Outcomes of rheumatic fever in Uganda: a prospective cohort study.

BACKGROUND: Rheumatic heart disease is the largest contributor to cardiac-related mortality in children worldwide. Outcomes in endemic settings after its antecedent illness, acute rheumatic fever, are not well understood. We aimed to describe 3-5 year mortality, acute rheumatic fever recurrence, changes in carditis, and correlates of mortality after acute rheumatic fever. METHODS: We conducted a prospective cohort study of Ugandan patients aged 4-23 years who were diagnosed with definite acute rheumatic fever using the modified 2015 Jones criteria from July 1, 2017, to March 31, 2020, enrolled at three rheumatic heart disease registry sites in Uganda (in Mbarara, Mulago, or Lira), and followed up for at least 1 year after diagnosis. Patients with congenital heart disease were excluded. Patients underwent annual review, most recently in August, 2022. We calculated rates of mortality and acute rheumatic fever recurrence, tabulated changes in carditis, performed Kaplan-Meier survival analyses, and used Cox regression models to identify correlates of mortality. FINDINGS: Data were collected between Sept 1 and Sept 30, 2022. Of 182 patients diagnosed with definite acute rheumatic fever, 156 patients were included in the analysis. Of these 156 patients (77 [49%] male and 79 (51%) female; data on ethnicity not collected), 25 (16%) died, 21 (13%) had a cardiac-related death, and 17 (11%) had recurrent acute rheumatic fever over a median of 4·3 (IQR 3·0-4·8) years. 16 (24%) of the 25 deaths occurred within 1 year. Among 131 (84%) of 156 survivors, one had carditis progression by echo. Moderate-to-severe carditis (hazard ratio 12·7 [95% CI 3·9-40·9]) and prolonged PR interval (hazard ratio 4·4 [95% CI 1·7-11·2]) at acute rheumatic fever diagnosis were associated with increased cardiac-related mortality. INTERPRETATION: These are the first contemporary data from sub-Saharan Africa on medium-term acute rheumatic fever outcomes. Mortality rates exceeded those reported elsewhere. Most decedents already had chronic carditis at initial acute rheumatic fever diagnosis, suggesting previous undiagnosed episodes that had already compounded into rheumatic heart disease. Our data highlight the large burden of undetected acute rheumatic fever in these settings and the need for improved awareness of and diagnostics for acute rheumatic fever to allow earlier detection. FUNDING: Strauss Award at Cincinnati Children's Hospital, American Heart Association, and Wellcome Trust.

Cardiac Tamponade Related to a Large Pericardial Mass in a Female with Juvenile Idiopathic Arthritis.

We report the case of a young female with juvenile idiopathic arthritis presenting with cardiac tamponade secondary to an unusual pericardial mass. Pericardial masses are typically incidental findings. In rare circumstances they can cause compressive physiology warranting urgent intervention. She required surgical excision which revealed a pericardial cyst encapsulating a chronic solidified hematoma. Though certain inflammatory disorders are associated with myopericarditis, to our knowledge this is the first reported case of a pericardial mass in a well-controlled young patient. We theorize her immunosuppressant therapy resulted in hemorrhage into a pre-existing pericardial cyst, suggesting the need for further follow-up in those on adalimumab therapy.

Increasing Use of the Right Ventricle-to-Pulmonary Artery Shunt for Stage 1 Palliation.

