Cytokines as a predictor of progression to valvular disease in children with rheumatic fever

The immunologic basis of rheumatic fever is well established. However the role of penicillin in the control of the rheumatic process and the prevention of development of rheumatic heart disease is poorly understood.Objectivethe objective of this study was to monitor the changes in serum levels of Tumour Necrosis Factor (TNF-alpha) and interleukin-8 (IL-8) in children presenting with various stages of rheumatic fever over a time.Subjects and methodsStudy included 42 children aged 6–15 years with RHD followed up over one year by Doppler-echocardiography and laboratory tests to monitor IL-8 and TNF-alpha by ELISA technique.ResultsTwenty five children presented with acute arthritis with or without carditis (59.5%), all had statistically significantly high levels of IL-8 and TNF-alpha throughout the follow-up period. Of these 9 (36%) developed rheumatic reactivity and 6 (24%) developed valvular heart disease. Eight children (19%) presented with rheumatic chorea, all had significantly high levels of IL-8 and TNF-alpha throughout the follow-up period, of whom 4 (50%) developed valvular disease. Nine children (21.4%) presented with varying degrees of established chronic rheumatic heart disease, all of whom had no rise in the serum levels of IL-8 and TNF-alpha.ConclusionsThese findings indicate that the clinical and epidemiological pattern of rheumatic fever is changing. Immunemodulatory responses could assist us in tracking these changing patterns of disease and assessing current protocols of management

Clinical Outcomes in 3343 Children and Adults with Rheumatic Heart Disease from 14 Low and Middle Income Countries: 2-Year Follow-up of the Global Rheumatic Heart Disease Registry (the REMEDY study)

Background: There are few contemporary data on the mortality and morbidity associated with rheumatic heart disease or information on their predictors. We report the 2-year follow-up of individuals with rheumatic heart disease from 14 low- and middle-income countries in Africa and Asia. Methods: Between January 2010 and November 2012, we enrolled 3343 patients from 25 centers in 14 countries and followed them for 2 years to assess mortality, congestive heart failure, stroke or transient ischemic attack, recurrent acute rheumatic fever, and infective endocarditis. Results: Vital status at 24 months was known for 2960 (88.5%) patients. Two-thirds were female. Although patients were young (median age, 28 years; interquartile range, 18–40), the 2-year case fatality rate was high (500 deaths, 16.9%). Mortality rate was 116.3/1000 patient-years in the first year and 65.4/1000 patient-years in the second year. Median age at death was 28.7 years. Independent predictors of death were severe valve disease (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.80–3.11), congestive heart failure (HR, 2.16; 95% CI, 1.70–2.72), New York Heart Association functional class III/IV (HR, 1.67; 95% CI, 1.32–2.10), atrial fibrillation (HR, 1.40; 95% CI, 1.10–1.78), and older age (HR, 1.02; 95% CI, 1.01–1.02 per year increase) at enrollment. Postprimary education (HR, 0.67; 95% CI, 0.54–0.85) and female sex (HR, 0.65; 95% CI, 0.52–0.80) were associated with lower risk of death. Two hundred and four (6.9%) patients had new congestive heart failure (incidence, 38.42/1000 patient-years), 46 (1.6%) had a stroke or transient ischemic attack (8.45/1000 patient-years), 19 (0.6%) had recurrent acute rheumatic fever (3.49/1000 patient-years), and 20 (0.7%) had infective endocarditis (3.65/1000 patient-years). Previous stroke and older age were independent predictors of stroke/transient ischemic attack or systemic embolism. Patients from low- and lower-middle–income countries had significantly higher age- and sex-adjusted mortality than patients from upper-middle–income countries. Valve surgery was significantly more common in upper-middle–income than in lower-middle– or low-income countries. Conclusions: Patients with clinical rheumatic heart disease have high mortality and morbidity despite being young; those from low- and lower-middle–income countries had a poorer prognosis associated with advanced disease and low education. Programs focused on early detection and the treatment of clinical rheumatic heart disease are required to improve outcomes. </jats:sec

Assessment of the Baby Friendly Hospital Initiative Implementation in the Eastern Mediterranean Region

The Baby-Friendly Hospital Initiative (BFHI) is a global program for promoting support and protection for breastfeeding. However, its impact on malnutrition, especially in countries of the Eastern Mediterranean region (EMR) that are facing the turmoil of conflict and emergencies, deserves further investigation. Having said that, this paper aims to discuss the status and challenges to BFHI implementation in the EMR countries. Data on BFHI implementation, breastfeeding practices, and nutritional status were collected from countries through structured questionnaires, personal interviews, and databases. The 22 countries of the EMR were categorized as follows: 8 countries in advanced nutrition transition stage (group I), 5 countries in early nutrition transition stage (group II), 4 countries with significant undernutrition (group III), and 5 countries in complex emergency (group IV). The challenges to BFHI implementation were discussed in relation to malnutrition. BFHI was not implemented in 22.7% of EMR countries. Designated Baby-Friendly hospitals totaled 829 (group I: 78.4%, group II: 9.05%; group III: 7.36%; group: IV5.19%). Countries with advanced nutrition transition had the highest implementation of BFHI but the lowest breastfeeding continuity rates. On the other hand, poor nutritional status and emergency states were linked with low BFHI implementation and low exclusive breastfeeding rates but high continuity rates. Early initiation and longer duration of breastfeeding correlated negatively with overweight and obesity (p &lt; 0.001). In countries with emergency states, breastfeeding continues to be the main source of nourishment. However, suboptimal breastfeeding practices prevail because of poor BFHI implementation which consequently leads to malnutrition. Political willpower and community-based initiatives are needed to promote breastfeeding and strengthen BFHI in the region

