The Use of Artificial Intelligence Guidance for Rheumatic Heart Disease Screening by Novices.

INTRODUCTION: A novel technology utilizing artificial intelligence (AI) to provide real-time image-acquisition guidance, enabling novices to obtain diagnostic echocardiographic images, holds promise to expand the reach of echo screening for rheumatic heart disease (RHD). We evaluated the ability of nonexperts to obtain diagnostic-quality images in patients with RHD using AI guidance with color Doppler. METHODS: Novice providers without prior ultrasound experience underwent a 1-day training curriculum to complete a 7-view screening protocol using AI guidance in Kampala, Uganda. All trainees then scanned 8 to 10 volunteer patients using AI guidance, half RHD and half normal. The same patients were scanned by 2 expert sonographers without the use of AI guidance. Images were evaluated by expert blinded cardiologists to assess (1) diagnostic quality to determine presence/absence of RHD and (2) valvular function and (3) to assign an American College of Emergency Physicians score of 1 to 5 for each view. RESULTS: Thirty-six novice participants scanned a total of 50 patients, resulting in a total of 462 echocardiogram studies, 362 obtained by nonexperts using AI guidance and 100 obtained by expert sonographers without AI guidance. Novice images enabled diagnostic interpretation in >90% of studies for presence/absence of RHD, abnormal MV morphology, and mitral regurgitation (vs 99% by experts, P ≤ .001). Images were less diagnostic for aortic valve disease (79% for aortic regurgitation, 50% for aortic stenosis, vs 99% and 91% by experts, P < .001). The American College of Emergency Physicians scores of nonexpert images were highest in the parasternal long-axis images (mean, 3.45; 81% ≥ 3) compared with lower scores for apical 4-chamber (mean, 3.20; 74% ≥ 3) and apical 5-chamber images (mean, 2.43; 38% ≥ 3). CONCLUSIONS: Artificial intelligence guidance with color Doppler is feasible to enable RHD screening by nonexperts, performing significantly better for assessment of the mitral than aortic valve. Further refinement is needed to optimize acquisition of color Doppler apical views.

Evaluating the implementation of a dynamic digital application to enable community-based decentralisation of rheumatic heart disease case management in Uganda: protocol for a hybrid type III effectiveness-implementation study.

INTRODUCTION: Rheumatic heart disease (RHD) affects over 39 million people worldwide, the majority in low-income and middle-income countries. Secondary antibiotic prophylaxis (SAP), given every 3-4 weeks can improve outcomes, provided more than 80% of doses are received. Poor adherence is strongly correlated with the distance travelled to receive prophylaxis. Decentralising RHD care has the potential to bridge these gaps and at least maintain or potentially increase RHD prophylaxis uptake. A package of implementation strategies was developed with the aim of reducing barriers to optimum SAP uptake. METHODS AND ANALYSIS: A hybrid implementation-effectiveness study type III was designed to evaluate the effectiveness of a package of implementation strategies including a digital, cloud-based application to support decentralised RHD care, integrated into the public healthcare system in Uganda. Our overarching hypothesis is that secondary prophylaxis adherence can be maintained or improved via a decentralisation strategy, compared with the centralised delivery strategy, by increasing retention in care. To evaluate this, eligible patients with RHD irrespective of their age enrolled at Lira and Gulu hospital registry sites will be consented for decentralised care at their nearest participating health centre. We estimated a sample size of 150-200 registrants. The primary outcome will be adherence to secondary prophylaxis while detailed implementation measures will be collected to understand barriers and facilitators to decentralisation, digital application tool adoption and ultimately its use and scale-up in the public healthcare system. ETHICS AND DISSEMINATION: This study was approved by the Institutional Review Board (IRB) at Cincinnati Children's Hospital Medical Center (IRB 2021-0160) and Makerere University School of Medicine Research Ethics Committee (Mak-SOMREC-2021-61). Participation will be voluntary and informed consent or assent (>8 but <18) will be obtained prior to participation. At completion, study findings will be communicated to the public, key stakeholders and submitted for publication.

Development and User Testing of a Dynamic Tool for Rheumatic Heart Disease Management.

