm who underwent echocardiography and exercise stress test in our hospital from 2019 to 2021 were included. Exclusion criteria were suboptimal image quality for myocardial deformation analysis, significant mitral regurgitation or aortic valve lesions, coronary artery disease, intracardiac shunt, and atrial fibrillation. Standard echocardiographic parameters were measured, and all MW parameters were included. Exercise treadmill testing was performed using the modified Bruce protocol.

Results

A total of 33 individuals with isolated severe rheumatic MS in sinus rhythm (age 39.8 ± 9.8 years) were included in the study. Patients with severe isolated MS showed significantly impaired LV-global longitudinal strain values compared to normal reference values. Furthermore, patients with severe MS showed significantly lower values of global work index, global constructive work, and efficiency compared to normal values and higher wasted work. Global work efficiency was significantly correlated to the duration of exercise (P = 0.025, Pearson's r = 0.389).

Conclusions

In stable patients with isolated severe mitral stenosis, MW efficiency significantly correlated with functional capacity measured objectively through exercise testing.

Recent Scientific Advancements towards a Vaccine against Group A Streptococcus

Group A Streptococcus (GAS), or Streptococcus pyogenes, is a gram-positive bacterium that extensively colonises within the human host. GAS is responsible for causing a range of human infections, such as pharyngitis, impetigo, scarlet fever, septicemia, and necrotising fasciitis. GAS pathogens have the potential to elicit fatal autoimmune sequelae diseases (including rheumatic fever and rheumatic heart diseases) due to recurrent GAS infections, leading to high morbidity and mortality of young children and the elderly worldwide. Antibiotic drugs are the primary method of controlling and treating the early stages of GAS infection; however, the recent identification of clinical GAS isolates with reduced sensitivity to penicillin-adjunctive antibiotics and increasing macrolide resistance is an increasing threat. Vaccination is credited as the most successful medical intervention against infectious diseases since it was discovered by Edward Jenner in 1796. Immunisation with an inactive/live-attenuated whole pathogen or selective pathogen-derived antigens induces a potent adaptive immunity and protection against infectious diseases. Although no GAS vaccines have been approved for the market following more than 100 years of GAS vaccine development, the understanding of GAS pathogenesis and transmission has significantly increased, providing detailed insight into the primary pathogenic proteins, and enhancing GAS vaccine design. This review highlights recent advances in GAS vaccine development, providing detailed data from preclinical and clinical studies across the globe for potential GAS vaccine candidates. Furthermore, the challenges and future perspectives on the development of GAS vaccines are also described.

Echocardiographic Screening of Rheumatic Heart Disease: Current Concepts and Challenges

The incidence of acute rheumatic fever (ARF), which most commonly affects children aged 5-15 years after group A Streptococcus (GAS) infection, ranges from 8 to 51 per 100 000 people worldwide. Rheumatic heart disease (RHD), which occurs when patients with ARF are inappropriately treated or not given regular prophylaxis, is the most common cause of non-congenital heart disease in children and young adults in low-income countries. Timely treatment of GAS infection can prevent ARF, and penicillin prophylaxis can prevent recurrence of ARF. Secondary prophylaxis with benzathine penicillin G has been shown to decrease the incidence of RHD and is a key aspect of RHD control. The most important factor determining the prognosis of RHD is the severity of cardiac involvement. Although approximately 70% of patients with carditis in the acute phase of the disease recover without sequelae, carditis is important because it is the only complication of ARF that causes sequelae. One-third of patients with ARF are asymptomatic. Patients with mild symptoms of recurrent ARF and silent RHD will develop severe morbidities within 5-10 years if they do not receive secondary preventive treatments. A new screening program should be established to prevent cardiac morbidities of ARF in moderate- and highrisk populations. In the present study, we examined the applicability of echocardiographic screening programs for RHD. Cite this article as: Topçu S, Uçar T. Echocardiographic screening of rheumatic heart disease: Current concepts and challenges. Turk Arch Pediatr. 2024;59(1):3-12.

