Handheld echocardiographic screening for rheumatic heart disease in rural South Kordofan, Sudan by junior medicals: Supporting task shifting for control of a serious disease

Background Rheumatic heart disease (RHD) is a major and preventable cause of cardiac mortality in Sudan, particularly in Kordofan. It can be detected early with a handheld echocardiography machine. Methods A cross-sectional study was conducted in South Kordofan State, Sudan (as part of a medical convoy organized by Khartoum Medical Students Association). A team of shortly trained medical students and newly graduated doctors conducted a handheld echocardiographic screening using a simplified protocol. All suspected cases were recorded and reviewed later by a senior pediatric cardiologist. Demographic and clinical features of screened subjects were studied. Data analysis was performed using the Statistical Package for Services and Solutions (SPSS 25). Descriptive statistics were presented as “number (%)” or “mean ± SD”. RHD prevalence was expressed as cases per 1000, and Chi-Square test/Fisher’s Exact test was used to compare RHD findings between different groups. Results The disease frequency was found to be 50 per 1000. Out of 452 screened subjects (age 10-25 years), 23 were found to have RHD with a male to female ratio of 1:1.5. Echocardiographic quality was acceptable in 93% of studies. The disease was mild in 70% and moderate or involving 2 valves in 30% of patients. Patients were contacted, advised to start penicillin prophylaxis and referred to cardiologists. Risk factors for the disease included father's occupation and village of residence. Conclusion Shortly trained junior medicals can assist in RHD echocardiographic surveillance in remote areas. South Kordofan state is highly endemic for RHD and a control program needs to be implemented. Handheld echocardiography is of value for early detection and management.

Assessing The Performance Characteristics of Handheld Ultrasound In A Rheumatic Heart Disease Screening Program

Background: Rheumatic heart disease affects 33 million people in low and middle income countries and is the leading cause of cardiovascular death among children and young adults. Penicillin prophylaxis has been shown to improve valvular function among patients with clinically silent or mild disease. Efforts to expand echocardiographic screening are focusing on simplified protocols, non-physician ultrasonographers, and portable ultrasound devices, including handheld ultrasound. Recent advances support the use of single-view screening protocols. With the increasing availability and low cost of handheld devices, prospective studies are needed to evaluate their performance in these settings. Methods: We conducted a cross-sectional pilot study among 19 at-risk school-children participating in a rheumatic heart disease screening program in Ethiopia comparing a handheld ultrasound device (Phillips Lumify) to a fully-equipped portable ultrasound machine (Sonosite M-Turbo). Results: Agreement between devices was similar for expert and non-expert review (84%). However, when reviewed by a non-expert the Lumify identified fewer screen-positive cases (p-value 0.083). We also compared non-expert to expert interpretation by device and found a significant difference in interpretation for the Lumify (p-value 0.025). There was a trend towards shorter jet length by color Doppler in the handheld ultrasound device for both expert and non-expert review. Conclusions: Our study highlights that screening echocardiograms for RHD may yield different results when a handheld ultrasound device is used.

Cost analysis of treating cardiovascular diseases in a super-specialty hospital

Cardiovascular care is expensive; hence, economic evaluation is required to estimate resources being consumed and to ensure their optimal utilization. There is dearth of data regarding cost analysis of treating various diseases including cardiac diseases from developing countries. The study aimed to analyze resource consumption in treating cardio-vascular disease patients in a super-specialty hospital. An observational and descriptive study was carried out from April 2017 to June 2018 in the Department of Cardiology, Cardio-Thoracic (CT) Centre of All India Institute of Medical Sciences, New Delhi, India. As per World Health Organization, common cardiovascular diseases i.e. Coronary Artery Disease (CAD), Rheumatic Heart Disease (RHD), Cardiomyopathy, Congenital heart diseases, Cardiac Arrhythmias etc. were considered for cost analysis. Medical records of 100 admitted patients (Ward & Cardiac Care Unit) of cardiovascular diseases were studied till discharge and number of patient records for a particular CVD was identified using prevalence-based ratio of admitted CVD patient data. Traditional Costing and Time Driven Activity Based Costing (TDABC) methods were used for cost computation. Per bed per day cost incurred by the hospital for admitted patients in Cardiac Care Unit, adult and pediatric cardiology ward was calculated to be Indian Rupee (INR) 28,144 (US$ 434), INR 22,210 (US$ 342) and INR 18,774 (US$ 289), respectively. Inpatient cost constituted almost 70% of the total cost and equipment cost accounted for more than 50% of the inpatient cost followed by human resource cost (28%). Per patient cost of treating any CVD was computed to be INR 2,47,822 (US $ 3842). Cost of treating Rheumatic Heart Disease was the highest among all CVDs followed by Cardiomyopathy and other CVDs. Cost of treating cardiovascular diseases in India is less than what has been reported in developed countries. Findings of this study would aid policy makers considering recent radical changes and massive policy reforms ushered in by the Government of India in healthcare delivery.

