Silent Acute Rheumatic Fever Unmasked by Using Handheld Echocardiography for Febrile Children Presenting in a Rheumatic Heart Disease-Endemic Area.

OBJECTIVE: To understand the burden of acute rheumatic fever (ARF) among children living in low-income countries who present to the hospital with febrile illness and to determine the role of handheld echocardiography (HHE) in uncovering subclinical carditis as a major manifestation of ARF. STUDY DESIGN: This was a cross-sectional study carried at the Pediatric Hospital in Al Obeid, North Kordofan, Sudan, from September 2022 to January 2023 and including febrile children 3 through 18 years of age with or without clinical features of ARF and without another cause for their fever (not excluding malaria). History, examination, blood investigations, and HHE were done. ARF was diagnosed according to the Jones criteria. Clinical ARF was diagnosed if there was a major clinical Jones criterion and silent ARF if the only major Jones criteria was subclinical carditis. RESULTS: The study cohort included 400 children with a mean age of 9 years. Clinical ARF was diagnosed in 95 patients (95/400, 24%), most of whom presented with a joint major manifestation (88/95, 93%). Among the 281 children who did not present with a clinical manifestation of ARF, HHE revealed rheumatic heart disease (RHD) in 44 patients (44/281, 16%); 31 of them fulfilled criteria for silent ARF (31/281, 11%). HHE increased the detection of ARF by 24%. HHE revealed mild RHD in 41 of 66 (62%) and moderate or severe RHD in 25 of 66 (38%) patients. Both sensitivity and specificity of HHE compared with standard echocardiography were 88%. CONCLUSIONS: There is a significant burden of ARF among febrile children in Sudan. HHE increased the sensitivity of diagnosis, with 11% of children having subclinical carditis as their only major manifestation (ie, silent ARF). RHD-prevention policies need to prioritize decentralization of echocardiography to improve ARF detection.

Advocacy at the Eighth World Congress of Pediatric Cardiology and Cardiac Surgery.

The Eighth World Congress of Pediatric Cardiology and Cardiac Surgery (WCPCCS) will be held in Washington DC, USA, from Saturday, 26 August, 2023 to Friday, 1 September, 2023, inclusive. The Eighth World Congress of Pediatric Cardiology and Cardiac Surgery will be the largest and most comprehensive scientific meeting dedicated to paediatric and congenital cardiac care ever held. At the time of the writing of this manuscript, The Eighth World Congress of Pediatric Cardiology and Cardiac Surgery has 5,037 registered attendees (and rising) from 117 countries, a truly diverse and international faculty of over 925 individuals from 89 countries, over 2,000 individual abstracts and poster presenters from 101 countries, and a Best Abstract Competition featuring 153 oral abstracts from 34 countries. For information about the Eighth World Congress of Pediatric Cardiology and Cardiac Surgery, please visit the following website: [www.WCPCCS2023.org]. The purpose of this manuscript is to review the activities related to global health and advocacy that will occur at the Eighth World Congress of Pediatric Cardiology and Cardiac Surgery.Acknowledging the need for urgent change, we wanted to take the opportunity to bring a common voice to the global community and issue the Washington DC WCPCCS Call to Action on Addressing the Global Burden of Pediatric and Congenital Heart Diseases. A copy of this Washington DC WCPCCS Call to Action is provided in the Appendix of this manuscript. This Washington DC WCPCCS Call to Action is an initiative aimed at increasing awareness of the global burden, promoting the development of sustainable care systems, and improving access to high quality and equitable healthcare for children with heart disease as well as adults with congenital heart disease worldwide.

Sudan's rheumatic fever and rheumatic heart disease guidelines: a simplified approach in an endemic country.

