Inter-rater and intra-rater reliability and agreement of echocardiographic diagnosis of rheumatic heart disease using the World Heart Federation evidence-based criteria.

OBJECTIVE: Different definitions have been used for screening for rheumatic heart disease (RHD). This led to the development of the 2012 evidence-based World Heart Federation (WHF) echocardiographic criteria. The objective of this study is to determine the intra-rater and inter-rater reliability and agreement in differentiating no RHD from mild RHD using the WHF echocardiographic criteria. METHODS: A standard set of 200 echocardiograms was collated from prior population-based surveys and uploaded for blinded web-based reporting. Fifteen international cardiologists reported on and categorised each echocardiogram as no RHD, borderline or definite RHD. Intra-rater and inter-rater reliability was calculated using Cohen's and Fleiss' free-marginal multirater kappa (κ) statistics, respectively. Agreement assessment was expressed as percentages. Subanalyses assessed reproducibility and agreement parameters in detecting individual components of WHF criteria. RESULTS: Sample size from a statistical standpoint was 3000, based on repeated reporting of the 200 studies. The inter-rater and intra-rater reliability of diagnosing definite RHD was substantial with a kappa of 0.65 and 0.69, respectively. The diagnosis of pathological mitral and aortic regurgitation was reliable and almost perfect, kappa of 0.79 and 0.86, respectively. Agreement for morphological changes of RHD was variable ranging from 0.54 to 0.93 κ. CONCLUSIONS: The WHF echocardiographic criteria enable reproducible categorisation of echocardiograms as definite RHD versus no or borderline RHD and hence it would be a suitable tool for screening and monitoring disease progression. The study highlights the strengths and limitations of the WHF echo criteria and provides a platform for future revisions.

Pre-participation cardiovascular evaluation in Pacific Island athletes.

BACKGROUND: Pre-participation cardiovascular evaluation (PPE) aims to detect cardiac disease with sudden cardiac death (SCD) risk. No study has focused on Pacific Island athletes. METHODS: A total of 2281 Pacific Island athletes were studied with (i) a questionnaire on family, personal history and symptoms, (ii) a physical examination and (iii) a 12-lead ECG. RESULTS: 85% presented a normal history and examination. A positive family history was 1.4-1.9 fold higher in Melanesians, Polynesians and Métis than in Caucasians, while a positive personal history, abnormal symptoms and abnormal examination was 1.3 fold higher in Melanesians and Métis than in others. Neither gender nor training level had a bearing on these results. Melanesians had higher T wave inversions (TWIs) in V2-V4 leads but had no CV abnormalities. Lateral or infero-lateral TWIs were found in 6 male and in 5 highly trained athletes and cardiomyopathies were diagnosed in 3/6 athletes. Overall, 3.9% athletes were found to have a CV abnormality and 0.8% had a risk of SCD. Polynesians and males were more at risk than the others while the level of training made no difference. In athletes at risk of SCD, the main detected CV diseases were cardiomyopathies, Wolff-Parkinson-White (WPW) and severe valve lesions of rheumatoid origin. CONCLUSIONS: PPE revealed that 3.9% presented CV abnormalities. A risk of SCD was found in 0.8% with cardiomyopathies, WPW, and severe valve lesions of rheumatoid origin. Melanesians, Polynesians and male of high level of training were more at risk than others.

Salt intake and iodine status of women in Samoa.

The objective of this study was to determine iodine nutrition status and whether iodine status differs across salt intake levels among a sample of women aged 18-45 years living in Samoa. A cross-sectional survey was completed and 24-hr urine samples were collected and assessed for iodine (n=152) and salt excretion (n=119). The median urinary iodine concentration (UIC) among the women was 88 µg/L (Interquartile range (IQR)=54-121 µg/L). 62% of the women had a UIC <100 µg/L. The crude estimated mean 24-hr urinary salt excretion was 6.6 (standard deviation 3.2) g/day. More than two-thirds (66%) of the women exceeded the World Health Organization recommended maximum level of 5 g/day. No association was found between median UIC and salt excretion (81 µg/L iodine where urinary salt excretion >=5 g/day versus 76 µg/L where urinary salt excretion <5 g/day; p=0.4). Iodine nutrition appears to be insufficient in this population and may be indicative of iodine deficiency disorders in Samoan women. A collaborative approach in monitoring iodine status and salt intake will strengthen both programs and greatly inform the level of iodine fortification required to ensure optimal iodine intake as population salt reduction programs take effect.

Salt Intakes, Knowledge, and Behavior in Samoa: Monitoring Salt-Consumption Patterns Through the World Health Organization's Surveillance of Noncommunicable Disease Risk Factors (STEPS).