Effect of Educational Intervention on Awareness, Attitude, and Practices of Mothers Regarding the Prevention of Rheumatic Fever: A Quasi-Experimental Study

The awareness, attitudes, and practices of mothers regarding rheumatic fever (RF) remain obscure, therefore, this study aimed to assess the level of awareness, attitude, and practice of mothers regarding RF. A Quasi-experimental study was conducted on 100 mothers who visited medical centers in Yazd province in 2023 to evaluate the level of awareness, attitude, and practice, with the results reported after the intervention using self-made questionnaires. Statistical tests such as the Kruskal-Wallis test, T-test, One-Way analysis of variance, and Mann-Whitney were used. A significance level of P < .05 was assumed. The mean score of awareness was 6.63 (2.6) and 9.52 (2.59), attitude was 12.56 (4.75) and 17.51 (6.72) and practice was 13.97(5.52) and 19.25 (7.04) of mothers regarding rheumatic fever were before and after study, respectively. The results of mixed effects models showed that education has a significant effect on awareness (P < .001), attitude (P < .001), and practice (P < .001). The mean score of attitude, practice, and awareness were increased by 2.98, 5.28, and 4.95, respectively, after the intervention. Based on the findings, it was observed that mothers have a moderate awareness of rheumatic fever (RF) despite the high burden, poor attitude, and practice. The results of the current study also demonstrate the influence of education in promoting positive practices. Effective training can have a positive impact on the awareness, attitudes, and practices of mothers.

Temporal Trends of Age-Adjusted Mortality Rates for Rheumatic Heart Disease in Brazil From 2000 to 2021

Background Rheumatic heart disease (RHD) is a chronic cardiovascular condition stemming from an infectious origin, posing a substantial health burden, particularly in economically disadvantaged regions. It starts with acute rheumatic fever (ARF), a complication following group A Streptococcus infection, leading to heart valve damage and, over time, structural heart abnormalities. RHD contributes to premature deaths, especially in low-middle-income countries. Although the incidence and prevalence have generally reduced globally due to antibiotics and improved healthcare, it remains a significant public health concern in Brazil, echoing its prevalence in many developing nations around the world. RHD stands as a poignant testament to the intersection of socio-economic disparities and healthcare challenges within Brazil's diverse population. In Brazil, despite advancements in healthcare, RHD continues to impact communities, highlighting the urgent need for enhanced prevention strategies, access to quality healthcare services, and heightened awareness to combat this preventable, yet persistent, cardiac condition. Understanding the epidemiological landscape and socio-cultural factors influencing RHD in Brazil is crucial for developing targeted interventions aimed at mitigating its burden on individuals, families, and the healthcare system at large. Thus, our study focuses on analyzing age-related mortality rates linked to ARF and chronic RHD (ARHD) in Brazil from 2000 to 2021, particularly examining gender disparities. Materials and methods This retrospective cohort study employed a descriptive time-series approach, utilizing comprehensive nationwide data from Brazil spanning from 2000 to 2021 to assess trends in diverse age groups, among both sexes, enabling a detailed analysis of temporal patterns. Mortality data, extracted and categorized meticulously, were subjected to Joinpoint statistical analyses enabling comparative assessments, with average annual percent change (AAPC) and annual percent change (APC) serving as key metrics to quantify and interpret trends over the analyzed period. Results The acute RHD (ARHD)-related mortality declined over the analyzed years supported by AAPC, with higher mortality reduction in females. The age-adjusted mortality rate for "males and females" decreased from 78 to 67 deaths/100,000 from 2000 to 2021. Female mortality dropped from 85 to 69/100,000, and male mortality decreased from 73 to 63/100,000 over the same period. For ARHD, male age groups (20-29, 60-69, 70-79, 80+) showed declining mortality, while the 30-59 age group exhibited an upward. Females AAMR for chronic RHD (CRHD) decreased across all age groups, with significant reductions in the 80 years and above age group from 2000-2002 (APC: -11.94*) and steadily from 2002 onwards (APC: -1.33). Conclusions Our study revealed an overall decline in mortality rates for both acute and CRHD across both sexes. Females consistently exhibited higher mortality rates and a more pronounced reduction compared to males in both acute and CRHD. In ARHD, males experience the highest mortality in the 50-59 age group, while females have a peak in the 40-49 age group. The 60-69 age group had the highest mortality in CRHD for both sexes. Conversely, the 20-29 age group displayed the lowest mortality in CRHD, and the 80-89 age group had the lowest mortality in ARHD.