Background: Rheumatic heart disease (RHD) is a preventable sequelae of group A beta hemolytic streptococcal infection leading to an immune reaction: acute rheumatic fever (ARF) and progressive heart valve dysfunction. RHD is the leading cause of acquired heart disease in children and young adults in Sudan and many low/middle-income countries. In 2018, the World Health Organization (WHO) issued a resolution for RHD mandating that each country adopt updated guidelines for ARF and RHD management. These current guidelines are mainly directed to primary healthcare workers. Methods: Sudan's Federal Ministry of Health (FMOH) in collaboration with the WHO East Mediterranean Regional Office (EMRO) assembled a committee for updating RHD guidelines. We conducted a systematic literature search from 2000 to 2022 in National Institute of Health Database (PubMed) under the following titles: streptococcal pharyngitis, acute rheumatic fever, rheumatic heart disease, benzathine penicillin. Best available, evidence-based practices for diagnosis and management of ARF/RHD were selected and adapted to Sudan's situation. The guidelines were critically appraised by the committee then endorsed to the FMOH and WHO EMRO Noncommunicable Disease Departments in January 2023. This paper describes the updated guidelines. Results: Simplified algorithms are provided for diagnosis of bacterial pharyngitis including two clinical criteria: sore throat and the absence of viral symptoms in the target age group. A simplified algorithm for diagnosis and management of ARF is adopted using two levels of diagnosis: suspected case at primary level where penicillin prophylaxis is started and secondary/tertiary care where echocardiography is performed and diagnosis confirmed or excluded. Echocardiography screening is recognized as the standard method for early diagnosis of RHD; however, due to the anticipated limitations, its implementation was not adopted at this time. Streptococcal skin infection is included as a precursor of ARF and a detailed protocol for benzathine penicillin administration is described. Conclusion: The Sudan guidelines for ARF/RHD management were updated. Endorsement of these guidelines to FMOH and WHO EMRO is expected to improve control of RHD in the region.

Kawarabi: Administrative Structuring of a Multicenter Research Collaborative to Study Kawasaki Disease in the Arab Countries.

Kawasaki disease (KD), the leading cause of acquired heart disease in children in developed countries, merits conducting detailed studies in Arab countries. We introduce Kawarabi, as a multicenter research collaborative effort dedicated to improving diagnosis, care, and outcome of children and adults with KD in the Arab world. During the COVID-19 pandemic, there emerged a new multisystem inflammatory syndrome in children; a disease similar to KD. This highlighted the challenges that Arab physicians face in diagnosing and managing children with KD and KD-like illnesses. Kawarabi brings together experts in North America and Arab nations to study this family of diseases in a not-for-profit, voluntary scientific collaborative setting. Bylaws addressing the vision, objectives, structure, and governance of Kawarabi were established, and vetted by the 45 organizing members in 2021. An initial scientific publication showed evidence of a decreased level of awareness of the disease in the general population, as well as the lack of access to resources available for physicians caring for children with KD in Arab countries. Kawarabi has since held several educational webinars and an inaugural yearly meeting. The groundwork for future initiatives targeted at increasing awareness and understanding of the management and the long-term outcomes of children with KD in the region was established. Data on KD in the Arab world are lacking. Kawarabi is a multicenter research collaborative organization that has the unique resources, diversified ethnic makeup, and energy, to accomplish significant advances in our understanding and management of KD and its variants.

Handheld echocardiographic screening for rheumatic heart disease by non-experts in rural South Kordofan, Sudan: Supporting task shifting for control of a serious disease.

BACKGROUND: Rheumatic heart disease (RHD) is a major and preventable cause of cardiac morbidity in Sudan. It can be detected early with a handheld echocardiography (HHE) machine. Our study aimed to screen for RHD in rural South Kordofan and to investigate the ability of non-experts to obtain good quality HHE records. METHODS: A cross-sectional study was conducted in South Kordofan, Sudan. A team of non-experts was trained for two weeks on handheld echocardiographic screening for RHD using a simplified protocol. Cases were recorded and reviewed by a pediatric cardiologist. Demographic and clinical features of screened subjects were studied. Descriptive statistics were presented as "number (%)" or "mean ± SD". RHD frequency was expressed as cases per 1000, and the Chi-Square test/Fisher's Exact test was used to compare RHD findings between different groups. RESULTS: A total of 467 subjects were screened. Echocardiographic quality was acceptable in 93% of recorded studies, hence 452 cases were included in the analysis. 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. The disease was mild in 70% and moderate or involving two valves in 30% of patients. Risk factors for the disease included the father's occupation and the village of residence. CONCLUSION: Shortly trained non-expert medicals can assist in RHD surveillance in remote areas using HHE for early detection and management. South Kordofan state is highly endemic to RHD and a control program needs to be implemented.

Recommendations for developing effective and safe paediatric and congenital heart disease services in low-income and middle-income countries: a public health framework.

