Fatores intervenientes na gerência do cuidado de enfermagem à criança hospitalizada com cardiopatia reumática / Intervening factors in the management of nursing care for children hospitalized with rheumatic heart disease / Factores que intervienen en la gestión del cuidado de enfermería al niño hospitalizado con cardiopatía reumática

Objetivo: analisar os fatores intervenientes na gerência do cuidado de enfermagem à criança hospitalizada com cardiopatia reumática. Método: estudo descritivo-exploratório com abordagem qualitativa, que utilizou a Teoria Fundamentada em Dados e o Interacionismo Simbólico, respectivamente, como referencial metodológico e teórico. A coleta de dados foi realizada em uma instituição especializada em atendimento cardiológico, no munícipio do Rio de Janeiro. Foram entrevistados 19 profissionais de enfermagem através de um roteiro semiestruturado. Resultado: emergiram os seguintes fatores intervenientes na prática da gerência do cuidado: condição socioeconômica da família, comportamento da criança, condições de trabalho, comunicação ineficaz, educação permanente, trabalho em equipe e experiência profissional. Conclusão: os resultados apontam para a necessidade de proposição de estratégias de ação e interação que facilitem a prática gerencial de cuidado à criança com cardiopatia reumática e sua família face aos fatores intervenientes identificados.

Objective: to analyze the factors involved in the management of nursing care for children hospitalized with rheumatic heart disease. Method: this is a descriptive-exploratory study with a qualitative approach, which used Data-Based Theory and Symbolic Interactionism, respectively, as methodological, and theoretical references. Data was collected in an institution specializing in cardiac care in the city of Rio de Janeiro. Nineteen nursing professionals were interviewed using a semi-structured script. Result: the following intervening factors in the practice of care management emerged: the family's socioeconomic status, the child's behavior, working conditions, ineffective communication, continuing education, teamwork, and professional experience. Conclusion: the results point to the need to propose strategies for action and interaction that facilitate management practice in caring for children with rheumatic heart disease and their families, given the intervening factors identified.

Objetivo: analizar los factores que intervienen en la gestión del cuidado de enfermería al niño hospitalizado con cardiopatía reumática. Método: estudio descriptivo-exploratorio con enfoque cualitativo, cuyos marcos metodológico y teórico fueron la Teoría Fundamentada y el Interaccionismo Simbólico, respectivamente. La recolección de datos se realizó en una institución especializada en atención cardiológica, en la ciudad de Río de Janeiro. Fueron entrevistados 19 profesionales de enfermería mediante un cuestionario semiestructurado. Resultado: surgieron los siguientes factores intervinientes en la práctica de la gestión del cuidado: condición socioeconómica de la familia, comportamiento del niño, condiciones de trabajo, comunicación ineficaz, educación continua, trabajo en equipo y experiencia profesional. Conclusión: los resultados indican que es necesario proponer estrategias de acción e interacción que faciliten la práctica de la gestión del cuidado al niño con cardiopatía reumática y a sus familiares, con respecto a los factores intervinientes identificados.

Risk Factors of Rheumatic Heart Disease in a Children's Hospital in Khartoum: A Case-Control Study.

BACKGROUND: Rheumatic heart disease (RHD) is the most prevalent acquired cardiac illness in Sudan, arising as a complication of acute rheumatic fever (ARF). Additionally, Sudan exhibited a wide diversity in the distribution of RHD. The echocardiographic screening revealed 3/1000 cases in one region (Khartoum), while in another region (Nort Kordofan), it revealed 61/1000 cases. Consequently, further research is warranted to shed light on this disease, particularly its risk factors. There is a lack of research on the risk factors in Sudan. The objective of this study is to evaluate Sudan's RHD risk factors. METHODS: This case-control study was conducted at Jafar Ibn Auf Children's Hospital from August to December 2016. A questionnaire was used to study RHD risk factors, including socioeconomic status, maternal education and employment, housing conditions, residence, and history of sore throat and ARF. Comparison between cases and controls was estimated using conditional logistic regression with 95% confidence intervals (CI). RESULTS: A total of 78 participants, including 39 established RHD cases and 39 age- and sex-matched normal controls, were recruited. The age in years for cases and controls was 11.1 +/- 2.9 and 11+/- 2.9, respectively. In the univariate analysis, only the history of ARF was significantly associated with RHD (odds ratio (OR) 60.8, 95% CI 10.3-356). There was a trend toward increased risk of RHD in association with a history of sore throat in 69.2% of the patients and origin from western states in 41% of the patients, but this did not reach statistical significance. CONCLUSIONS:  ARF history and a six-month history of throat infections are linked to RHD. Mothers do not have a correlation with RHD, but a correlation exists when there is a connection between a history of ARF and a recent throat infection (effect modification). Furthermore, an association was found between throat infections and living in a western state. Consequently, it is imperative to adopt RHD prevention, particularly the prevention and treatment of both ARF and throat infections.

