Echocardiography Learning by Pediatricians While Screening Congenital Heart Disease with the Aid of Telemedicine.

Background: Congenital heart disease (CHD) affects 1% of all newborns and is a major public health problem. Most children with CHD benefit from early diagnosis to optimize management. However, in many places there are no specialized professionals to do so. Introduction: A screening method for CHD was developed between two states in Northeast Brazil. It was based upon the performance of an echocardiogram by local pediatricians with support of pediatric cardiologists through telemedicine. Objective: To determine if the continuous performance of examinations together with online supervision increased the level of understanding of the pediatricians about the echocardiograms. Methods: Pediatricians received online support to perform echocardiograms for 7 years (2012-2018). Although the project aimed to teach them to acquire images and send to the cardiologists for analysis and interpretation, they were encouraged to describe their own diagnostic impressions. The level of agreement between pediatricians and cardiologists was calculated. Results: A large number (n = 3,951) echocardiograms was analyzed. From them, 2,818 were classified as abnormal, inconclusive, or normal by both the pediatricians and the cardiologists. The 7-year analysis demonstrated an overall agreement of 63.7%. As for the final diagnosis, it was possible to compare 1,457 echocardiograms. The combined analysis of the 7 years demonstrated agreement in 62.2%. Discussion: The screening of CHD under online support led to more in-depth learning of echocardiography by the pediatricians. This approach potentialized the accuracy of the screening through the years. Conclusion: By enrolling in a telemedicine-based screening program, the pediatricians' degree of understanding of echocardiography increased considerably.

A telemedicine network for remote paediatric cardiology services in north-east Brazil.

PROBLEM: Providing health care for children with congenital heart diseases remains a major challenge in low- and middle-income countries. APPROACH: In October 2011, the Government of Paraíba, Brazil, established a paediatric cardiology network in partnership with the nongovernmental organization Círculo do Coração. A cardiology team supervised all network activities, using the Internet to keep in contact with remote health facilities. The network developed protocols for screening heart defects. Echocardiograms were performed by physicians under direct online supervision of a cardiologist; alternatively, a video recording of the examination was subsequently reviewed by a cardiologist. Cardiovascular surgeons came to a paediatric hospital in the state capital once a week to perform heart surgeries. LOCAL SETTING: Until 2011, the State of Paraíba had no structured programme to care for children with heart disease. This often resulted in missed or late diagnosis, with adverse health consequences for the children. RELEVANT CHANGES: From 2012 to 2014, 73,751 babies were screened for heart defects and 857 abnormalities were identified. Detection of congenital heart diseases increased from 4.09 to 11.62 per 1000 live births (P < 0.001). Over 6000 consultations and echocardiograms were supervised via the Internet. Time to diagnosis, transfers and hospital stays were greatly reduced. A total of 330 operations were carried out with 6.7% (22/330) mortality. LESSONS LEARNT: Access to an echocardiography machine with remote supervision by a cardiologist improves the detection of congenital heart disease by neonatologists; virtual outpatient clinics facilitate clinical management; the use of Internet technology with simple screening techniques allows resources to be allocated more efficiently.

Busca ativa por cardiopatias congênitas é factível? Experiência em oito cidades Brasileiras / Active search for congenital heart disease is possible? Experience from eight brazilian cities

Fundamentos: As cardiopatias congênitas são causa de alta morbimortalidade na faixa etária pediátrica. Em regiões em desenvolvimento, a falta de diagnóstico precoce pode acarretar a piora do quadro; uma busca ativa por cardiopatias congênitas pode colaborar na resolução dessa situação.Objetivo: Descrever os principais achados de uma busca ativa por cardiopatias na infância, realizada em oito cidades brasileiras do estado da Paraíba. Métodos: Estudo realizado em oito cidades brasileiras do estado da Paraíba. A busca ativa compreendeu duas fases. Na primeira, os centros de saúde locais realizaram a triagem de crianças com sintomas ou história clínica de doenças cardiovasculares. Na segunda fase, realizada uma consulta clínica com posterior realização de ecocardiograma para identificação de cardiopatias. As frequências obtidas foram analisadas. Variáveis categóricas foram comparadas utilizando-se o teste do qui-quadrado. Resultados: Atendidas 440 crianças. Destas, 192 (43,63%) apresentaram alterações ao ecocardiograma. As presenças de sopro e da síndrome de Down mostraram correlação significativa (p<0,05) com a cardiopatia congênita. A maioria dos casos era de cardiopatia congênita por shunt (64,1%), seguida pelos defeitos valvares (12,5%) e pelas cardiopatias obstrutivas acianogênicas (8,3%). Conclusão: A busca ativa realizada foi capaz de identificar um número expressivo de cardiopatias congênitas na infância, não reconhecidas previamente, e inserir esses pacientes nos serviços de saúde para o tratamento adequado, garantindo-lhes melhor qualidade de vida.

