Olukemi Ige

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.

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.

Childhood acquired heart diseases in Jos, north central Nigeria.

Background: The patterns of childhood acquired heart diseases (AHD) vary in different parts of the world and may evolve over time. We aimed to compare the pattern of childhood AHD in our institution to the historical and contemporary patterns in other parts of the country, and to highlight possible regional differences and changes in trend. Materials and Methods: Pediatric echocardiography records spanning a period of 10 years were reviewed. Echocardiography records of children with echocardiographic or irrefutable clinical diagnoses of AHD were identified and relevant data extracted from their records. Results: One hundred and seventy five children were diagnosed with AHD during the period, including seven that had coexisting congenital heart disease (CHD). They were aged 4 weeks to 18 years (mean 9.84΁4.5 years) and comprised 80 (45.7%) males and 95 (54.3%) females. Rheumatic heart disease (RHD) was the cause of the AHD in 101 (58.0%) children, followed by dilated cardiomyopathy (33 cases, 18.9%) which was the most frequent AHD in younger (under 5 years) children. Other AHD encountered were cor pulmonale in 16 (9.1%), pericardial disease in 15 (8.6%), infective endocarditis in 8 (4.6%) and aortic aneurysms in 2 (1.1%) children. Only one case each of endomyocardial fibrosis (EMF) and Kawasaki Disease were seen during the period. Conclusions: The majority of childhood acquired heart diseases in our environment are still of infectious aeitology, with RHD remaining the most frequent, particularly in older children. Community-based screening and multicenter collaborative studies will help to better describe the pattern of AHD in our country. More vigorous pursuit of the Millennium development goals will contribute to reducing the burden of childhood acquired heart diseases in the country.

Pattern of neonatal admissions and outcome in a tertiary institution in north central Nigeria

Background/Purpose: Neonatal morbidity and mortality contributes significantly to under-five morbidity and mortality in sub-Saharan Africa accounting for 40% of under-five mortality. A substantial reduction in neonatal mortality is therefore necessary to achieve the Millennium Development Goal (MDG) 4 target by 2015. The aim of the study was to assess the pattern of neonatal morbidity and mortality in our environment which will help to identify interventions for better neonatal outcome. Materials and Methods: The study is a review of cases admitted into the neonatal unit of the Jos University Teaching Hospital situated in the North Central part of Nigeria. The unit started operating from the permanent site of the hospital on 1 March 2010 after the relocation of the hospital from the previous site. Data on all neonates admitted into the neonatal unit from 1 March 2010 to 28 February 2011 were obtained from the various registers/records and analyzed. Data extracted included biodata, gestational age, birth weight, main diagnosis, duration of admission, etc., In addition, the outcomes (discharged/died) were documented. All statistical analyses were performed using two-sided tests. A P Results: A total of 572 neonates were admitted, accounting for 54.6% of the 1047 pediatric medical admissions into the hospital. The main causes of admission were neonatal infections (37.1%), prematurity (20.1%), and birth asphyxia (11.5%). Out of the 572 neonates, 111 (19.4%) died. About three quarters (76.5%) of the mortalities occurred in the first week of life with 46.4% of these occurring in the first 24 hours (χ2 -20.2, P Conclusion: There is a high burden for neonatal care at the institution. The three main causes of morbidity and mortality are prematurity, infections, and birth asphyxia. Hence, neonatal care/facilities need to be improved especially to care for the high risk neonate. Also, the importance of infection control cannot be overemphasized.

Left Ventricular Systolic Function in Nigerian Children with Human Immunodeficiency Virus Infection

OBJECTIVE The objective of this article was to compare the left ventricular (LV) systolic function of human immunodeficiency virus (HIV)-infected children with that of healthy controls, determine the prevalence of LV systolic dysfunction in HIV-infected children, and its association with age, stage of disease, and use of zidovudine. STUDY DESIGN This was a comparative cross-sectional descriptive study. SETTING A University Teaching Hospital in North-Central Nigeria in 2008. PATIENTS One hundred fifty HIV-infected children aged 6 weeks-14 years, and an equal number of age- and sex-matched apparently healthy controls. OUTCOME MEASURES Left ventricular internal dimensions in diastole and systole, LV fractional shortening (FS) and ejection fraction (EF). Left ventricular systolic dysfunction was considered present when FS was <28% or EF was <50%. RESULTS Mean LV internal dimensions in diastole was similar in subjects and controls (P= .26). Left ventricular internal dimensions in systole was significantly larger in subjects (2.7 cm, 95% confidence interval [CI] 2.6-2.8 cm) than controls (2.4 cm, 95% CI 2.3-2.5 cm) (P < .001). Mean FS of 27.8% (26.8-28.8%) in subjects was significantly reduced compared with 33.7% (33.1-34.3%) in controls (P < .001), as was EF 61.5% (60.7-62.3%) in subjects and 70.5% (69.7-71.3%) in controls (P < .001). Left ventricular systolic dysfunction was detected in 75 (50.0%, 95% CI 41.7-58.3%) subjects and 5 (3.3%, 95% CI 2.2-6.7) controls (P < .001). Subjects with left ventricular systolic dysfunction were significantly older than those without (P < .001) but did not differ significantly from them with respect to zidovudine therapy or stage of disease. CONCLUSIONS Left ventricular systolic dysfunction is significantly more frequent in HIV-infected children compared with controls. Left ventricular systolic function in HIV-infected children deteriorates with increasing age and should be serially evaluated in them.