OBJECTIVE: Most rheumatic heart disease (RHD) registries are static and centralized, collecting epidemiological and clinical data without providing tools to improve care. We developed a dynamic cloud-based RHD case management application with the goal of improving care for patients with RHD in Uganda. METHODS: The Active Community Case Management Tool (ACT) was designed to improve community-based case management for chronic disease, with RHD as the first test case. Global and local partner consultation informed selection of critical data fields and prioritization of application functionality. Multiple stages of review and revision culminated in user testing of the application at the Uganda Heart Institute. RESULTS: Global and local partners provided feedback of the application via survey and interview. The application was well received, and top considerations included avenues to import existing patient data, considering a minimum data entry form, and performing a situation assessment to tailor ACT to the health system setup for each new country. Test users completed a postuse survey. Responses were favorable regarding ease of use, desire to use the application in regular practice, and ability of the application to improve RHD care in Uganda. Concerns included appropriate technical skills and supports and potential disruption of workflow. CONCLUSION: Creating the ACT application was a dynamic process, incorporating iterative feedback from local and global partners. Results of the user testing will help refine and optimize the application. The ACT application showed potential for utility and integration into existing care models in Uganda.

Cardiovascular diseases in Africa in the twenty-first century: Gaps and priorities going forward.

In 2015, the United Nations set important targets to reduce premature cardiovascular disease (CVD) deaths by 33% by 2030. Africa disproportionately bears the brunt of CVD burden and has one of the highest risks of dying from non-communicable diseases (NCDs) worldwide. There is currently an epidemiological transition on the continent, where NCDs is projected to outpace communicable diseases within the current decade. Unchecked increases in CVD risk factors have contributed to the growing burden of three major CVDs-hypertension, cardiomyopathies, and atherosclerotic diseases- leading to devastating rates of stroke and heart failure. The highest age standardized disability-adjusted life years (DALYs) due to hypertensive heart disease (HHD) were recorded in Africa. The contributory causes of heart failure are changing-whilst HHD and cardiomyopathies still dominate, ischemic heart disease is rapidly becoming a significant contributor, whilst rheumatic heart disease (RHD) has shown a gradual decline. In a continent where health systems are traditionally geared toward addressing communicable diseases, several gaps exist to adequately meet the growing demand imposed by CVDs. Among these, high-quality research to inform interventions, underfunded health systems with high out-of-pocket costs, limited accessibility and affordability of essential medicines, CVD preventive services, and skill shortages. Overall, the African continent progress toward a third reduction in premature mortality come 2030 is lagging behind. More can be done in the arena of effective policy implementation for risk factor reduction and CVD prevention, increasing health financing and focusing on strengthening primary health care services for prevention and treatment of CVDs, whilst ensuring availability and affordability of quality medicines. Further, investing in systematic country data collection and research outputs will improve the accuracy of the burden of disease data and inform policy adoption on interventions. This review summarizes the current CVD burden, important gaps in cardiovascular medicine in Africa, and further highlights priority areas where efforts could be intensified in the next decade with potential to improve the current rate of progress toward achieving a 33% reduction in CVD mortality.

Recent Advances in the Rheumatic Fever and Rheumatic Heart Disease Continuum.

Nearly a century after rheumatic fever (RF) and rheumatic heart disease (RHD) was eradicated from the developed world, the disease remains endemic in many low- and middle-income countries (LMICs), with grim health and socioeconomic impacts. The neglect of RHD which persisted for a semi-centennial was further driven by competing infectious diseases, particularly the human immunodeficiency virus (HIV) pandemic. However, over the last two-decades, slowly at first but with building momentum, there has been a resurgence of interest in RF/RHD. In this narrative review, we present the advances that have been made in the RF/RHD continuum over the past two decades since the re-awakening of interest, with a more concise focus on the last decade's achievements. Such primary advances include understanding the genetic predisposition to RHD, group A Streptococcus (GAS) vaccine development, and improved diagnostic strategies for GAS pharyngitis. Echocardiographic screening for RHD has been a major advance which has unearthed the prevailing high burden of RHD and the recent demonstration of benefit of secondary antibiotic prophylaxis on halting progression of latent RHD is a major step forward. Multiple befitting advances in tertiary management of RHD have also been realized. Finally, we summarize the research gaps and provide illumination on profitable future directions towards global eradication of RHD.

Acute Kidney Injury and Associated Factors in Intensive Care Units at a Tertiary Hospital in Northern Tanzania.