Background: Congenital heart defects are the cause of high morbidity and mortality in pediatric patients. In developing regions, the lack of early diagnosis may lead to worsening of the condition; an active search for congenital heart diseases can assist in resolving this situation. Objective: To describe the key findings of an active search for heart diseases in childhood, held in eight Brazilian cities in the state of Paraíba. Methods: A study conducted in eight Brazilian cities in the state of Paraíba. The active search included two phases. In the first, local health centers screened children with symptoms or a history of cardiovascular diseases. In the second phase, a clinical consultation with echocardiogram to identify diseases was conducted. The frequencies were then analyzed. Categorical variables were compared using the chi-square test. Results: 440 children were assisted. Of these, 192 (43.63%) had abnormalities on echocardiogram. The presence of heart sounds and Down’s syndrome showed a significant correlation (p <0.05) with the congenital heart disease. Most cases were congenital heart disease by shunt (64.1%), followed by valve defects (12.5%) and acyanogenic obstructive heart diseases (8.3%). Conclusion: The active search conducted was able to identify a significant number of congenital heart diseases in childhood not previously recognized and inserting these patients in health services for appropriate treatment, thus ensuring them a better quality of life.

Taquicardia ventricular polimórfica catecolaminérgica com Morte súbita abortada / Catecholaminergic polymorphic ventricular tachycardia with reserved sudden death

A taquicardia ventricular polimórfica catecolaminérgica (TVPC) é uma rara arritmia geneticamente herdada que pode acometer crianças sem cardiopatia estrutural e intervalo QTc normal. As crianças acometidas demostram eletrocardiograma (ECG) normal ao repouso, sendo deflagrada arritmia somente com frequência cardíaca ente 110-120bpm, podendo levar a quadros de síncope e morte súbita. Relata-se caso de paciente feminina, com história de síncopes frequentes e história pregressa de bradicardia sinusal. Sem melhora dos casos de síncope, a família procurou um serviço especializado em arritmia cardíaca. Durante este esforço, a paciente apresentou TVPC que evoluiu para morte súbita, tendo sido abortada.

Catecholaminergic polymorphic ventricular tachycardia (CPVT) s a rare genetically inherited arrhythmia that affects children without structural heart disease and with normal QTc intrval. Affected children presente normal at-rest electrocardiograms (ECG) with arrhytmia triggered at heart rates between 110 and 120bpm, sometimes leading to syncope and sudden death. This case report describes a female patient with a history of frequente syncope and sinus bradycardia. With no syncope improvement, the family sought out a facility specializing in cardiac arrhythmia. During the stress test, the patient presented CPVT and progressed to sudden death, which was then reversed.

Visitas em ambientes virtuais manejadas por cardiologistas pediátricos: relato de experiência / Visits in virtual environments managed by pediatric cardiologists: report of experience / Visitas en entornos virtuales administrados por cardiólogos pediátricos: relato de experiencia

Objetivo: Relatar a experiência de contatos diários entre um centro de cardiologia pediátrica e 14 centros de saúde públicos da Paraíba. Metodologia: Diariamente, os cardiologistas deveriam estabelecer contato com as maternidades paraibanas. Essa comunicação poderia ser por WebEx, Skype ou, em último caso, via telefone. Foram anotados todos os casos clínicos e análises de ecocardiogramas, além das dificuldades enfrentadas para uma comunicação eficaz. O período entre 02/01/2013 e 05/08/2013 foi analisado. Resultados: Houve 1523 contatos entre o centro de referência e os 14 centros. Dificuldade técnica ocorreu em 363 das comunicações, sendo a dificuldade de responder ao chamado a maior responsável (57,7%) seguida pelos problemas com a conexão a internet (11,8%). Durante o período, foram discutidos 871 casos e 100 ecocardiogramas. Conclusão: Apesar das dificuldades estruturais foi possível manter uma boa comunicação e conduzir um grande número de casos. Por outro lado, o fator humano foi responsável pela maioria das dificuldades...