Global Status of Breastfeeding and Infant Feeding in book titled: “Curriculum Guide In Breastfeeding Medicine for Health Professionals”,

Breastfeeding protection and support are mandates for achieving optimum health and well-being for children and future generations in many of the developed and developing countries. Countries of the Eastern Mediterranean region (EMR) are struggling to meet the World Health Organization (WHO) recommendations for exclusive breastfeeding (EBF) during the first six months of life and continued breastfeeding for two years or more as recommended by the WHO and UNICEF, (27) by implementation of interventions as the Baby-friendly Hospital Initiative (BFHI) at maternity health facility level and the ‘First One thousand days’ at the community.(47,96,97,98) Breastfeeding is a Human right and is supported by the Convention of the human rights for protecting the child. (27</p

Influence of early feeding practices on biomarkers of cardiovascular disease risk in later life

Background: An analysis of risk factors linked to ischemic heart disease (IHD) shows a strong link between these risk factors and early feeding practices. Aim of the work: The aim of this study was to evaluate cardiac biomarkers that could predict cardiovascular disease (lipid profile and highly sensitive C-reactive protein (hs-CRP) for both mothers and their children and demonstrate their associations with early feeding practices. Methods: This was a cross-sectional study comprising one hundred twenty pairs of mother and their children, one half of whom were exclusively breastfed for 6 months, the other half their children were formula fed from birth. The groups were matched for age and sex. Full feeding history was taken for children and assessments of risk behaviour of cardiovascular disease including Anthropometric measurements to assess Body Mass Index, blood pressures and blood samples for lipid profile and hs-CRP for both mothers and children. Results: There was a statistically significant difference between the two groups regarding hs-CRP as it was higher in mothers and their children who were artificially feed than mothers and their children who were breastfeed (m = 3.3 + 2.2–1.72 ± 1.96, 2.08 ± 1.64–0.84 ± 1.09 respectively), however there was no a statistically significant difference for both mothers and their children regarding lipid profile. Conclusion: Early feeding practices can influence the development of cardiovascular diseases as breast fed infants and their mothers had lower hs- CRP levels which is considered as a biomarker of CVD risk

41. Echocardiographic interpretation of cardiac function with puberty in girls

Puberty is accompanied by significant changes in hemodynamics that can influence interpretation of clinical states. However the extent to which this is influenced by the nutritional status of children is poorly understood. To study the changes in cardiac dimensions with onset of early puberty and their relation to growth and nutritional status in females. Methods: Survey was conducted for 200 schools girls aged 9–12 years including full cardiac exam, blood pressure (BP), weight-for-age (W/A), height-for-age (H/A) and body mass index (BMI) and echocardiography for aortic, atrial and ventricular dimensions, as well pressure gradients and flow velocities. Further analysis was conducted for forty cases that were identified with flow abnormalities. Findings: Only 17.5% had audible murmurs. Mean BP ranged from 90.4 in the 9 years olds, 94 in the 10 year olds, 95.9 in the 11 year olds and 97.5 in the 12 year olds. Morphologic dimensions were measured for the ventricles, left atria (LA) and aorta (Ao). Aortic dimensions increased with the onset of puberty and correlated with the BMI increase, but the mean aortic to left atrial dimensions were unchanged with puberty onset. Also ventricular dimensions did not change with puberty. The E wave of the mitral valve signal and deceleration velocity showed some change with age, with an exaggerated E wave. BMI averaged 17.1 at 9 years increasing to 21 at 12 years. Underweight (−2SDS) occurred in 22.5% and stunting (−2SDS) in 10% and wasting (underweight for height) in 17.5%. Fifty percent of the children were exposed to passive smoking from family member, 69.2% did not consume a healthy diet and 97% did not practice sports. Conclusions: Onset of puberty is accompanied by an increase in aortic dimensions to cope with the increased venous return from the developing body systems. Growth disturbances may result in echo abnormalities in flow across the cardiac valves. Improving nutritional status and healthy living lifestyles of children in this period may prevent abnormalities and restore hemodynamics of the heart

INTERNATIONAL TEXTBOOK OF BREASTFEEDING, INFANT AND YOUNG CHILD FEEDING: From Evidence to Policy and Action