At the Heart of the Community: Implementation of Echocardiographic Screening for Rheumatic Heart Disease in Primary Care Facilities of Northern Borneo Island

BACKGROUND

Rheumatic heart disease (RHD) is a potentially life-threatening condition that causes long-standing public health concerns. Echocardiography is a reliable diagnostic and screening technique for many cardiovascular conditions, including RHD. It is commonly used in tertiary care facilities worldwide but less so in the community setting. The primary aim of this study was to introduce and elaborate on the echocardiographic screening for RHD that was implemented by a Malaysian primary care clinic in Penampang district, Sabah. We also set out to present the uptake of the service in its initial years of establishment, as well as the challenges faced.

METHODS

In the first part of this study, document reviews were conducted to compile relevant information about the conceptualization and implementation of this service. Following that, we also obtained secondary data on the echocardiographic screening service from its first implementation in April 2020 until May 2021 to examine the uptake and the patient profile.

RESULTS

From April 2020 to May 2021, a total of 189 echocardiographic screening was conducted by primary care doctors using handheld ultrasound. Of the 189 children screened, 19 (10.1%) were found to have cardiac anomalies and were referred for a formal echocardiogram. Upon follow-up, 8 were detected with mild mitral regurgitation and referred to the nearest tertiary hospital for further management.

CONCLUSION

Based on our review, the echocardiographic screening for RHD among children conducted by the Penampang Health Clinic was deemed successful. Echocardiogram service provided by primary care centers located in suburban and rural areas is highly beneficial for patients with poor access to specialized health care services because they stay far away from tertiary care facilities. Tapping into family medicine physicians located closer to communities to conduct echocardiographic screening and review the results can improve the detection of cardiac anomalies requiring further investigation. With the success of this project, echocardiographic services in the primary healthcare setting can be expanded by garnering the necessary collaborative efforts and consistent support from various stakeholders.

Research opportunities for the primordial prevention of rheumatic fever and rheumatic heart disease-streptococcal vaccine development: a national heart, lung and blood institute workshop report

Streptococcus pyogenes, also known as group A streptococcus (StrepA), is a bacterium that causes a range of human diseases, including pharyngitis, impetigo, invasive infections, and post-infection immune sequelae such as rheumatic fever and rheumatic heart disease. StrepA infections cause some of the highest burden of disease and death in mostly young populations in low-resource settings. Despite decades of effort, there is still no licensed StrepA vaccine, which if developed, could be a cost-effective way to reduce the incidence of disease. Several challenges, including technical and regulatory hurdles, safety concerns and a lack of investment have hindered StrepA vaccine development. Barriers to developing a StrepA vaccine must be overcome in the future by prioritising key areas of research including greater understanding of StrepA immunobiology and autoimmunity risk, better animal models that mimic human disease, expanding the StrepA vaccine pipeline and supporting vaccine clinical trials. The development of a StrepA vaccine is a complex and challenging process that requires significant resources and investment. Given the global burden of StrepA infections and the potential for a vaccine to save lives and livelihoods, StrepA vaccine development is an area of research that deserves considerable support. This report summarises the findings of the Primordial Prevention Working Group-VAX, which was convened in November 2021 by the National Heart, Lung, and Blood Institute. The focus of this report is to identify research gaps within the current StrepA vaccine landscape and find opportunities and develop priorities to promote the rapid and successful advancement of StrepA vaccines.

Global burden and trends of three common road injuries from 1990 to 2019 and the implications for prevention and intervention

BACKGROUND

Analysis on the burden of specific types of road injuries (RIs) in the previous Global burden of disease (GBD) studies is lacking. The present work aimed to analyze the burden of three common RIs using the updated data of the GBD 2019, which would inform policy-making.

METHODS

Data on cyclist road injuries (CRIs), motorcyclist road injuries (MRIs), and motor vehicle road injuries (MVRIs) were extracted from the GBD 2019. Trends of age-standardized rate (ASR) were predicted using estimated annual percentage change (EAPC) from 1990 to 2019.

RESULTS

Over the past three decades, the global incident ASRs of CRIs and MRIs presented increasing trends, but that of MVRIs declined slightly. However, trends of death and disability adjusted life years (DALYs) caused by three common RIs decreased in most regions and countries. Particularly, trends in ASRs of years of life lost (YLLs) cuased by RIs decreased more pronouncedly than that of years of life lived with disability (YLDs). The burden of three common RIs showed significant social and demographic characteristics. Low-middle and middle socio-demographic index (SDI) areas had a heavy burden of RIs, particularly CRIs and MRIs. However, the high SDI area undertook a relatively low burden, and presented more pronounced downward trends in death and DALYs.