Objective: to report the experience of daily contact between a pediatric cardiology center and 14 public hospitals in Paraíba. Methodology: Everyday, cardiologists made contact with the maternities from Paraíba. This communication was done by WebEx, Skype and some cases via telephone. All clinical cases, analyzes of echocardiograms and the difficulties in effective communication were registered. For this analyzes we are only considering the time frame between 02/01/2013 and 05/08/2013. Results: A total of 1523 contacts between the reference center and 14 hospitals were made. Technical difficulty occurred in 363 of the communications: the difficulty of answering the call (57.7%), followed by problems with the internet connection (11.8%). During the period, 871 cases and 100 echocardiograms were discussed. Conclusion: Despite the structural problems, it was possible to maintain good communication and conduct a large number of cases. On the other hand, the human factor was responsible for the majority of technical difficulties...

Objetivo: Relatar las experiencias de contactos diarios entre un Centro de Cardiología Pediátrica y 14 Maternidades Públicas de Paraíba. Metodología: Diariamente los cardiologistas deberían establecer contacto con las maternidades Paraibanas. Esa comunicación podría ser por WebEx, Skype o en último caso, vía teléfono. Fueron anotados todos los casos clínicos y análisis de eco cardiogramas, además de las dificultades enfrentadas para una comunicación eficaz. El período entre 02/01/2013 y 05/08/2013 fue analizado. Resultado: Hubo 1523 contactos entre el Centro de referencia y las 14 maternidades. Dificultades técnicas ocurrieron en 363 comunicaciones, siendo la dificultad de responder al llamado la mayor responsable (57,7%), seguida por los problemas con la conexión a internet (11,8%). Durante el período fueron discutidos 871 casos y efectuados 100 eco cardiogramas. Conclusión: A pesar de las dificultades estructurales fue posible mantener una buena comunicación y atender un gran número de casos. Por otro lado, el factor humano fue responsable por la mayoría de las dificultades...

Características dos pacientes em serviço privado de cardiologia pediátrica: análise de sete anos / Characteristics of patients in private pediatric cardiology unit: seven-year analysis

Fundamentos: Apesar dos avanços no diagnóstico etratamento das cardiopatias na infância, as cardiopatias congênitas figuram como fator de destaque namorbimortalidade neonatal. Cardiopatias adquiridas,como a febre reumática, também têm alto impacto nasaúde pública. Logo, o conhecimento do perfil dessescardiopatas é importante para focalizar recursos eotimizar resultados. Objetivo: Descrever os principais achados clínicos ediagnósticos de pacientes atendidos em clínica privadade cardiologia pediátrica por faixa etária. Métodos: Analisados 17873 prontuários de pacientesatendidos nos últimos sete anos, com ênfase em: sexo, idade, motivo do encaminhamento, principais achadosna história da doença atual, achados ao exame físico,exames complementares realizados e principais diagnósticos ao ecocardiograma. Resultados: Houve predomínio do sexo masculino(53,7 %). A média de idade foi 63,5 meses, compacientes abaixo de 2 anos representando aproximadamente 25,0 % da amostra. O motivoprincipal do encaminhamento foi o parecer cardiológicoem pacientes acima de 2 anos, e suspeita de cardiopatianas faixas etárias menores. Ao exame físico, 59,8 %apresentavam anormalidades, com sopro presente em35,8%. O ecocardiograma foi realizado em 96,93% daamostra. Dentre as cardiopatias detectadas ao ecocardiograma, as mais frequentes foram as de shuntE-D (62,75%). Conclusão: A maioria das cardiopatias ocorreu empacientes de menor faixa etária no momento doencaminhamento. A diferença entre as faixas etáriasfoi essencial na diferenciação das cardiopatias e dosachados clínicos.

Background: Despite advances in the diagnosis andtreatment of heart diseases during childhood, congenital heart defects remain a prominent factor in neonatal morbidity and mortality. Acquired heart diseases, such as rheumatic fever, also have high impact on public health. Knowledge of these cardiac patient profiles is thus important for focus ingresources and optimizing results. Objective: To describe the main diagnostic and clinical findings for patients seen at a private pediatric cardiology center, by age bracket. Methods: We analyzed 17,873 records for patients seen during the past seven years, emphasizing: gender, age, reason for referral, the main findings in the history of the current disease, main findings from physical examinations, supplementary tests and the main diagnoses through echocardiograms. Results: There was a predominance of males (53.7%), with an average age of 63.5 months, with some 25% of the sample younger than two years of age. The main reasons for referral were cardiological reports for patients more than two years old, and suspected CHD for younger children. On physical examination, 59.8% presented anomalies, with murmurs found in 35.8%. Echocardiography was performed for 96.93% of the sample. The most frequent CHDs detected by echocardiography were left-to-right shunt lesions (62.75%).Conclusion: Most CHDS were found in younger children, on referral. The difference between the age brackets was essential for distinguishing CHDs and clinical findings.