Rheumatic heart disease manifesting as mitral stenosis and tricuspid regurgitation in a young Asian male: a case report.

Background: Rheumatic heart disease (RHD) is a major global health issue because of its potential to cause heart failure. While RHD has been reported more frequently in women, this case report highlights the clinical manifestations, diagnosis, and management of rheumatic multivalvular disease in a young Asian male. Case summary: A 46-year-old Asian man with a history of percutaneous mitral valvuloplasty (PMV) was admitted with dyspnoea and generalized oedema that severely hindered his quality of life. Transthoracic and transoesophageal echocardiography revealed severe mitral stenosis, left atrial appendage (LAA) thrombus, and severe tricuspid regurgitation due to RHD. Following a comprehensive evaluation by a multidisciplinary team, we advised mitral valve replacement, LAA thrombectomy, and tricuspid valve annuloplasty based on the detailed imaging of the valve anatomy and the patient's low surgical risk. Surgical intervention led to considerable improvement in the patient's symptoms, enabling a return to routine activities. Discussion: This case highlights the chronic nature of RHD and its potential to cause heart failure. This report emphasizes the need for regular follow-up in patients with a history of RHD to detect potential complications and ensure timely management. The successful outcome in this case underscores the importance of a team-based approach for managing complex valvular heart disease.

Direct Oral Anticoagulants for Rheumatic Heart Disease-Associated Atrial Fibrillation Post-Bioprosthetic Mitral Valve Replacement.

BACKGROUND: The efficacy of direct oral anticoagulants (DOACs) in preventing ischemic and thromboembolic events may be suboptimal in atrial fibrillation (AF) patients with rheumatic mitral stenosis. However, their safety and effectiveness after mitral valve replacement (MVR) using bioprosthetic valves is unclear. OBJECTIVES: This study sought to evaluate the safety and effectiveness of DOACs vs warfarin among patients with rheumatic heart disease (RHD)-associated AF after bioprosthetic MVR. METHODS: We performed an observational analysis identifying patients with RHD and AF who underwent bioprosthetic MVR. Primary effectiveness and safety outcomes were ischemic events and major bleeding, respectively. Secondary outcomes included all-cause mortality, cardiac thrombosis, myocardial infarction, and all-cause hospitalization. Propensity score matching was performed to account for the differences in baseline characteristics and comorbidities. RESULTS: A total of 3,950 patients were identified; 76% were on warfarin and 24% on DOAC post-MVR. The DOAC group had a higher burden of baseline comorbidities and prior cardiovascular procedures compared with the warfarin group. The propensity score matching balanced baseline characteristics in 1,832 patients (916 in each group), with a mean age of 69 years. At the 5-year follow-up, DOACs were associated with a lower incidence of major bleeding compared with warfarin (HR: 0.76; 95% CI: 0.62-0.94), with no significant difference in ischemic events, mortality, cardiac thrombosis, myocardial infarction, or hospitalization. CONCLUSIONS: Among patients with RHD-associated AF patients post-bioprosthetic MVR, DOACs are associated with lower major bleeding and comparable effectiveness, indicating a potential alternative to warfarin. Further randomized controlled trials are warranted to validate these findings in this population.

Open Heart Dual Valve Surgery Without Blood Transfusion: A Case Report.

