Salah R. Zaher

Quality of life among parents of children with heart disease

BackgroundQuality of life of parents of chronically ill children has become increasingly important as the mortality rates associated with such illnesses have decreased and survival rates have increased.AimTo describe the Health related quality of life (HRQOL) of parents whose children are suffering from heart diseases and to identify the most important factors that could affect it.MethodsA cross sectional study was conducted in Alexandria, Egypt in the two main hospitals that treat children with heart diseases. 400 parents of children with heart diseases were recruited and a comparison group (400) of parents of children with minor illnesses were included from both hospitals. Socioeconomic and disease related data were collected, SF36 was used to collect data regarding the QOL. MANOVA was used to compare the SF-36 scores between groups and to explore the impact of different variables.ResultsIn all SF-36 subscales, parents of children with heart diseases reported significantly poorer HRQOL, except for pain subscale. The most striking differences were for General Health, Vitality and role limitation physical. Factors that had a significant impact of HRQOL were severity of illness, type of heart disease in addition to age of child, having multiple children, financial situation and presence of comorbid condition. The mean scores for different domains were the lowest for younger age, rheumatic heart disease and female children.ConclusionQOL of parents of children with heart diseases was significantly impaired and it was influenced by several factors; mainly related to the clinical status of the child. Psychological status, social support and reassurance of the parents should be considered when making treatment decision for their children.

Identification of clinical criteria for group A-β hemolytic streptococcal pharyngitis in children living in a rheumatic fever endemic area

A cross-sectional study was conducted over a 1-year period (1 January-31 December 2000) during which cases suffering from uncomplicated tonsillopharyngitis were recruited from the private and public health services in Alexandria. The objective was to determine the prevalence of group A-beta haemolytic streptococci (GABHS) among children suffering from tonsillopharyngitis and to identify the clinical criteria predicting GABHS pharyngitis in children. A total of 578 children aged between 1 and 15 years with a mean of 6.3 +/- 3.7 years, presenting with sore throat were enrolled in the study. Demographic data and presenting signs and symptoms for each patient were recorded on a standardized form and a throat swab was taken using the filter paper technique. The overall prevalence of GABHS was 17 per cent and the highest isolation rate was reported in children aged 10-15 years. Non-GABHS comprised 11.9 per cent of the total isolates. The most prevalent of them were group C and G streptococci. The highest frequency of both GABHS and non-GABHS was in early spring. Significant predictors of GABHS pharyngitis were: age 10-15 years, the presence of dysphagia, vomiting, pharyngeal exudate, and scarlatiniform rash. Watery eyes and/or rhinitis had a protective value against the diagnosis of GABHS pharyngitis, while fever was considered to be a non-specific finding in cases with GABHS pharyngitis. Antibiotic sensitivity test showed higher sensitivity to both penicillin and erythromycin. Only 1 per cent of the GABHS isolates showed resistance to cephadroxil. We concluded that a syndrome of signs and symptoms could be used as a clinical predictor for the diagnosis of GABHS pharyngitis.

Reversibility of mitral regurgitation following rheumatic fever: Clinical profile and echocardiographic evaluation

The clinical disappearance of the murmur of rheumatic mitral regurgitation after period of time has been documented by many researchers. However no studies have related the disappearance of the murmur with the functional or anatomical state of the mitral valve. This study was done to elucidate the mitral valve status using doppler and color coded echocardiography among those children who have lost their apical pansystolic murmur on auscultation following a documented attack of rheumatic fever. The study sample consisted of 51 patients including 31 patients in whom the murmur has disappeared (group I), and 20 patients with persistent isolated mitral regurgitation (group II). Patients of group I had significantly lower grades of murmur intensity, lower incidence of cardiomegaly, and had no heart failure in the initial attack. They were more compliant with prophylaxis and had less recurrences than patients of group II. The murmur disappeared in patients of group I from 1/2 to 14 years after the initial attack. Echocardiography revealed that such patients had a normal mitral valve apparatus, and a normal heart size and function. Only 5 patients of this group had a significant regurgitant jet demonstrated by colour doppler. We concluded that recovery of the mitral valve and return of cardiac functions to normal is possible in patients who had mitral regurgitation following rheumatic fever. Some of them may still have an inaudible mild regurgitation. Patients who have lost their murmur may be allowed to exorcise freely, yet penicillin prophylaxis should not be discontinued.

Benzathine penicillin G for rheumatic fever prophylaxis: 2-Weekly versus 4-weekly regimens

Rheumatic fever is still one of the major public health problems in Egypt and the developing countries. It is characterized by a high tendency to recur following streptococcal infections. The use of long acting penicillin for prophylaxis against strep infections was a good achievement in this field, yet, recurrences have been reported in patients following monthly prophylactic programs. Clinical experience in Alexandria have shown for a long time that giving penicillin every 2 weeks is followed by less recurrences of rheumatic fever. Recently, reports came showing that effective penicillin levels are not maintained except for 2 to 3 weeks after the injection.In the present study, we compared two regimens of prophylaxis with 190 patients in the 2-weekly regimen, and 170 patients in the 4-weekly regimen being followed up for 2 consecutive years. Two hundred and sixty nine streptococcal infections occurred during this period. Although the streptococcal infection rate was equal in both groups, the rheumatic fever recurrence rate and the RF attack rate were significantly higher in the group of patients on the 4-weekly schedule. The results of this study have shown the superiority of the 2-weekly schedule in the adequate control of RF recurrences. We suggest that this schedule should be implemented for secondary prophylaxis of rheumatic fever in Egypt and other areas with severe RF.