BACKGROUND: Stage 1 palliation of hypoplastic left heart syndrome entails use of the Norwood operation with a modified Blalock-Taussig shunt or a right ventricle-to-pulmonary artery shunt, or the hybrid procedure. Use trends and factors influencing palliation selection remain unclear. We aimed to evaluate these questions and to compare outcomes between types of stage 1 palliation. METHODS: The National Pediatric Cardiology Quality Improvement Collaborative phase 1 (June 2008-August 2016) and phase 2 (August 2016-September 2019) databases were used. Procedure type was assessed by operation year. Baseline characteristics and annual hospital volume were evaluated. Postsurgical admission duration and outcomes were compared. RESULTS: A total of 3497 patients were included, 30.8% with modified Blalock-Taussig shunt, 59.7% with right ventricle-to-pulmonary artery shunt, and 9.5% with hybrid. Use of the right ventricle-to-pulmonary artery shunt increased over time (P = .02). This increase was similar among all hospital volumes. Higher hospital volume (odds ratio [OR], 1.2; 95% CI, 1.1-1.4; P = .003), male sex (OR, 1.3; 95% CI, 1.1-1.6; P = .01), and isolated cardiac disease (OR, 1.33; 95% CI, 1.01-1.55; P = .05) were associated with relatively higher likelihoods of a modified Blalock-Taussig shunt. Mortality/transplant rates before stage 2 palliation were higher with the modified Blalock-Taussig shunt than with the right ventricle-to-pulmonary artery shunt (12.3% vs 9.6%, P = .03). CONCLUSIONS: In stage 1 palliation, use of right ventricle-to-pulmonary artery shunts has increased over time, use of modified Blalock-Taussig shunts has decreased, and use of hybrids was unchanged. The modified Blalock-Taussig shunt has a higher likelihood of use in higher-volume centers, males, and less complex patients but is associated with longer hospitalizations and lower transplant-free survival to stage 2 palliation.

Association of household food insecurity and childhood weight status in a low-income population.

One in seven US households with children are food insecure. The health effects of household food insecurity (HFI) are well documented, but its association with childhood weight status remains unclear. We aimed to assess this association and to describe correlates of HFI in children. We conducted a cross-sectional study of 3019 low-income children aged 2 to 17 years. Data were extracted via chart review. HFI was assessed using the hunger vital sign screener. Body mass index (BMI) was calculated from documented clinical measurements. We used adjusted linear and logistic regression to assess the association of HFI with BMI z-score (BMIz) and weight status. We used logistic regression to examine correlates of HFI including age, race/ethnicity, tobacco exposure, number of parents and siblings living at home, weight status, and census-tract poverty rate and food access. Of participants whose HFI status was documented, 91% were food secure and 9% were food insecure. The mean (SD) BMIz was 0.81 (1.11). Fifty five percentage of children were healthy weight, 18% overweight, and 26% obese. In adjusted analyses, HFI was not associated with BMIz but was associated with decreased odds of obesity (OR 0.56; 95% CI 0.36-0.87). Tobacco exposure (1.63; 1.10-2.44), additional siblings (1.16; 1.04-1.30), and residence census tract with high poverty rate (1.02; 1.01-1.03) were all associated with HFI. We concluded that food-insecure children were less likely to have obesity and had differences in household makeup, exposures, and residential location compared to food-secure children. Clinicians should understand these relationships when counselling families about weight status and food insecurity.

Feasibility and Impact of a Student-Led, Semi-Structured, Near-Peer Student Guides Program on Navigating Through Medical School.

BACKGROUND: Mentorship is critical to developing health professionals. Near-peer mentorship pairs senior mentors with junior peers to help navigate academic, professional, and social aspects of training. METHODS: In this convergent parallel mixed methods study, we assessed the feasibility, usability, professional and social impact, and barriers to implementation of a 16-week semi-structured, near-peer, student guides program involving 39 first year medical students (MS1s) and 41 fourth year medical students (MS4s). Student enrollment was quantified, guide-guidee meetings tracked, and > 2 meetings defined as feasible. Meeting topics, impact on student advising, and barriers to sustainability were contextualized qualitatively. RESULTS: Twenty-two percent of all MS4s and 46% of MS1s enrolled in the program; 67% of guides facilitated the requisite two meetings with their group, which was less than our predetermined feasibility criteria of 75%. Most guide-guidee interactions occurred in person (91%), but text messages (82%) and video/mobile messaging apps (78%) were also used. Ninety-two percent of guidees recommended the program, and 85% were satisfied with guidance received. Barriers included meeting coordination, infrequent meetings, and informal meeting structure. CONCLUSIONS: While the program was infeasible by predefined frequency criteria, participant satisfaction was high and academic, professional, and social benefits of near-peers were reported. In response, programmatic revisions now incorporate centralized support for meetings, e-mentorship, and guide training.