In Nepal, rheumatic heart disease (RHD) is alarmingly prevalent, marked by presentations like migratory joint arthritis, carditis, subcutaneous nodules, erythema marginatum, and Sydenham chorea. This condition can progress to instigate valvular defects. Although these patients are first approached medically, they may require surgery for severe cases. Refusal for blood transfusion might not be a major issue for other general surgeries; however, in cardiac surgery, where there is massive blood loss, it's quite a challenge. This challenge becomes even more pronounced in a developing country that lacks advanced facilities like a cell saver for autotransfusion. Herein, we report a case of a 22-year-old female, a Jehovah's Witness, suffering from RHD, severe mitral regurgitation, severe tricuspid regurgitation, and severe pulmonary artery hypertension. She underwent mitral valve replacement and tricuspid repair surgery (modified DeVega) by avoiding any form of blood product transfusion.

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.

Unmasking Rheumatic Heart Disease Decades Later in a Patient With a Remote History of Rheumatic Fever Despite Prolonged Antibiotic Prophylaxis.

Rheumatic heart disease (RHD) is one of the leading causes of valvular heart disease worldwide and still persists in the USA, particularly among vulnerable populations with limited healthcare. Depending on the risk, severity, and types of valve involvement, treatment includes guideline-directed medical therapy (GDMT) and surgical interventions like valve repair or replacement. Here, we present a unique case of a patient in his late fifties who presented with worsening heart failure symptoms and several heart murmurs. A transthoracic echocardiogram (TTE) revealed moderate to severe mitral regurgitation (MR), aortic regurgitation (AR), and mild aortic stenosis (AS) with a bicuspid aortic valve. However, coronary angiography and right heart catheterization showed no blockages, right ventricular dysfunction, or pulmonary hypertension. Furthermore, no valvular vegetation was noticed on the transesophageal echocardiogram. The patient had a history of acute rheumatic fever (RF) in adolescence and was treated until age 21. Despite potential alternative causes like myocardial infarction or endocarditis, the lack of ischemic findings, negative blood cultures, and absence of valvular vegetation suggested that RHD was the possible cause of his valvular issues. This case highlights the rare occurrence of RHD impacting multiple valves despite proper antibiotic prophylaxis and draws attention to the importance of considering RHD when diagnosing multiple valvular problems, as many patients are identified too late for surgical intervention.

Prognostic Value of Pulmonary Artery Systolic Pressure in Severe Rheumatic Mitral Stenosis.

BACKGROUND: Current guidelines recommend intervention for asymptomatic rheumatic mitral stenosis (MS) with mitral valve area ≤1.5 cm2 based on indicators including pulmonary arterial systolic pressure (PASP) >50 mm Hg and new-onset atrial fibrillation; however, evidence supporting this is lacking. METHODS: This single-center retrospective study included patients with rheumatic MS between 2006 and 2022. Pulmonary hypertension was evaluated by using echocardiography to estimate PASP. Primary outcomes were major adverse cardiovascular events (MACE), including all-cause mortality, hospitalization for heart failure, and arterial thromboembolic events for up to 5 years. RESULTS: Overall, 287 patients with severe rheumatic MS were enrolled (mean age, 62.5±11.3 years; 74.6% women). During a median follow-up of 2.52 years, MACE occurred in 99 patients. There were no differences in echocardiographic parameters, such as the mean mitral valve pressure gradient, mitral valve area, and proportion of mitral valve area <1.0 cm2, between patients who developed primary outcomes and those who did not. Survival analysis showed a worse prognosis in patients with estimated PASP (ePASP) >50 mm Hg than in those with ePASP ≤50 mm Hg (log-rank P<0.001); however, atrial fibrillation was not a significant prognostic indicator. As a continuous variable, ePASP (mm Hg) was a significant predictor of MACE (adjusted hazard ratio, 1.027 [95% CI, 1.011-1.042]; P<0.001). Receiver operating characteristic analysis revealed an optimal ePASP threshold of >45 mm Hg, which was an independent predictor of MACE in patients with severe rheumatic MS (adjusted hazard ratio, 2.127 [95% CI, 1.424-3.177]; P<0.001). Competing risk analysis considering mitral valve intervention as a competing risk showed similar results. CONCLUSIONS: Our study demonstrated the prognostic significance of ePASP, rather than atrial fibrillation, in relation to MACE among patients with severe rheumatic MS. Additionally, we proposed a lower ePASP threshold (>45 mm Hg) as a predictor of an unfavorable prognosis.