The QT interval in human immunodeficiency virus-positive Nigerian children

Introduction: The human immunodeficiency virus (HIV) and drugs taken for this infection are known to cause QTc interval prolongation which in turn can lead to severe arrhythmias. The prevalence and associated factors of prolonged QTc in HIV-positive children in sub- Saharan Africa have not been described. Objectives: To compare the mean QTc interval and prevalence of QTc prolongation in HIV-positive children and HIV-negative controls and to determine the factors associated with prolonged QTc in HIV-positive children. Methodology: In a cross-sectional comparative study the corrected QT intervals (QTc) of 100 HIV-positive children were compared with those of age- and sex-matched HIV-negative healthy controls. QTc > 0.46 seconds was regarded as prolonged. Results: Subjects were aged 9 months to 14 years. Mean QTc was significantly longer-43.31 (95% CI 43.30 43.32) seconds in HIV-positive children (62% of whom were on anti-retroviral therapy) compared with controls-41.43 (41.42 41.44) seconds (P < 0.0001). Mean QTc was also significantly longer in subjects receiving zidovudine (ZDV) -[0.46 (0.45 0.47) versus 0.43 (0.42 0.44) seconds] -.P = 0.007 and efavirnez (EFV) - [0.45 (0.43 0.47) versus 0.43 (0.42 0.44) seconds] - P = 0.047 in subjects not on these drugs. Prolonged QTc was significantly more frequent in HIV-positive children (18.0%) compared with controls (0%) - P = 0.0001. There was no significant relationship between either the mean QTc or the frequency of prolonged QTc and the subjects’ mean age sex clinical or immunological stage of disease. Conclusion: Mean QTc is significantly longer in HIV-positive children (especially those receiving ZDV or EFV) compared with controls. Prolonged QTc is also significantly more frequent in subjects. Baseline and periodic ECG screening of HIV-positive children may facilitate early detection of QTc prolongation and help prevent fatal arrhythmias.

Cardiovascular disease risk profile in Nigerian school children

Background: Cardiovascular disease (CVD) is a major cause of death among adults worldwide. It is acknowledged that its risk factors have their roots in childhood. The present study evaluated CVD risk factors in primary school children in a Nigerian peri-urban setting. Methodology: This cross-sectional study was carried out in two primary schools in Jos South local government area, Plateau State, Nigeria. The 241 children studied were chosen using a systematic random sampling technique to select the children from each school. Pretested questionnaire was used to elicit the information on family characteristics and individual characteristics while standard anthropometric and laboratory procedures were used in evaluating the CVD risk factors. Results: Overall, 137 (56.8%) were females (M:F = 0.76), 151 (62.7%) were from the middle class, 59 (24.5%) from lower class while 31 (12.9%) were from the upper class. The overall prevalence of at least one cardiovascular risk factor was 54%. Sedentary lifestyle was the most common CVD risk factor in 32.4% of subjects followed by obesity (13.7%), adverse CVD event in family (11.6%), high low-density cholesterol (10.3%), high total cholesterol (TC) (9.1%), and hypertension (9.1% combine, 7.1% diastolic, and 5.8% systolic). Linear regression analysis showed that body mass index (BMI) for age (β = 0.41, P < 0.001), systolic blood pressure (BP) (β = 0.94, P = 0.03), diastolic BP (β =1.26, P = 0.01), and TC (β = 0.07, P = 0.04) significantly rise with age. BMI for age (P = 0.02) was significantly higher in female subjects compared with their male counterparts. Conclusions: From the findings of the present study, interventions related to modifiable risk factors, such as encouragement of physical exercise and sports in schools, healthy and prudent diet, and weight control programs should be undertaken early in life so as to help control the development of and the epidemic of CVD in later life.

