Revisiting QT prolongation in acute rheumatic fever - Relevance for hydroxychloroquine treatment.

In-vitro evidence suggests hydroxychloroquine could be a potential immunomodulator for the inflammatory carditis of acute rheumatic fever (ARF). Hydroxychloroquine used as an anti-inflammatory agent has a low side effect profile but its use in the Covid-19 pandemic raised concerns about QTc interval prolongation and cardiac arrhythmias. The prolongation of QTc in ARF appears benign but has not been widely studied. We aim to report QTc intervals in a contemporary ARF population and consider implications for hydroxychloroquine use in ARF. The study cohort was 197 children <15 years of age with a clinical diagnosis of ARF. The QTc mean (SD) was 445 msec (28), range 370-545 msec. Eighteen percent of the cohort had a QTc > 99th percentile for normal by age and 8 patients (4%) had a QTc over 500 msec. There was no difference of QTc by age or gender. Inter-observer repeatability for QTc (n = 33) was 35 msec. The QTc is often prolonged in the early phase of ARF, meaning that QT prolonging medications should be used with caution in this setting. Serial ECG monitoring of the QT interval is recommended if hydroxycholoroquine is used in ARF.

Feasibility study assessing equitable delivery of newborn pulse oximetry screening in New Zealand's midwifery-led maternity setting.

OBJECTIVES: The aim of this study was to conduct New Zealand-specific research to inform the design of a pulse oximetry screening strategy that ensures equity of access for the New Zealand maternity population. Equity is an important consideration as the test has the potential to benefit some populations and socioeconomic groups more than others. SETTING: New Zealand has an ethnically diverse population and a midwifery-led maternity service. One quaternary hospital and urban primary birthing unit (Region A), two regional hospitals (Region B) and three regional primary birthing units (Region C) from three Health Boards in New Zealand's North Island participated in a feasibility study of pulse oximetry screening. Home births in these regions were also included. PARTICIPANTS: There were 27 172 infants that satisfied the inclusion criteria; 16 644 (61%) were screened. The following data were collected for all well newborn infants with a gestation age ≥35 weeks: date of birth, ethnicity, type of maternity care provider, deprivation index and screening status (yes/no). The study was conducted over a 2-year period from May 2016 to April 2018. RESULTS: Screening rates improved over time. Infants born in Region B (adjusted OR=0.75; 95% CI 0.67 to 0.83) and C (adjusted OR=0.29; 95% CI 0.27 to 0.32) were less likely to receive screening compared with those born in Region A. There were significant associations between screening rates and deprivation, ethnicity and maternity care provider. Lack of human and material resources prohibited universal access to screening. CONCLUSION: A pulse oximetry screening programme that is sector-led is likely to perpetuate inequity. Screening programmes need to be designed so that resources are distributed in the way most likely to optimise health outcomes for infants born with cardiac anomalies. ETHICS APPROVAL: This study was approved by the Health and Disability Ethics Committees of New Zealand (15/NTA/168).

Beyond first-degree heart block in the diagnosis of acute rheumatic fever.

OBJECTIVES: First-degree heart block is a minor manifestation of acute rheumatic fever. Second and third degree heart block and junctional rhythms occur less commonly. We report patients presenting with these latter three electrocardiographic abnormalities and investigate their diagnostic utility. DESIGN: Patients admitted to our centre meeting the 2014 New Zealand Rheumatic Fever Guideline Diagnostic Criteria for rheumatic fever over a 5-year period from January 2010 to December 2014 were identified. Clinical, haematologic, electrocardiographic, and echocardiographic records were reviewed. Electrocardiograms (ECG) were considered abnormal if there was second- or third-degree atrioventricular block or junctional rhythms. Comparative data from patients with advanced conduction abnormalities without a diagnosis of rheumatic fever during the same time period were reviewed. RESULTS: A total of 201 patients met inclusion criteria for rheumatic fever. Of these, 17 (8.5%) had transient abnormalities of atrioventricular conduction, 5 (2.5%) with second or third-degree atrioventricular block, and 12 (6%) junctional rhythms. The remaining 173 (86%) patients had evidence of rheumatic valvulitis at presentation. Only one patient without rheumatic fever was found to have advanced conduction abnormalities over the study period, from a total of 3702 ECG. CONCLUSIONS: This large contemporary cohort of acute rheumatic fever shows that 8.5% of cases had either advanced atrioventricular block or junctional rhythms both highly suggestive of the diagnosis in our population.