The global burden of paediatric and congenital heart disease (PCHD) is substantial. We propose a novel public health framework with recommendations for developing effective and safe PCHD services in low-income and middle-income countries (LMICs). This framework was created by the Global Initiative for Children's Surgery Cardiac Surgery working group in collaboration with a group of international rexperts in providing paediatric and congenital cardiac care to patients with CHD and rheumatic heart disease (RHD) in LMICs. Effective and safe PCHD care is inaccessible to many, and there is no consensus on the best approaches to provide meaningful access in resource-limited settings, where it is often needed the most. Considering the high inequity in access to care for CHD and RHD, we aimed to create an actionable framework for health practitioners, policy makers and patients that supports treatment and prevention. It was formulated based on rigorous evaluation of available guidelines and standards of care and builds on a consensus process about the competencies needed at each step of the care continuum. We recommend a tier-based framework for PCHD care integrated within existing health systems. Each level of care is expected to meet minimum benchmarks and ensure high-quality and family centred care. We propose that cardiac surgery capabilities should only be developed at the more advanced levels on hospitals that have an established foundation of cardiology and cardiac surgery services, including screening, diagnostics, inpatient and outpatient care, postoperative care and cardiac catheterisation. This approach requires a quality control system and close collaboration between the different levels of care to facilitate the journey and care of every child with heart disease. This effort was designed to guide readers and leaders in taking action, strengthening capacity, evaluating impact, advancing policy and engaging in partnerships to guide facilities providing PCHD care in LMICs.

Rheumatic heart disease control: the time for a paradigm shift.

Rheumatic heart disease (RHD) is a completely preventable, life-threatening complication of group A streptococcal pharyngitis and the commonest cause of acquired heart disease in children and young adults in low- and middle-income countries. Conventional control measures are faced with many obstacles including the difficulty of early diagnosis of bacterial pharyngitis and acute rheumatic fever (ARF) leading to late presentation with established RHD which is not curable. Recent evidence confirmed the role of echocardiography screening of asymptomatic children in the early detection of 'latent' RHD. Benzathine penicillin prophylaxis was shown to be effective in halting the progression of latent RHD. There is enough evidence to warrant the implementation of control strategies that use lower thresholds for the diagnosis of group A streptococcal infection and ARF and we believe that it is high time to introduce an echocardiography screen-to-treat policy in endemic areas.

Pediatric cardiac services in Sudan: Achievements, challenges, and future perspectives (2004-2021).

Pediatric cardiology (PC) is a rapidly advancing specialty addressing a large population of children as well as adults with congenital heart disease. It requires huge technical and financial resources; therefore, establishing, maintaining, and developing such services in limited resource settings are challenging. A PC program that includes clinical aspects, echocardiography, diagnostic and interventional cardiac catheterization and cardiac surgery, and rheumatic heart disease control was established in Sudan in 2004. There are currently three public centers with facilities to evaluate and treat children with heart disease: two in Khartoum and one in Wad Medani. Major obstacles include the shortage of trained personnel and operation rooms, the deficiency of intensive care facilities, and the financial burden of interventional procedures. This paper details the establishment and progress of the program, its challenges, potential solutions, and future perspectives for PC programs in Sudan and African countries.

Echocardiographic surveillance of rheumatic heart disease in West and North Darfur compared with Kassala State: socioeconomic or genetic differences?

Rheumatic heart disease (RHD), a preventable complication of group A beta-haemolytic streptococcal infection, is highly prevalent in Sudan. Echocardiographic (echo) screening has an established role in disease surveillance. This study aims to measure the echo prevalence of RHD using handheld echo (HHE) in West and North Darfur and Kassala states and initiate control programs. School children 10-18 years of age were selected from the three states and HHE screening was performed by trained paediatric residents supervised by cardiologists using a pre-tested protocol. Health worker training and public awareness sessions were carried out. The study was conducted between November 2020 and December 2021. In West Darfur, 1,547 children were screened, echo prevalence was found to be 17.4/1,000, and 22% had moderate to severe disease. In North Darfur, 800 children were screened and echo prevalence was 16.2/1,000, 23% had moderate to severe disease while in Kasala 2,225 children were screened and the prevalence was 3.1/1,000 and all cases were mild. One hundred and fifty-eight health workers were trained and 20,150 people benefited from health education sessions. The prevalence of RHD in Darfur is 5 times more than in Kassala. This may reflect socioeconomic and genetic differences between the two regions. RHD control in Darfur needs to be consolidated, and echo surveillance is an important tool for early detection and the institution of secondary prophylaxis.