Elevated Trans-mitral Pressure Gradient Predicts Surgery in Young People with Moderate-Severe Rheumatic Mitral Regurgitation.

Mitral regurgitation (MR) is the most common lesion in children with rheumatic heart disease (RHD). Progression of RHD results in the need for surgical intervention, the timing of which is dictated by left ventricular dilatation and the onset of heart failure symptoms. We sought to determine whether elevation in trans-mitral pressure gradient (TMPG) in those with moderate or severe rheumatic MR without significant mitral stenosis (MS) could predict the need for future surgical intervention. Echocardiographic studies were reviewed for 116 children and young people with moderate or severe rheumatic MR. Those with significant mitral stenosis or concurrent aortic valve disease were excluded. Trans-mitral pressure gradient was measured at baseline and details of mitral valve surgical intervention were retrieved from a registry database. Time to future surgery (up to six years) was compared between those with TMPG < 5 mmHg and TMPG ≥ 5 mmHg. Survival curves demonstrated an increased risk of surgery for those with TMPG ≥ 5 mmHg with Cox proportional regression analysis providing a hazard ratio of 5.8. The proportion free from mitral valve surgery at one year for the TMPG < 5 mmHg group was 0.94 (95% CI 0.86-0.97), compared to 0.62 (95% CI 0.42-0.77) in the ≥ 5 mmHg group. Trans-mitral pressure gradient is a strong predictor of future mitral valve surgery in children and young people with significant rheumatic MR without MS. This non-invasive measure could be used to signal the need for more aggressive monitoring in order to optimize the timing of intervention.

Infective endocarditis following percutaneous balloon mitral valvuloplasty: A case report of a 25-year-old female from Jimma Medical Center of Ethiopia.

Rheumatic mitral stenosis is a common rheumatic heart diseases in sub-Saharan Afrleading to increased morbidity and mortality. Percutaneous mitral balloon valvuloplasty is the mainstay of less invasive therapy in those with moderate to severe valve stenosis, being symptomatic despite optimal medical therapy. Though generally save with experienced hand and setup, post procedural complications include development of mitral regurgitation, tear and thrombosis. Mitral leaflet tear and development of infective endocarditis are an uncommon but might lead to increased morbidity, rehospitalization and mortality.

Methods for Establishing a Rat Model of Rheumatic Heart Disease.

Rheumatic heart disease (RHD) is responsible for nearly 250,000 deaths annually and poses a significant health threat in developing areas. The unclear pathogenesis of RHD makes the development of cost-effective treatments challenging, particularly as current surgical options are expensive and technologically demanding, exacerbating the economic and quality-of-life burdens for patients. Given the risks associated with direct human experimentation due to the uncertain pathogenesis, using a rat model infected with Group A Streptococcus (GAS) has become a crucial experimental strategy for RHD research. The development of an RHD rat model, refined over 23 years, now stands as a pivotal approach in studies aiming to understand the disease's pathogenesis. This review summarizes the evolution, characteristics, advantages, and limitations of the RHD rat model, offering insights into potential areas for improvement. It aims to provide researchers with a comprehensive understanding of the model, supporting the advancement of research methodologies and the discovery of innovative treatments for RHD.

The heart of the matter: a re-iteration of the role of the social determinants of health in addressing health inequity in Central Australia.

The persisting life-expectancy 'gap' between First Nations and non-First Nations Australians is fundamentally driven by the social determinants of health. These include income and social protection, access to adequate housing and food security, among others. These factors are particularly prominent in Central Australia. Inadequate housing has led to some of the highest rates of Streptococcus pyogenes infection in the world, which in turn drives an extremely high prevalence of rheumatic heart disease. Food insecurity and inadequate social protection manifesting as energy insecurity result in inadequate nutrition and have resulted in a huge burden of diabetes in Central Australia. These factors, combined with social exclusion, racism and the pervasive effect of colonisation, also drive a high rate of alcohol misuse. Only by prioritising equity in these 'social determinants' and emphasising the importance of First Nations leadership in formulating and implementing solutions will health inequity be addressed.

Prevalence, Management, and Outcomes of Atrial Fibrillation in Paediatric Patients: Insights from a Tertiary Cardiology Centre.