CONCLUSIONS

The burden and changing trends of three common RIs were geographically heterogeneous. The findings highlighted that increasing incident trends of RIs needed more cost-effective measures of prevention and intervention.

The burden of rheumatic heart disease in the Middle East and North Africa region, 1990-2019

BACKGROUND

Rheumatic heart disease (RHD) is a treatable and preventable condition resulting from acute rheumatic fever.

AIM

To report the prevalence, mortality and disability-adjusted life-years (DALY) due to RHD in the Middle East and North Africa (MENA) region from 1990 to 2019, by sex, age group, country and sociodemographic index (SDI).

METHODS

Information on the prevalence, mortality and DALY associated with RHD were obtained from the Global Burden of Disease Study 2019. Data were gathered for all countries in the MENA region over the period 1990-2019. These data included counts and age-standardized rates per 100,000, accompanied by 95% uncertainty intervals (UIs).

RESULTS

The MENA region had an age-standardized point prevalence of 388.9 per 100,000 in 2019, which was 5.4% higher than in 1990. The annual incidence rate was 1.6, which was 63.4% lower than in 1990. There were 379.4 thousand DALY attributable to RHD in 2019, with an age-standardized rate of 67.1, which was 61.3% lower than in 1990. In 2019, an estimated 7.4 thousand deaths were due to RHD, and the age-standardized death rate was 63.4% lower in 2019 than in 1990. DALY rates rose steadily with increasing age in both males and females. The SDI correlated negatively with the rate of DALY for RHD throughout the study period.

CONCLUSION

The burden of RHD in MENA declined from 1990 to 2019, demonstrating the importance of regularly updating health data and identifying risk factors, and developing effective guidelines on prevention.

Analysis and comparison of the trends in burden of rheumatic heart disease in China and worldwide from 1990 to 2019

OBJECTIVES

This study aimed to describe the temporal trends in age and gender burdens of rheumatic heart disease (RHD) in China from 1990 to 2019, including incidence, prevalence, mortality, and disability-adjusted life years (DALYs), and to compare them with the global burden of the disease.

METHODS

Using open data from the Global Burden of Disease (GBD) database from 1990 to 2019, this study analyzed the characteristics of RHD burden in China and worldwide, including changes in incidence, prevalence, mortality, and DALYs. Joinpoint was used to calculate the average annual percentage change (AAPC) and the corresponding 95% confidence interval (95% CI) to reflect the trends in the burden of RHD. A comprehensive comparative analysis of the differences in RHD burden between China and the rest of the world was conducted from multiple dimensions, including age, gender, and time periods.

RESULTS

From 1990 to 2019, the age-standardized incidence rate (ASIR) of RHD in China decreased from 29.62/100,000 to 23.95/100,000, while the global ASIR increased from 32.69/100,000 to 37.40/100,000. The age-standardized prevalence rate (ASPR) in China decreased from 446.15/100,000 to 390.24/100,000, while the global ASPR increased from 451.56/100,000 to 513.68/100,000. The age-standardized rates of mortality (ASMR) in China decreased from 18.11/100,000 to 4.04/100,000, while the global ASMR decreased from 8.94/100,000 to 3.85/100,000. The age-standardized DALY rate (ASDR) in China decreased from 431.45/100,000 to 93.73/100,000, while the global ASDR decreased from 283.30/100,000 to 132.88/100,000. The AAPC of ASIR, ASPR, ASMR, and ASDR in China was - 0.73%, -0.47%, -5.10%, and - 5.21%, respectively, while the AAPC of the global burden of RHD was 0.48%, 0.45%, -2.87%, and - 2.58%, respectively. The effects of age and gender on the burden of RHD were different. ASIR generally decreased with increasing age, while ASPR increased first and then decreased. ASMR and ASDR increased with increasing age. Women had higher incidence and mortality rates of RHD than men.

CONCLUSION

From 1990 to 2019, the incidence, prevalence, mortality, and DALYs of RHD in China decreased, indicating a relative reduction in the burden of RHD in China. The burden of RHD is age-related, with a higher prevalence observed in the younger population, a peak incidence among young adults, and a higher mortality rate among the elderly population. Women are more susceptible to RHD and have a higher risk of mortality than men. Given China's large population and aging population, RHD remains a significant public health challenge in China.