Impact of Outpatient-Based Exercise Prescription on Stable Rheumatic Heart Disease and Post Coronavirus Infection Individual- A Case Report

The outcome of covid-19 patients with co-morbidities has reported to be poor. Post covid exercise-based rehabilitation may have a major role in improving exercise tolerance and quality of life in post-covid-19 patients with co-morbidities. This case report discusses the clinical scenario of a 35-year-old person who is a known case of stable rheumatic heart disease since 29 years and recently diagnosed with covid-19 moderate pneumonia. He was referred to post covid outpatient department for post-covid physiotherapy rehabilitation. After one month of structured exercise-based rehabilitation, improvement recorded in his SF-12 and 6-minute walk distance. COVID-19 patients with co-morbidities seemed to have a poor prognosis, according to various studies. Post covid exercise-based rehabilitation may have a major role in improving exercise tolerance and quality of life in post-covid-19 patients with co-morbidities. There is no structured rehabilitative protocol designed for such unusual combination as of now hence our study focuses on this lacunae. This case report discusses the clinical scenario of a 35-year-old person who is a known case of stable Rheumatic heart disease in the last 29 years and recently diagnosed with COVID-19 moderate pneumonia. He was referred to post covid outpatient department for post-covid physiotherapy rehabilitation. The individual followed a structured exercise-based rehabilitation protocol for one month 6 times/week and improvement recorded in his SF-12 and 6-minute walk distance. There was improvement in six-minute walk distance by 150 meters and rate of perceived exertion was also improved from 9 score to 7 in 6-20 borg scale post one month. In comparison to pre-Rehabilitation, SF-12 improved the quality of life in both physical and mental sore. This case report concluded that there was a definite improvement in the walking distance and quality of life of the patient after post COVID physiotherapy rehabilitation.

Mean Levels of B-type Natriuretic Peptide (BNP) in Patients with Mitral Stenosis Caused by Rheumatic Heart Disease

Objective: Mitral stenosis caused by rheumatic heart disease (RHD) is the most common cause of valvular lesion in adults and prevalent in developing countries like Pakistan. Higher natriuretic peptide (BNP) levels can be observed in patients with moderate to severe untreated mitral stenosis and are associated with higher rates of morbidity and mortality. That is why this study aims to determine the association between levels of pro-BNP with severity (mild. Moderate, and severe) of mitral stenosis. Patients and Methods: This was a clinical prospective study carried out in the department of adult cardiology, national institute of cardiovascular diseases, Karachi from 8th august 2019 to 7th February 2020. Total 68 patients of either gender with age between 25-70 years had mitral stenosis of moderate to severe intensity (mitral valve area ≤1.5 cm2), diagnosed on echocardiography were included for final analysis. A simple blood sample was taken for the assessment of pro-BNP levels. Questionnaire was used for demographic & clinical data collection and analysed using SPSS version 22.0. Results: The overall mean age of study subjects was 42.21±11.50 years, ranging from 25 – 70 years. Among them, females were prevalent (n = 43, 63.2%). The overall mean serum BNP level was 1071.12±807.26 pg/ml and the mean difference of serum BNP level was not significant among groups of gender, age, and diabetes mellitus with p>0.05. Significantly raised levels of BNP were observed in patients with severe mitral stenosis as compared to moderate mitral stenosis, p<0.05 Conclusion: In conclusion, the mean BNP levels were higher in patients with severe Mitral Stenosis. Therefore, BNP may be used to complement the clinical and echocardiographic assessments in patients with Mitral Stenosis.

Relationship between Environmental Factors and Rheumatic Heart Disease

Background. Rheumatic fever (RF) and rheumatic heart disease (RHD) are the most common acquired heart diseases in children. Environmental factors have been reported to play an important role in RHD’s prevalence Aim. The main purpose of this study is to assess the associations between environmental factors and RHD in children. Methods. A case control study was conducted in the Department of Child Health, Haji Adam Malik Hospital from April to June 2017. The case group consisted of children aged 5-18 years with RHD while control group consisted of healthy children. Demographic, anthropometric, and laboratory data were collected along with environmental factors. Statistical analysis was done using Statistical Product and Service Solution (SPSS). A P value of <0,05 with 95% confidence interval was considered significant. Results. A total of 39 children were enrolled in each group. Subjects’ father who only went to elementary and junior high school had a higher risk of having children with RHD (OR 28; p = 0.032 and OR 15.75; p = 0.011, respectively). Subjects’ mother who only went to junior high school had 7 times higher risk of having children with RHD (p = 0.026). Low monthly income increased the risk of RHD (OR 3,68; p = 0,009). Tap water usage, meat consumption more than once per week, and feasibility to buy clothes >1 pair per year decreased the risk of RHD at 0,31 (p = 0,013), 0,3 (p = 0,016), and 0,04 times (p <0,001) respectively. Conclusion. Parent’s education, monthly family income, water source, frequency of meat consumption, and feasibility to buy clothes are related to RHD in children.