Background and Objectives: Atrial fibrillation (AF) is increasingly recognised in paediatric patients, presenting unique challenges in management due to its association with various underlying heart conditions. This study aimed to evaluate the prevalence, management strategies, and outcomes of AF in this population. Materials and Methods: A retrospective analysis was conducted at a tertiary paediatric cardiology centre, including patients aged ≤18 years diagnosed with AF between January 2015 and December 2023. The study focused on demographic details, clinical presentations, treatments, and outcomes. Descriptive statistics were employed to assess treatment efficacy, recurrence rates, and complications. Results: The study included 36 paediatric patients (median age: 15 years, IQR: 13-17; 58% male). Of these, 52.8% had acquired heart disease, 16.7% had congenital heart anomalies, and 16.7% presented with lone AF. The initial management strategies involved electrical cardioversion in 53.3% of patients and pharmacological conversion with amiodarone in 46.7%. Rhythm control therapy was administered to over 80% of the cohort, and 63.9% were placed on oral anticoagulation, predominantly for rheumatic and congenital heart diseases. The overall success rate of rhythm control was 96.2%, with an AF recurrence rate of 3.8%. Ischemic stroke was the most common complication, occurring in three patients, all with underlying rheumatic heart disease. Conclusions: AF in paediatric patients is predominantly associated with rheumatic and congenital heart diseases, though a significant proportion of patients present with lone AF. Despite effective rhythm control in most cases, neurological complications, particularly ischemic strokes in patients with underlying heart disease, remain a critical concern. These findings underscore the need for more comprehensive studies to better understand the aetiology, risk factors, and optimal management strategies for paediatric AF.

Out-of-Pocket Expenditure and Challenges Faced by Patients Undergoing Heart Valve Replacement in Follow-Up Care at a Tertiary Care Center in South India: A Mixed Methods Study.

Background Heart valve replacement surgery is one of the most commonly performed cardiac surgeries in India. Post-surgery, the patient requires lifetime anticoagulation therapy with regular follow-up, leading to financial and nonfinancial burdens for the patients. This study aimed to determine the out-of-pocket (OOP) expenditure (OOPE) for follow-up visits to the heart valve clinic and explore and assess the challenges faced by patients during these follow-ups. Methodology This mixed methods study was conducted at a tertiary care center from June 2018 to August 2018, focusing on patients attending the Valve Replacement clinic. The qualitative component of the study involved conducting three focus group discussions, which were transcribed and manually analyzed using thematic analysis to generate categories. The monthly OOPE and the proportion of irregular patients were assessed using a pretested and validated questionnaire developed based on the findings from the qualitative study. The data from the quantitative study were entered into EpiData version 3.1 (EpiData, Odense, Denmark) and analyzed using Stata 14 (StataCorp., College Station, TX). Results The median (interquartile range [IQR]) total OOPE for patients was Rs. 765 (475-1,100). The median (IQR) direct and indirect expenditures were Rs. 420 (210-600) and Rs. 590 (330-948), respectively. The patients faced difficulties in the categories of financial, travel, hospital, family, and personal. Out of a total of 143 participants, 86 (60.14%) had incurred catastrophic health expenditures. The cost also significantly increased with the presence of an accompanying person and longer travel durations. Conclusions The major difficulties faced by the patients were distance and expense. Telemedicine can help overcome these challenges by decentralizing follow-up care to the primary care level.

Secondary prophylaxis and specialist review compliance in paediatric patients with acute rheumatic fever and rheumatic heart disease in a Western Australian metropolitan setting.