Coxsackie virus infections in rheumatic fever

The close relationship between Group A beta Hemolytic Streptococci (GABS) and rheumatic fever is a well established one. However, the concept of the streptococcus as the sole etiologic agent of the rheumatic heart disease (RHD) has been challenged over the past years. Since coxsackievirus group B (CVB) has long been proposed as a cause of acquired valvular disease simulating rheumatic fever, we attempted in this study to document infections with this group of viruses in patients with rheumatic fever. We obtained blood samples from 106 patients with old (quiescent) rheumatic fever/rheumatic heart disease [group I], 94 patients with acute rheumatic fever (ARF) [group II], and 74 normal matched controls. We tested for the presence of neutralizing antibodies to the 6 serotypes of CVB by a micro neutralization test. We have found that infection with CVB, especially types B2 and B4, was common in the studied population. Forty two percent of normal individuals had evidence of infection with any of the 6 serotypes of CVB. Patients of group I had significantly more frequent infections with CVB 2. Patients in group II had significantly more frequent infections with CVB 2 and CVB 6. There was no clear correlation between such infections and the clinical course of rheumatic fever. There was no difference in the incidence of CVB infections between patients with definite ARF, and patients with suspected ARF. We set a low order association between rheumatic fever and infection with CVB types B2 and B6. We emphasize the importance of pursuing the investigation of the role of CVB in relation to RHD.

Quality of Care of Children With Chronic Diseases in Alexandria, Egypt: The Models of Asthma, Type I Diabetes, Epilepsy, and Rheumatic Heart Disease

Objectives. To evaluate the quality of care delivered to children suffering from index chronic diseases using specific indicators of health care delivery and to study the predictors of suboptimal quality of care (SQC) and its outcome on children. Design. Over a 9-month period, guidelines for optimal care were formulated. A specific questionnaire for every studied chronic disease was prepared in collaboration with the clinicians in charge of the diseased children (66% pediatricians and pediatric specialists and 34% adult specialists). The clinicians were asked to write the details of daily practice, ie, how these children were managed on a routine basis as well as in an emergency situation. A cross-sectional study was conducted over a 4-month period and included 953 children suffering from bronchial asthma (BA), childhood epilepsy (CE), type I diabetes mellitus (IDDM), and rheumatic heart disease (RHD). A systematic random sample of children was selected from children visiting the ambulatory settings of all childrens hospitals. Every fourth child was selected on 2 randomly chosen days each week, while all diseased children admitted in the hospital settings of the childrens hospitals during the study were included. A general form describing the impact of the diseases on the child was prepared. A network of clinicians was created in all childrens hospitals; seminars were held during which the content validity of the questionnaire was tested. Items were evaluated for their internal consistency using the Cronbach α. According to the degree of adherence to the recent therapeutic guidelines concerning selected indicators of the quality of care specific to every disease, children were categorized as receiving optimal quality of care or SQC. These indicators were: the use of inhaled bronchodilators in acute asthmatic attacks in mild asthma and the use of the prophylactic drugs (inhaled sodium cromoglycate or inhaled beclomethasone) in moderate to severe chronic BA in between acute asthmatic attacks; compliance with antiepileptic drugs in epileptic children; regular performance of self-monitoring of blood glucose and/or urine testing in diabetic children; and compliance with prophylactic antibiotics in children suffering from RHD. The records of the outpatient clinics for ambulatory and hospitalized cases were reviewed to assess the degree of compliance with the prescribed management before the index visit. Sociodemographic characteristics and health care system-related predictors of SQC were analyzed via stepwise logistic regression analysis. The impact of illness on the child was assessed by 7 items which were: dependence on parents in domestic activities, level of activity compared with peers, mood compared with peers, level of socializing, degree of discomfort attributable to illness, level of physical disadvantage, and urinary incontinence. Factor analysis with Varimax rotation was performed on items related to the impact of illness. Parental satisfaction with care was rated as excellent, very good, fair, or poor. Information on school outcome was obtained by asking the caretakers whether the child was able to attend school regularly despite his sickness. Scholastic achievement was also rated as excellent, very good, good, and acceptable. Parents were asked whether the child had ever repeated a grade because of his sickness. Setting. Ambulatory and hospital settings of all childrens hospitals in Alexandria, Egypt. Results. Only 52% of mild asthmatics were given inhaled bronchodilators during acute attacks and 6.84% of moderate to severe asthmatics were taking prophylactic drugs (inhaled sodium cromoglycate and/or inhaled beclomethasone) between acute attacks. Similarly, only 53 of 134 (39.6%) of diabetic children were regularly performing self-monitoring of blood glucose and/or urine testing. In contrast, in epileptic children, 121 of 173 (69.9%) were judged as being compliant by their managing clinicians and more than two thirds 82/123 (66.7%) of children with RHD were compliant with the secondary prophylactic antibiotic. Predictors of SQC were younger age of the child (in BA and CE), lower maternal education (in BA and IDDM), charged medication (in BA, IDDM, and RHD), suburban residence (in moderate to severe BA), lower paternal education (in CE), and management in health facilities other than university hospital (in IDDM). Regarding the outcome of chronic diseases on children, factor analysis revealed 2 factors (physical and psychosocial impact) that explained 41.5% of variance with moderate adequacy (Kaiser-Meyer-Olkin test of sampling adequacy = .67). Dependence on parents in domestic activities, urinary incontinence, physical disadvantage, and the degree of discomfort attributable to illness were all aggregated into the physical impact factor, whereas the level of socializing, mood, and the level of activity compared with peers were aggregated into the psychosocial impact factor. There was a strong association between the severity of psychosocial impact and the quality of delivered care in CE and RHD, as well as between the parental satisfaction with care and the quality of delivered care for the 4 index diseases. However, there was no significant association between the severity of physical impact or school performance parameters and the quality of delivered care (apart from grade repeating in RHD). Conclusions. With respect to the declared primary goal of the study, the most interesting findings could be summarized as follows: Cultural and economic factors are the primary predictors of SQC for childhood chronic diseases. Noncompliance to medication reflects the quality of delivered care in terms of defective health education rather than problems in the availability of medications in the local market as in many other developing countries or problems in the access to pharmacy or health services. Parental satisfaction with care seems to be a reliable marker of the quality of health care delivery regardless of the educational level of the community. Therefore, it could be used as a sensitive marker for the quality of health care even in developing countries. Chronic diseases have a profound impact on children, especially those belonging to the lower socioeconomic levels of the society, their scholastic performance, and the health care system. Regular monitoring of the health system performance is warranted, along with emphasis on health education programs for caretakers of children with chronic diseases. quality of care, chronic diseases, outcome.