BACKGROUND: Acute kidney injury (AKI) is a recognized complication in critically ill patients. The epidemiology of AKI varies worldwide, depending on the diagnostic criteria used and the setting. The International Society of Nephrology has called for a reduction in preventable deaths from AKI to zero by the year 2025. It is suspected that the majority of AKI cases are in limited-resource countries, but the true burden of AKI in these settings remains unknown. OBJECTIVE: We aimed to determine, using standardized KDIGO (Kidney Disease Improving Global Outcomes) criteria, the prevalence of AKI, associated factors, and clinical characteristics of adult (≥18 years) patients admitted to intensive care units (ICUs) at a tertiary hospital in Tanzania. DESIGN: Prospective observational study from November 2017 to May 2018. METHODS: In all, 320 patients admitted to medical and surgical ICUs were consecutively enrolled. Baseline, clinical, and laboratory data were collected on admission and during their ICU stay. Serum creatinine and urine output were measured, and KDIGO criteria were used to determine AKI status. RESULTS: More than half (55.3%) of ICU patients were diagnosed with AKI. Of these, 80% were diagnosed within 24 hours of admission. Acute kidney injury stage 3 accounted for 35% of patients with AKI. Patients with AKI were older, more likely to have cardiovascular comorbidities, and with higher baseline serum levels of creatinine, potassium, universal vital assessment admission scores, and total white cell count ≥12. Sepsis (odds ratio [OR] = 3.81; confidence interval [CI] = 1.21-11.99), diabetes (OR = 2.54; CI = 1.24-5.17), and use of vasopressors (OR = 3.78; CI = 1.36-10.54) were independently associated with AKI in multivariable logistic regression. Less than one-third of those who needed dialysis received it. There was 100% mortality in those who needed dialysis but did not receive (n = 19). LIMITATIONS: Being based at a referral center, the findings do not represent the true burden of AKI in the community. CONCLUSION: The prevalence of AKI was very high in ICUs in Northern Tanzania. The majority of patients presented with AKI and were severely ill, suggesting late presentation, underscoring the importance of prioritizing prevention and early intervention. Further studies should explore locally suitable AKI risk scores that could be used to identify high-risk patients in the community health centers from where patients are referred.

CONTEXTE: L'insuffisance rénale aiguë (IRA) est une complication reconnue chez les patients gravement malades et son épidémiologie varie dans le monde en fonction du contexte et des critères diagnostiques utilisés. L'International Society of Nephrology (ISN) en appelle à une réduction à zéro des décès évitables dus à l'IRA d'ici 2025. On soupçonne que la majorité des cas d'IRA se trouvent dans des pays disposant de ressources limitées, mais le fardeau réel de la maladie dans ces contextes demeure inconnu. OBJECTIFS: Notre objectif était de déterminer, avec les critères normalisés KDIGO, la prévalence de l'AKI, les facteurs associés et les caractéristiques cliniques des patients adultes admis aux unités de soins intensifs (USI) d'un hôpital de soins tertiaires en Tanzanie. TYPE D'ÉTUDE: Étude observationnelle prospective couvrant la période de novembre 2017 à mai 2018. MÉTHODOLOGIE: Les 320 patients admis aux USI médicale et chirurgicale ont été inscrits de façon consécutive. Les données initiales, cliniques et de laboratoire ont été recueillies à l'admission et au cours du séjour à l'USI. Le taux de créatinine sérique et le débit urinaire ont été mesurés et le stade de l'IRA a été déterminé avec les critères KDIGO. RÉSULTATS: Plus de la moitié (55,3 %) des patients admis aux USI avaient reçu un diagnostic d'IRA, et 80 % de ceux-ci avaient été diagnostiqués dans les 24 heures suivant leur admission. L'IRA de stade 3 représentait 35 % des patients diagnostiqués. Les patients atteints d'IRA étaient plus âgés, présentaient des taux initiaux de créatinine et de potassium sériques plus élevés, et étaient plus susceptibles d'avoir une maladie cardiovasculaire concomitante, de même qu'un score d'évaluation universelle des signes vitaux à l'admission et un nombre total de leucocytes d'au moins 12. Une analyse de régression logistique multivariée a permis d'associer de façon indépendante l'IRA à la septicémie (RC: 3,81; IC: 1,21­11,99), au diabète (RC: 2,54; IC: 1,24­5,17) et à l'utilisation de vasopresseurs (RC: 3,78; IC: 1,36­10,54). Moins d'un tiers des patients ayant besoin de dialyse en avaient reçu. Tous les patients ayant besoin de dialyse, mais n'en ayant pas reçu (n = 19) sont décédés. LIMITES: L'étude s'est tenue dans un seul centre, les conclusions ne sont donc pas représentatives du véritable fardeau que représente l'IRA dans la communauté. CONCLUSION: La prévalence de l'IRA était très élevée dans les unités de soins intensifs du nord de la Tanzanie. La majorité des patients à l'étude souffraient d'IRA et étaient gravement malades, ce qui suggère une présentation tardive et souligne l'importance de prioriser la prévention et les interventions précoces. D'autres études devraient explorer les scores de risque localement accessibles qui pourraient être utilisés pour cerner les patients à haut risque dans les centres de santé communautaire d'où ils sont aiguillés.