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Trends in Deaths from Rheumatic Heart Disease in the Eastern Mediterranean Region: Burden and Challenges

Rheumatic heart disease (RHD) is a preventable disease that is prevalent in developing regions of the world. Its eradication from most of the developed world indicates that this disease can be controlled and eliminated. Aim: To conduct an in-depth analysis of the trends and challenges of controlling RHD in the Eastern Mediterranean region (EMR). Methodology: Global data from the World Health Organization (WHO) data banks were retrieved for total deaths and age standardized death rate per 100,000 (ASDR) by age group, sex, and year (from 2000 to 2015). The data was compared with the five other WHO regions of the world. We also performed in-depth analysis by socio-economic groups in relation to other attributes in the region related to population growth, illiteracy, and nutritional status. Indicators of service delivery were correlated with ASDR from RHD. Findings: Prevalence of RHD in 2015 in the EMR region was one-third of that of the total deaths reported in the Asian and West Pacific regions. The total deaths for the region peaked twice: in early adulthood and again later in old age, and was higher in females than in males. There was a rising trend in deaths from RHD from 2000 to 2015. The highest total deaths were reported from Egypt, Pakistan, Iran, Afghanistan, and Yemen, representing 80% of the total death rates for the region (35,248). The highest ASDR was Afghanistan (27.5), followed by Yemen (18.78) and Egypt (15.59). The ASDR for RHD was highest in low income countries. It correlated highly, in all income groups, with anemia during pregnancy. Conclusions: Trends and patterns of deaths from RHD in the EMR have shifted to a later age group and are linked with poverty related to inequalities in development and service delivery for certain age groups and gender

Seven key actions to eradicate rheumatic heart disease in Africa: the Addis Ababa communiqué

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain major causes of heart failure, stroke and death among African women and children, despite being preventable and imminently treatable. From 21 to 22 February 2015, the Social Cluster of the Africa Union Commission (AUC) hosted a consultation with RHD experts convened by the Pan-African Society of Cardiology (PASCAR) in Addis Ababa, Ethiopia, to develop a ‘roadmap’ of key actions that need to be taken by governments to eliminate ARF and eradicate RHD in Africa. Seven priority areas for action were adopted: (1) create prospective disease registers at sentinel sites in affected countries to measure disease burden and track progress towards the reduction of mortality by 25% by the year 2025, (2) ensure an adequate supply of high-quality benzathine penicillin for the primary and secondary prevention of ARF/RHD, (3) improve access to reproductive health services for women with RHD and other non-communicable diseases (NCD), (4) decentralise technical expertise and technology for diagnosing and managing ARF and RHD (including ultrasound of the heart), (5) establish national and regional centres of excellence for essential cardiac surgery for the treatment of affected patients and training of cardiovascular practitioners of the future, (6) initiate national multi-sectoral RHD programmes within NCD control programmes of affected countries, and (7) foster international partnerships with multinational organsations for resource mobilisation, monitoring and evaluation of the programme to end RHD in Africa. This Addis Ababa communiqué has since been endorsed by African Union heads of state, and plans are underway to implement the roadmap in order to end ARF and RHD in Africa in our lifetime

Characteristics, complications, and gaps in evidence-based interventions in rheumatic heart disease: the Global Rheumatic Heart Disease Registry (the REMEDY study)

AIMS: Rheumatic heart disease (RHD) accounts for over a million premature deaths annually; however, there is little contemporary information on presentation, complications, and treatment. METHODS AND RESULTS: This prospective registry enrolled 3343 patients (median age 28 years, 66.2% female) presenting with RHD at 25 hospitals in 12 African countries, India, and Yemen between January 2010 and November 2012. The majority (63.9%) had moderate-to-severe multivalvular disease complicated by congestive heart failure (33.4%), pulmonary hypertension (28.8%), atrial fibrillation (AF) (21.8%), stroke (7.1%), infective endocarditis (4%), and major bleeding (2.7%). One-quarter of adults and 5.3% of children had decreased left ventricular (LV) systolic function; 23% of adults and 14.1% of children had dilated LVs. Fifty-five percent (n = 1761) of patients were on secondary antibiotic prophylaxis. Oral anti-coagulants were prescribed in 69.5% (n = 946) of patients with mechanical valves (n = 501), AF (n = 397), and high-risk mitral stenosis in sinus rhythm (n = 48). However, only 28.3% (n = 269) had a therapeutic international normalized ratio. Among 1825 women of childbearing age (12–51 years), only 3.6% (n = 65) were on contraception. The utilization of valvuloplasty and valve surgery was higher in upper-middle compared with lower-income countries. CONCLUSION: Rheumatic heart disease patients were young, predominantly female, and had high prevalence of major cardiovascular complications. There is suboptimal utilization of secondary antibiotic prophylaxis, oral anti-coagulation, and contraception, and variations in the use of percutaneous and surgical interventions by country income level