Balloon dilation of the right ventricular outflow tract in tetralogy of Fallot: a palliative procedure.

Fifteen patients requiring palliation for tetralogy of Fallot were treated by balloon dilation because of hypercyanotic spells. The mean age at dilation was 1.9 +/- 0.7 years (range 0.5-3), and the mean weight 9.8 +/- 2.1 kg (range 6.0-13.5). Dilation of the outflow tract was combined with dilation of the left and/or right pulmonary arteries in 5 patients. Successful dilation was achieved in 12 patients (80%), but failed in 3 patients with hypoplastic pulmonary arteries. In one patient, the stenosis of the right pulmonary artery could not be dilated because of a very sharp angle at the site of the stenosis. Two of the 3 patients in whom the procedure failed died of severe cyanotic spells within 24 hours of the unsuccessful procedure. No major complications occurred during or after the procedure in the cases undergoing successful dilation. The arterial oxygen saturation increased significantly, from 71 +/- 5.7% to 89 +/- 3.9%, immediately after the procedure (p < 0.005). During a period of follow up of 6 +/- 3.7 months (range 1-13), the procedure was repeated on 3 occasions, and successfully accomplished in 2 of these. In conclusion, balloon dilation is a satisfactory palliative procedure for tetralogy of Fallot in those units in which total correction is not performed under 2 to 3 years of age.

An International Comparison of the Prevalence of Streptococcal Infections and Rheumatic Fever in Children

Differences in the socioeconomic standards of living remain an important and feasible partial explanation for the difference in incidence of rheumatic fever following GABHS infection in Egyptian compared with American children. However, past and ongoing studies of the epidemiology, diagnosis, and treatment of GABHS infections in Egypt, the United States, and elsewhere suggest other significant factors are relevant. Additional knowledge about the rheumatogenic GABHS serotypes that are most prevalent in all countries is an important area where additional research is needed. Streptococcal research will help not only in improving the quality of primary prevention of rheumatic fever, but also in developing streptococcal vaccines.

Management of recurrent tonsillitis in children

OBJECTIVE To compare azithromycin (AZT) and benzathine penicillin (BP) in the treatment of recurrent tonsillitis in children. METHODS The study comprised of 350 children with recurrent streptococcal tonsillitis, 284 of whom completed the study and 162 children received conventional surgical treatment. The rest of the children, 122, were divided randomly into two equal main groups. Group A children received a single intramuscular BP (600,000IU for children≤27kg and 1,200,000IU for ≥27kg) every two weeks for six months. Group B children received single oral AZT (250mg for children≤25kg and 500mg for ≥25kg) once weekly for six months. RESULTS Both groups showed marked significant reduction in recurrent tonsillitis that is comparable to results of tonsillectomy. There were no statistical differences between group A and B regarding the recurrence of infections and drug safety after six-month follow-up. Group B showed better compliance. CONCLUSION AZT proved to be good alternative to BP in the management of recurrent tonsillitis with results similar to those obtained after tonsillectomy.