Penicillin Reactions in Patients With Severe Rheumatic Heart Disease: A Presidential Advisory From the American Heart Association.

Secondary antibiotic prophylaxis with regular intramuscular benzathine penicillin G (BPG) is the cornerstone of rheumatic heart disease management. However, there is a growing body of evidence that patients with rheumatic heart disease who have severe valvular heart disease with or without reduced ventricular function may be dying from cardiovascular compromise following BPG injections. This advisory responds to these concerns and is intended to: (1) raise awareness, (2) provide risk stratification, and (3) provide strategies for risk reduction. Based on available evidence and expert opinion, we have divided patients into low- and elevated-risk groups, based on symptoms and the severity of underlying heart disease. Patients with elevated risk include those with severe mitral stenosis, aortic stenosis, and aortic insuffiency; those with decreased left ventricular systolic dysfunction; and those with no symptoms. For these patients, we believe the risk of adverse reaction to BPG, specifically cardiovascular compromise, may outweigh its theoretical benefit. For patients with elevated risk, we newly advise that oral prophylaxis should be strongly considered. In addition, we advocate for a multifaceted strategy for vasovagal risk reduction in all patients with rheumatic heart disease receiving BPG. As current guidelines recommend, all low-risk patients without a history of penicillin allergy or anaphylaxis should continue to be prescribed BPG for secondary antibiotic prophylaxis. We publish this advisory in the hopes of saving lives and avoiding events that can have devastating effects on patient and clinician confidence in BPG.

Clinical and echocardiographic patterns and outcomes of Sudanese children with cardiomyopathy.

Cardiomyopathy (CMP) constitutes a group of diseases of heart muscle that lead to significant mortality and morbidity, with limited data in Africa. This study aims to describe clinical and echocardiographic (echo) patterns and short-term outcomes of Pediatric CMP. The study was carried at Gaafar Ibnauf Children's Hospital and included all children 0-18 years with an echo diagnosis of CMP. A retrospective part of the study was carried from January 2013 to 2019 and a prospective part from January to June 2019. Clinical and echo data were collected on presentation and on at least one follow up. A total of 146 patients were diagnosed with CMP during the study period. Most patients (48%) presented at 1-6 years of age, neonatal CMP was present in 4%. Familial incidence was detected in 11% of cases. Heart failure was the most common mode of presentation in 96% of patients; 65% needed hospitalisation; a third of them needed intensive care unit admission. The most common type of CMP was the dilated type (67%). Others included noncompaction CMP (19%), restrictive CMP and hypertrophic CMP (each of them in 6% of patients). Hospital mortality was 20% for the whole cohort and 100% for neonates. Other complications occurred in 21% of patients including arrhythmias, cerebrovascular accidents and end stage renal disease. Echo follow up showed that most patients (52%) remained the same, 26% worsened and 21% improved. Genetic and metabolic studies that could help to improve management and outcomes of CMP are needed.

A multi-sectoral, non-governmental program for control of rheumatic heart disease: SUR I CAAN: A model for developing countries.

Rheumatic heart disease (RHD) is a leading cause of cardiovascular mortality in developing countries. Control of RHD requires addressing the disease at its different stages through health system variables that are complex and intersecting. To achieve that, a multi-sectoral program is needed that is best implemented through ministries of health. In this report we present the SUR I CAAN program (Surveillance, Integration, Communication, Awareness, Advocacy and Training) that is implemented in Sudan utilizing nongovernmental resources and nonconventional funding. The program objectives are: 1. To improve primary, secondary and tertiary prevention of RHD, 2. To improve public awareness, 3. To implement strategic research projects, and 4. To improve advocacy through collaboration with regional and international organizations dealing with RHD. We established a hospital-based register and managed to identify high burden areas where sentinel sites for RHD control were established. A package of training and awareness material was utilized to conduct training workshops in these areas. Handheld echocardiography was utilized for studying the prevalence as well as for early detection and treatment of RHD. Although we did not conduct a structured evaluation for this program, we believe that its structure can serve as a model for other resource-limited countries.