AIM: Rheumatic heart disease (RHD), a consequence of acute rheumatic fever (ARF), continues to cause significant morbidity and mortality in susceptible young people. Secondary antibiotic prophylaxis is an effective strategy to prevent ARF recurrence and RHD progression. However, the proportion of patients receiving the recommended minimum benzathine penicillin injections (>80%) remains low. This retrospective cohort study reviews the utility of the Hospital in the Home nursing service in providing secondary prophylaxis for outpatients in a metropolitan state capital. METHODS: Fifty-eight patients with ARF/RHD receiving secondary prophylaxis through the Hospital in the Home service between 1 July 2012 and 30 June 2020 were included. Compliance of secondary prophylaxis, specialist review and echocardiogram frequency were compared against the recommendations from the Australian RHD guidelines. RESULTS: Forty-six (79%) patients received >80% of recommended doses, with 36% (n = 21) receiving 100% and a further 29% (n = 17) achieving compliance of 90%-99%. We found that 35% of patients attended all specialist reviews (including echocardiography) at the recommended frequency, with 75% of those not attending all reviews, missing only one or two appointments. Compliance was greater in those with more severe disease. In the 12 (21%) patients who did not meet the >80% target, compliance ranged between 33% and 79% (mean 64.5%) and all had priority 3 disease. CONCLUSION: Community-based administration of secondary prophylaxis through a registry-based system is an effective strategy of improving compliance within a metropolitan area and should be utilised in a culturally safe and collaborative manner to increase uptake.

Housing Initiatives to Address Strep A Infections and Reduce RHD Risks in Remote Indigenous Communities in Australia.

Group A Streptococcus (Strep A) skin infections (impetigo) can contribute to the development of acute rheumatic fever (ARF) and rheumatic heart disease (RHD). This is of particular concern for Indigenous residents of remote communities, where rates of ARF and RHD are much higher than their urban and non-Indigenous counterparts. There are three main potential Strep A transmission pathways: skin to skin, surface to skin, and transmission through the air (via droplets or aerosols). Despite a lack of scientific certainty, the physical environment may be modified to prevent Strep A transmission through environmental health initiatives in the home, identifying a strong role for housing. This research sought to provide an outline of identified household-level environmental health initiatives to reduce or interrupt Strep A transmission along each of these pathways. The identified initiatives addressed the ability to wash bodies and clothes, to increase social distancing through improving the livability of yard spaces, and to increase ventilation in the home. To assist with future pilots and evaluation, an interactive costing tool was developed against each of these initiatives. If introduced and evaluated to be effective, the environmental health initiatives are likely to also interrupt other hygiene-related infections.

Transmission potential of Streptococcus pyogenes during a controlled human infection trial of pharyngitis.

Controlled human infection (CHI) models can provide insights into transmission of pathogens such as Streptococcus pyogenes (Strep A). As part of the Controlled Human Infection with Penicillin for Streptococcus pyogenes (CHIPS) trial, we explored the potential for transmission among participants deliberately infected with the Strep A emm75 strain. Three approaches to understanding transmission were employed: the use of agar settle plates to capture possible droplet or airborne spread of Strep A; measurement of distance droplets could spread during conversation; and environmental swabbing of high-touch items to detect Strep A on surfaces. Of the 60 (27%) CHIPS trial participants across five cohorts, 16 were enrolled in this sub-study; availability of study staff was the primary reason for selection. In total, 189 plates and 260 swabs were collected. Strep A was grown on one settle plate from a participant on the second day, using plates placed 30 cm away. This participant received the placebo dose of penicillin and had met the primary endpoint of pharyngitis. Whole-genome sequencing identified this to be the challenge strain. Strep A was not detected on any swabs. In this small sample of CHI participants, we did not find evidence of Strep A transmission by the airborne route or fomites, and just one instance of droplet spread while acutely symptomatic with streptococcal pharyngitis. Although these experiments provide evidence of minimal transmission within controlled clinical settings, greater efforts are required to explore Strep A transmission in naturalistic settings.IMPORTANCEStreptococcus pyogenes remains a significant driver of morbidity and mortality, particularly in under-resourced settings. Understanding the transmission modalities of this pathogen is essential to ensuring the success of prevention methods. This proposed paper presents a nascent attempt to determine the transmission potential of Streptococcus pyogenes nested within a larger controlled human infection model.

Rheumatic heart disease on an Eastern Arizona Reservation, 2007-2022.

Contemporary studies of rheumatic heart disease (RHD) within American Indian communities are lacking, despite recent work indicating high rates of group A streptococcus, the precursor to RHD. Utilizing retrospective chart review of the Indian Health Service, we sought to characterize the burden of acute rheumatic fever and RHD within an American Indian tribe in Eastern Arizona. Our study found that, in line with other high-income countries, RHD in the US continues to disproportionately impact native peoples, with rates 10 times that of the general population.