Research priorities for the primordial prevention of acute rheumatic fever and rheumatic heart disease by modifying the social determinants of health

The social determinants of health (SDH), such as access to income, education, housing and healthcare, strongly shape the occurrence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) at the household, community and national levels. The SDH are systemic factors that privilege some more than others and result in poverty and inequitable access to resources to support health and well-being. Primordial prevention is the modification of SDH to improve health and reduce the risk of disease acquisition and the subsequent progression to RHD. Modifying these determinants using primordial prevention strategies can reduce the risk of exposure to Group A Streptococcus, a causative agent of throat and skin infections, thereby lowering the risk of initiating ARF and its subsequent progression to RHD.This report summarises the findings of the Primordial Prevention Working Group-SDH, which was convened in November 2021 by the National Heart, Lung, and Blood Institute to assess how SDH influence the risk of developing RHD. Working group members identified a series of knowledge gaps and proposed research priorities, while recognising that community engagement and partnerships with those with lived experience will be integral to the success of these activities. Specifically, members emphasised the need for: (1) global analysis of disease incidence, prevalence and SDH characteristics concurrently to inform policy and interventions, (2) global assessment of legacy primordial prevention programmes to help inform the co-design of interventions alongside affected communities, (3) research to develop, implement and evaluate scalable primordial prevention interventions in diverse settings and (4) research to improve access to and equity of services across the RHD continuum. Addressing SDH, through the implementation of primordial prevention strategies, could have broader implications, not only improving RHD-related health outcomes but also impacting other neglected diseases in low-resource settings.

Global, Regional, and National Advances Toward the Management of Rheumatic Heart Disease Based on the Global Burden of Disease Study 2019

Background Population growth, aging, and major alterations in epidemiologic trends inadvertently modulate the status of rheumatic heart disease (RHD) epidemiology. This investigation predicted RHD burden pattern and temporal trends to provide epidemiologic evidence. Methods and Results Prevalence, mortality, and disability-adjusted life-years data for RHD were obtained from the GBD (Global Burden of Disease) study. We performed decomposition analysis and frontier analysis to assess variations and burden in RHD from 1990 to 2019. In 2019, there were >40.50 million RHD cases worldwide, along with nearly 0.31 million RHD-related deaths and 10.67 million years of healthy life lost to RHD. The RHD burden was commonly concentrated within lower sociodemographic index regions and countries. RHD primarily affects women (22.52 million cases in 2019), and the largest age-specific prevalence rate was at 25 to 29 years in women and 20 to 24 years in men. Multiple reports demonstrated prominent downregulation of RHD-related mortality and disability-adjusted life-years at the global, regional, and national levels. Decomposition analysis revealed that the observed improvements in RHD burden were primarily due to epidemiological alteration; however, it was negatively affected by population growth and aging. Frontier analysis revealed that the age-standardized prevalence rates were negatively linked to sociodemographic index, whereas Somalia and Burkina Faso, with lower sociodemographic index, showed the lowest overall difference from the frontier boundaries of mortality and disability-adjusted life-years. Conclusions RHD remains a major global public health issue. Countries such as Somalia and Burkina Faso are particularly successful in managing adverse outcomes from RHD and may serve as a template for other countries.

Comparison of machine learning algorithms to predict intentional and unintentional poisoning risk factors

Introduction

A major share of poisoning cases are perpetrated intentionally, but this varies depending on different geographical regions, age spectrums, and gender distribution. The present study was conducted to determine the most important factors affecting intentional and unintentional poisonings using machine learning algorithms.

Materials and methods

The current cross-sectional study was conducted on 658 people hospitalized due to poisoning. The enrollment and follow-up of patients were carried out during 2020-2021. The data obtained from patients' files and during follow-up were recorded by a physician and entered into SPSS software by the registration expert. Different machine learning algorithms were used to analyze the data. Fit models of the training data were assessed by determining accuracy, sensitivity, specificity, F-measure, and the area under the rock curve (AUC). Finally, after analyzing the models, the data of the Gradient boosted trees (GBT) model were finalized.

Results

The GBT model rendered the highest accuracy (91.5 ± 3.4) among other models tested. Also, the GBT model had significantly higher sensitivity (94.7 ± 1.7) and specificity (93.2 ± 4.1) compared to other models (P < 0.001). The most prominent predictors based on the GBT model were the route of poison entry (weight = 0.583), place of residence (weight = 0.137), history of psychiatric diseases (weight = 0.087), and age (weight = 0.085).