Novo modelo de teletriagem das cardiopatias congênitas / Tele-screening new model of congenital heart disease

Um modelo de triagem das cardiopatias congênitas foi criado associando a telemedicina com a captação de imagens ecocardiográficas básicas por neonatologistas. Foi baseado num treinamento presencial e na orientação dos casos via internet. Esse modelo é viável, desde que sob tutela de um cardiologista pediátrico, pois reduz custos e distâncias no contexto do diagnóstico das cardiopatias congênitas.

A “tele-screening” model for CHD was developed using telemedicine coupled with online training of neonatologists on the acquisition of basic cardiac views. An initial live training session was provided and subsequently the examinations were oriented online. Under cardiology supervision, the tele-screening model proved to be reliable as it reduced cost and distances in the context of congenital heart disease.

Sistema interativo em ambiente móvel para o diagnóstico diferencial de cardiopatias congênitas / Interactive system on mobile environment for differential diagnosis of congenital heart disease / Sistema interactivo para el entorno móvil en el diagnóstico diferencial de la enfermedad cardíaca congénita

Objetivo: Descrever a elaboração de um sistema interativo de apoio ao diagnóstico de cardiopatias congênitas (CCs). Métodos: Para a captação da Base de Conhecimento foi usado um fluxograma elaborado por cardiologistas pediátricos sobre sinais e sintomas das CCs. Para a construção do sistema utilizou-se o ambiente de desenvolvimento para Sistema Android ?App Inventor?, elaborado pelo Massachusetts Institute of Technology (MIT). Resultados: Repostas pré-determinadas levam a grupos de CCs mais prováveis. Os sintomas iniciais foram cianose, insuficiência cardíaca congestiva (ICC), a associação de ambas ou apenas sopro isolado. Nas perguntas sequenciais também foram utilizadas características dos sopros, do raio-x, do ECG, dos pulsos e do precórdio. A resposta sequencial leva a grupos cada vez mais restritos de patologias. Conclusão: Um sistema de apoio ao diagnóstico diferencial das cardiopatias congênitas elaborada para não especialistas na área que lidam com neonatos pode ter impacto positivo na morbimortalidade neonatal.

Objective: To describe the development of an interactive system to support the diagnosis of congenital heart disease (CHDs). Methods: To capture the knowledge base we used a flow chart prepared by pediatric cardiologists about signs and symptoms of CHDs. For the construction of the system we used the environment Development System for Android ?App Inventor?, prepared by Massachusetts Institute of Technology (MIT). Results: Responses lead to predetermined groups of CHDs more likely. Initial symptoms were cyanosis, congestive heart failure (CHF), the combination of both or just blowing isolated. In sequential questions were also used features of blows, x-ray, ECG, pulses and precordium. The response sequential groups leads to increasingly restricted conditions. Conclusion: A support system for differential diagnosis of congenital designed for non-specialists in the area dealing with newborns can have positive impact on neonatal morbidity and mortality.

Objetivo: Describir el desarrollo de un sistema interactivo para apoyar el diagnóstico de las cardiopatías congénitas (CCs). Métodos: Para capturar la base de conocimientos se utilizó un diagrama de flujo elaborado por cardiólogos pediatras acerca de las señales y síntomas de CCs. Para la construcción del sistema que se utiliza el medio ambiente Sistema de Desarrollo para Android ?App Inventor?, preparado por Massachusetts Institute of Technology (MIT). Resultados: Las respuestas conducen a grupos predeterminados de CC más probables. Los síntomas iniciales fueron cianosis, insuficiencia cardíaca congestiva (ICC), la combinación de ambos o simplemente soplando aislado. En las preguntas secuenciales eran características también se utilizan de golpes, rayos x, ECG, legumbres y región precordial. Los grupos secuenciales de respuesta da lugar a condiciones cada vez más restringido. Conclusión: Un sistema de apoyo para el diagnóstico diferencial de la congénita diseñado para quienes no son especialistas en el área frente a los recién nacidos pueden tener un impacto positivo en la morbilidad y mortalidad neonatal.