This project measured population salt intake in Samoa by integrating urinary sodium analysis into the World Health Organization's (WHO's) STEPwise approach to surveillance of noncommunicable disease risk factors (STEPS). A subsample of the Samoan Ministry of Health's 2013 STEPS Survey collected 24-hour and spot urine samples and completed questions on salt-related behaviors. Complete urine samples were available for 293 participants. Overall, weighted mean population 24-hour urine excretion of salt was 7.09 g (standard error 0.19) to 7.63 g (standard error 0.27) for men and 6.39 g (standard error 0.14) for women (P=.0014). Salt intake increased with body mass index (P=.0004), and people who added salt at the table had 1.5 g higher salt intakes than those who did not add salt (P=.0422). A total of 70% of the population had urinary excretion values above the 5 g/d cutoff recommended by the WHO. A reduction of 30% (2 g) would reduce average population salt intake to 5 g/d, in line with WHO recommendations. While challenging, integration of salt monitoring into STEPS provides clear logistical and cost benefits and the lessons communicated here can help inform future programs.

Cost-effectiveness of reducing salt intake in the Pacific Islands: protocol for a before and after intervention study.

BACKGROUND: There is broad consensus that diets high in salt are bad for health and that reducing salt intake is a cost-effective strategy for preventing chronic diseases. The World Health Organization has been supporting the development of salt reduction strategies in the Pacific Islands where salt intakes are thought to be high. However, there are no accurate measures of salt intake in these countries. The aims of this project are to establish baseline levels of salt intake in two Pacific Island countries, implement multi-pronged, cross-sectoral salt reduction programs in both, and determine the effects and cost-effectiveness of the intervention strategies. METHODS/DESIGN: Intervention effectiveness will be assessed from cross-sectional surveys before and after population-based salt reduction interventions in Fiji and Samoa. Baseline surveys began in July 2012 and follow-up surveys will be completed by July 2015 after a 2-year intervention period.A three-stage stratified cluster random sampling strategy will be used for the population surveys, building on existing government surveys in each country. Data on salt intake, salt levels in foods and sources of dietary salt measured at baseline will be combined with an in-depth qualitative analysis of stakeholder views to develop and implement targeted interventions to reduce salt intake. DISCUSSION: Salt reduction is a global priority and all Member States of the World Health Organization have agreed on a target to reduce salt intake by 30% by 2025, as part of the global action plan to reduce the burden of non-communicable diseases. The study described by this protocol will be the first to provide a robust assessment of salt intake and the impact of salt reduction interventions in the Pacific Islands. As such, it will inform the development of strategies for other Pacific Island countries and comparable low and middle-income settings around the world.

The metabolic syndrome identifies a heterogeneous group of metabolic component combinations in the Asia-Pacific region.

AIM: To compare the prevalence of metabolic syndrome (MetS) by combinations of MetS components derived from the National Cholesterol Education Program Adult Treatment Panel III (ATPIII) and International Diabetes Federation (IDF) definitions. METHODS: Four studies with ethnically distinct populations from the Asia-Pacific region were selected from the DETECT-2 study database. The prevalences of combinations of MetS components using the modified ATPIII (modATPIII) and IDF MetS definitions were compared between sexes and across populations. RESULTS: A total of 22,952 participants from Australia, Japan, Korea and Samoa were included. The age-adjusted prevalence of modATPIII MetS varied from 9.4 to 35.8% in men and 10.3 to 57.2% in women; results for IDF were generally higher. Prevalences of the 16 possible MetS component combinations from the modATPIII definition that result in a diagnosis of MetS ranged from 0 to 12.7%. Of those with IDF-defined abdominal obesity, the prevalences of the 11 IDF-defined MetS component combinations ranged from 0.2 to 18.3%. CONCLUSIONS: The large variation in the prevalence of possible MetS component combinations to diagnose MetS may explain the different risk of cardiovascular outcomes associated with MetS in different populations, especially since particular combinations of MetS components are associated with different risk of cardiovascular disease.

Comparisons of metabolic syndrome definitions in four populations of the Asia-Pacific region.

BACKGROUND: To compare the prevalence of metabolic syndrome (MetS) by four MetS definitions in four Asia-Pacific populations, and to compare the prevalence of individual metabolic components. METHODS: Population-based cross-sectional studies from Australia, Japan, Korea, and Samoa were used to assess the World Health Organization (WHO), European Group for the Study of Insulin Resistance (EGIR), modified National Cholesterol Education Program Adult Treatment Panel III (modATPIII), and International Diabetes Federation (IDF) MetS definitions. Age-adjusted MetS prevalences were compared within and between countries and kappa statistics were used to determine the agreement between IDF and the other three definitions. RESULTS: Japanese people had the lowest prevalence of MetS regardless of definition, and Samoans generally the highest prevalence. Age-adjusted prevalences for the four definitions ranged from 16% to 42% in Australia, 3% to 11% in Japan, 7% to 29% in Korea and 17% to 60% in Samoa. With the exceptions of Korean and Japanese males, the highest prevalence of MetS was obtained with the IDF definition. The best overall agreement with IDF MetS definition was for modATPIII, and the worst for EGIR. There were marked differences in the prevalence of MetS between the sexes, with no systematic pattern, and between the prevalences of individual metabolic components. CONCLUSIONS: Differences in the prevalence of MetS and its components, using the various definitions, both within and between populations, indicate that caution is required when comparing studies from different countries. Determining the clinical significance of these differences will require prospective outcome studies.