Conclusion

The present study suggests the GBT model as a reliable predictor model for identifying the factors affecting intentional and unintentional poisoning. According to our results, the determinants of intentional poisoning included the route of poison entry into the body, place of residence, and the heart rate. The most important predictors of unintentional poisoning were age, exposure to benzodiazepine, creatinine levels, and occupation.

The rise and fall of acute rheumatic fever and rheumatic heart disease: a mini review

Introduction

The incidences of acute rheumatic fever (ARF) and rheumatic heart disease (RHD), which were leading causes of death in children in the 1920s, have decreased substantially. Considering the recent resurgence of scarlet fever and increased incidence of streptococcal pharyngitis in children, an investigation of the current status of ARF and RHD may be worthwhile.

Objective

To summarize the prevalence trends, pathogenic factors, and prevention strategies for ARF and RHD in children.

Methods

A selective search of literature published between January 1920 and February 2023 was done in PubMed, using the terms "acute rheumatic fever", "rheumatic heart disease", "group A Streptococcus", "pharyngitis", "pharyngeal tonsillitis", "scarlet fever", "impetigo", "obstructive sleep apnea syndrome" and "child".

Results

Overcrowded homes and inadequate sanitation led to recurrent group A streptococcal infection, and the causal relationship between group A streptococcal infection and ARF/RHD was well established. Streptococcal infectious diseases, such as group A streptococcal pharyngeal tonsillitis, SF, impetigo, and obstructive sleep apnea syndrome, were associated with the occurrence of ARF and RHD. ARF and RHD were still prevalent in young people of developing countries and economically poor populations of high-income countries. Universal disease registration systems were critical to locating disease outbreaks, tracking disease transmission, and identifying high-risk populations. Four-level prevention strategies were effective in reducing the incidence and mortality of ARF and RHD.

Conclusions

Registry and preventive measures for ARF and RHD should be strengthened in areas of dense population; poor sanitation; resurgence of SF; and high incidence of streptococcal pharyngitis, impetigo, and obstructive sleep apnea syndrome.

Sub-clinical rheumatic heart disease (RHD) detected by hand-held echocardiogram in children participating in a school-based RHD prevention program in Tanzania

BACKGROUND

Rheumatic Heart Disease (RHD) continues to cause suffering and premature deaths in many sub-Saharan Africa (SSA) countries, where the disease is still endemic. RHD is largely preventable and determining its community burden is an important critical step in any RHD prevention program.

METHODS

We conducted a cross-sectional study of 5-16 years old pupils from 11 primary schools participating in an RHD prevention program in 4 districts in Tanzania, between 2018 and 2019. At the school, all children were invited to participate after receiving consent from their parents/guardians. Participating children filled a questionnaire and were auscultated for cardiac murmurs. Echocardiographic screening was done by two experienced cardiologists, using a hand-held machine (V-Scan, GE®). All positive screening tests were stored for further examination by the same two cardiologists to reach to a consensus of definite, borderline or no RHD, using a modified World Heart Federation (WHF) criterion.

RESULTS

Of the 6895 children invited, 4738 (68.7%) were screened and 4436 (64.3%) had complete data. The mean (SD) age was 10.04 (2.43) years, and 2422 (54.6%) were girls. Fifty three (1.2%) children were found to have a murmur. The proportion of children with trace or mild valvular regurgitation, sub-valvular/chordal thickening and valvular thickening/deformity were 8.3%, 1.3%, and 1.0%, respectively. Sub-clinical RHD was found in 95 children (59 definite and 36 borderline), giving a prevalence of 2.1%, [95% CI 1.7% - 2.6%]. Sub-clinical RHD was independently associated with female sex (aOR 1.83, 95% CI 1.18-2.85, p = 0.007), older age groups (aOR 1.73, 95% CI 1.10-2.72, p = 0.018 for age group 11-14 years; and aOR 3.02 95% CI 1.01-9.05, p = 0.048 for age group 15-16 years), as well as presence of a cardiac murmur, aOR 5.63 95% CI 2.31-13.69, p < 0.0001. None of the studied socio- or economic factors was associated with the presence of sub-clinical RHD in this study.

CONCLUSION

The prevalence of sub-clinical RHD among primary school children in Tanzania is 2.1%, similar to previous reports in SSA. Efforts to prevent and control RHD in our communities are highly warranted.