Knowledge and application of APGAR score among residents in a tertiary hospital

Introduction: The APGAR score rapidly assesses the condition of the newborn at birth and is a predictor of neonatal mortality. Despite the fact that this scoring system is limited by inter and intra-observer variation, its knowledge is essential to residents involved in newborn care at delivery. This study was therefore carried out to determine the knowledge and application of the APGAR score by these residents. Materials and Methods: The questionnaire-based survey was conducted at the Jos University Teaching Hospital and administered to all consecutive residents in pediatrics, obstetrics and gynecology (O and G), anesthesia, family medicine and public health. Domains assessed both knowledge and application of the APGAR scoring system. Data analyzed with the Epi Info 3.5.1 and P < 0.05 was considered as statistically significant. Results: Of the 74 completed questionnaires, 21 were filled by Pediatric residents, 27 by O and G residents and 26 by other residents. Residents with 10-15 years of work experience had a significantly higher mean score on their knowledge compared with those with <10 years work experience (P = 0.015). The mean application score was significantly higher among the Pediatric residents compared with the O and G and other residents (P = 0.015). Using linear regression, there was a significant association between the knowledge and application of the APGAR scoring system - coefficient = 0.179, P ≤ 0.001. Conclusion: Adequate knowledge and application of the APGAR scoring system by residents who use it frequently is necessary to avoid its misuse. Training and retraining of these residents on the correct use of the APGAR score during neonatal resuscitation is important to ensure adequate knowledge and its proper application.

Left ventricular mass and diastolic dysfunction in children infected with the human immunodeficiency virus

Background: Increased left ventricular mass (LVM) and diastolic dysfunction are associated with higher morbidity and mortality among adult patients with human immunodeficiency virus (HIV) infection. Objective: The objective of the following study is to determine the prevalence of increased LVM and diastolic dysfunction in Nigerian children infected with HIV. Methods: Cross-sectional comparative study of LVM and left ventricular (LV) diastolic function of 150 HIV-positive children and controls asymptomatic for cardiac disease. Results: Mean LVM was larger in subjects than controls - 66.5 (95% confidence interval, 63.7-69.3) versus 56.9 (54.1-59.7) g/m 2 respectively - P < 0.001. An increased LVM was present in 21 (14.0%) subjects and 4 (2.7%) controls - P < 0.001. Mean mitral valve peak flow velocities and pressure gradients for the early and late diastolic waves were higher among HIV positive children than controls (P < 0.001). LV diastolic dysfunction was present in 46 (30.7%) subjects and 19 (12.7%) controls (P < 0.001). Subjects with increased LVM were younger and had more severe disease than those with normal LVM. Subjects and controls were similar with respect to their clinical and immunological stages of disease and use of nucleoside reverse transcriptase inhibitors. Conclusion: Increased LVM and diastolic dysfunction are significantly more common in HIV-infected children compared with controls and occur in asymptomatic subjects.

Clinical screening for heart disease in apparently healthy Nigerian school children

Background: Heart diseases of childhood are of public health importance, especially in developing countries. Community-based studies are important in ascertaining the burden of disease. We set out to clinically evaluate the prevalence of heart disease among primary school children in Hwolshe electoral Ward, Jos, Plateau State. Subjects and Methods: A total of 418 primary school pupils were selected by multistage sampling from three schools in Hwolshe ward of Jos South Local Government Area, Plateau State. They were studied for the prevalence of heart disease using clinical examination, followed by chest radiography, electrocardiography and echocardiography (echo) in those with clinical signs of heart disease. Results: The 418 subjects were aged 6-12 (mean 9.0 ± 1.95) years. 252 (55.5%) were girls. Significant tachycardia and pulse irregularity were present in 1 (0.24%) and 3 (0.72%) children respectively. None had hypertension - according to the seventh Joint National Committee criteria. 4 (0.96%) had audible murmurs of which 3 (0.72%) were pathologic. These three subjects were subsequently confirmed by echo to have congenital heart disease (CHD) - two ventricular septal defects and one atrial septal defect. The heart disease prevalence was therefore, 0.72%. All three identified cases of CHD had associated cardiac dysrhythmias: Wandering atrial pacemaker, first degree heart block, and incomplete right bundle branch block, respectively. No case of rheumatic heart disease was identified. Conclusions: Prevalence of heart disease by clinical screening in Jos South school children is approximately 0.72%. Careful cardiac auscultation as part of compulsory health screening at primary school entry and exit will help detect asymptomatic children with heart disease and facilitate treatment before the onset of complications.