Endomyocardial fibrosis: an under-diagnosed cause of cardiomyopathy in Sudanese children.

Endomyocardial fibrosis (EMF) is a tropical cardiomyopathy reported in many tropical countries. Patients were seen at the Children's Hospital-Khartoum, Sudan during September 2007-08 where cardiac evaluation was done. Six patients were identified (18% of all children with cardiomyopathy); all were males aged 8-17 years. All patients presented with abdominal distention, stunted growth, raised jugular venous pressure, ascites and hepatosplenomegaly. Electrocardiogram abnormalities included atrial fibrillation, first and third degree AV block and tall P wave. Echocardiography revealed huge right atrium dilatation and right ventricle apex obliteration by fibrous tissue. One patient had left-side affection with moderate mitral regurgitation. Eosinophilia was present in three patients. Two patients received antituberculosis drugs with no improvement, two had history of treated bilharziasis and two had been labeled as having Ebstein disease. EMF is an important cause of cardiomyopathy in Sudan that is often misdiagnosed. Clinical and echocardiographic examinations can lead to the correct diagnosis.

Patterns, outcomes and trends in hospital visits of un-operated and operated children with rheumatic heart disease in Sudan.

BACKGROUND: Rheumatic heart disease (RHD) is an important public health problem in Sudan. METHODS: Clinical and echocardiographic findings from an RHD registry in Khartoum (January 2005-March 2018) are described. Operated and un-operated children were prospectively followed. The quality of life (QOL) for children who had surgery was evaluated using pediatric QOL cardiac module. RESULTS: A total of 818 children (51% males) were included, patients were clustered in White Nile and Kordofan area. RHD was found in 78% and acute rheumatic fever (ARF) in 22% of cases. RHD was severe in 65% and the most common lesion was mitral regurgitation (MR) in 37%. Follow-up of 107 un-operated children for a mean of 2 years revealed major complications in 38% including a mortality of 14%. Severe valve dysfunction tended to remain unchanged. There were 3 deaths in children with severe valve lesions immediately following benzathine penicillin injections. Only 19% of patients underwent surgery with an average post-operative mortality of 10.5% in the last 8 years. Of those, only 34 were reached for follow-up (23%), all were in New York Heart Association (NYHA) class 1, however adverse outcomes were observed including noncompliance with benzathine penicillin and warfarin (51% and 29% respectively) and more than mild valve dysfunction in 35%. All children who had valve surgery have a good QOL scores. In the last 3 years, the outpatient visits, admissions and mortality rates decreased by 20%, 48% and 22% respectively. CONCLUSIONS: RHD is clustered in certain areas and presents with severe valve lesions with a high mortality for un-operated patients. Operative mortality improved over the last years but the follow-up rates are poor and adverse outcomes are common. There is an apparent trend of decline in the number of patients with RHD seen at referral hospitals.

Validation of the accuracy of handheld echocardiography for diagnosis of congenital heart disease.

BACKGROUND: Handheld echocardiography (HHE) has been increasingly used for rheumatic heart disease screening and in adult emergency room settings. AIMS: This study aimed to validate the accuracy of HHE in the diagnosis of congenital heart disease (CHD). SETTINGS AND DESIGN METHODOLOGY: This is a prospective study carried out at three pediatric cardiology outpatient clinics in Khartoum, Sudan.All patients with suspected CHD were evaluated by clinical examination followed by HHE, performed using a modified segmental approach. Then, a complete study was performed using a standard echocardiography machine. The results were then compared using appropriate statistical tools. RESULTS: A total of eighty cases were included with the following diagnoses either in isolation or combination: ventricular septal defect (n = 23), atrial septal defect (n = 10), pulmonary stenosis (n = 7), tetralogy of Fallot (n = 7), patent ductus arteriosus (n = 6), atrioventricular septal defect (n = 6), transposition of the great arteries (n = 6), and other diagnoses (n = 15). Agreement between HHE and SE was excellent both for visualizing heart segments (κ =77%-100% with a mean of 92.9%) and for diagnosis of CHD (κ =66%-100% with a mean of 91.7%). The sensitivity of HHE was 69.2%-100% (mean = 90.2%) and specificity was 98.5%-100% (mean = 99.3%). CONCLUSION: This study supports extending the utility of HHE in children for screening of CHD in addition to its current role in rheumatic heart disease screening.

Rheumatic heart disease in North Darfur: an alarmingly high burden and control initiative.

Rheumatic heart disease (RHD) is the most common cause of cardiac morbidity in Sudanese young people and it is particularly prevalent in Darfur area. A retrospective review of clinical and echocardiography (echo) data for children with RHD seen in Al Fashir Hospital from 2010 to 2016 was conducted. Data from the hospital statistics, outpatient and echo clinic records were collected and analysed. A control program was started based on training modules and public awareness material. In the study period, 324 patients were admitted and 3,777 patients with RHD were seen in outpatient clinics. Complications occurred in 33% of inpatients with a case fatality of 12%. Echo revealed that 83% of patients have severe disease and 50% have a combination of more than two valves affected. Training of 50 medical assistants, 30 physicians and 10 health promoters was achieved. Public awareness programs were conducted. We found a significant burden of RHD in Al Fashir Hospital. A control program was initiated that needs substantial support from governmental and nongovernmental organizations.

Echocardiographic screening for rheumatic heart disease in 4 515 Sudanese school children: marked disparity between two communities.

INTRODUCTION: Echocardiographic (echo) screening has unmasked a high prevalence of subclinical rheumatic heart disease (RHD) in many countries, and it can be used as a surveillance tool to control the disease. METHODS: School children of 10 to 15 years of age were selected in two areas of Sudan, Khartoum, the capital, and Niyala in western Sudan. Echo screening using a hand-held echo (HHE) was conducted in Khartoum using a three-view protocol, and in Niyala, a one-view protocol, both modified from the World Heart Federation protocol. Suspected cases were referred for standard echo study. Training of health personnel was conducted and health education sessions were delivered to the public. RESULTS: In Khartoum, a total of 3 000 school children were screened; seven cases were positive for RHD using HHE and one case was confirmed by standard echocardiography. The prevalence of RHD using echocardiography was 0.3 per 1 000 children. In Niyala, a total of 1 515 school children were screened. Using HHE, 59 cases were positive for RHD; 44 had definite and 15 borderline disease. Out of 34 who underwent standard echocardiography, 29 (85.2%) were found to have RHD; 22 had definite and seven borderline disease. The prevalence using echocardiography was 19 per 1 000 children. A total of 779 health workers were trained in South Darfur and 50 000 posters and pamphlets were distributed. CONCLUSION: Using echocardiography, there was a significant disparity in RHD prevalence between the two communities in Sudan. Efforts to control RHD should be directed to this area, and other rural communities should be investigated.

Handheld echocardiography for screening and control of rheumatic heart disease study in Gezira state, Sudan: a double approach model.

BACKGROUND: Rheumatic heart disease (RHD) is prevalent in Sudan's rural areas including Gezira state in central Sudan. We initiated a control program aiming at measurement of the echocardiographic (echo) prevalence of RHD, training of health workers and public awareness. METHODS: This is a cross-sectional and interventional study conducted in Gezira State, Al Managil Locality from Nov 2016 to February 2018. We used handheld echo (HHE) to detect the prevalence of RHD in school children and those tested positives were referred for standard echo. In addition, training on detection of RHD for health professionals was offered using training modules for physicians and nurses. Evaluation of health facilities was carried out using a questionaire. This was coupled with educational sessions to increase public awareness about RHD using posters and pamphlets. RESULTS: Two thousand and one hundred twenty-nine school children were screened, 36 cases were positive by HHE, out of these 31 underwent standard echo and 5 were confirmed to have RHD, giving an echo prevalence of 2.3/1,000. All cases had mild mitral regurgitation. Knowledge, attitudes and practices of 175 health workers were assessed then a tailored training program was implemented. Practices that are not compatible with Sudan's RHD Guidelines were detected including performing skin testing prior to administration of benzathine penicillin and under-utilization of local anesthetic to decrease the pain when giving the injection. Benzathine penicillin was available in only 32% of health facilities and only 25% of their personnel received training in RHD management. CONCLUSIONS: RHD echo prevalence in Gezira is relatively high and the health system needs to be strengthened. A double approach, screen-to-control program that utilizes HHE screening, health workers' training, public awareness and providing medical supplies in primary health care centers is feasible.