Download Application and Effect of “Leapfrog” Technology on Diagnosis and

Application and Effect of “Leapfrog” Technology on Diagnosis and
Treatment of Cardiac Disease in Tanzania: A Case Series
Short Title: Application of “Leapfrog” Technologies
Keywords: Echocardiography, Rural Healthcare, Cardiac Disease
Authors: Hayte Samo MD1,5,6, Naftal Naman AMO1,5,6, Jan Vargas MD3,5 Peter Zwerner
MD3,5,, Eric R Powers MD3, Jeffrey Hall MD4, Dilantha B. Ellegala MD5,6, Doyle B.
Word BS5,6, Joyce S. Nicholas PhD3,5,6, Mohamed Janabi MD2,5,6
Affiliations: Haydom Hospital Tanzania1, Muhimbili National Hospital, Tanzania2,
Department of Medicine, and Department of Neurosciences, Medical University of South
Carolina3 , Department of Family and Preventatitve Medicine, University of South
Carolina4, Centra Neurosciences Institute5, and Madaktari Africa6
Disclosure: The authors would like to affirm that there is no conflict of interest to report.
Address Correspondence:
Joyce Nicholas, PhD , Medical University of South Carolina
135 Cannon St. Room 302M
Charleston, SC 29403 USA
Abstract
Background: Cardiac disease is a growing problem in the developing world, and is an
important cause of death and disability. Part of the difficulty in combating these diseases
is a lack of diagnostic tools. One solution is to utilize “leapfrog” technologies, such as
portable echocardiography, to provide care to poorly accessible areas.
Methods: 15 patients were evaluated and included in this report by consulting
physicians. Evaluation included chart review, history, physical examination, and portable
echocardiography.
Results: Of the 15 patients seen, definitive cardiac diagnosis was established for all and
in 11 patients the final diagnosis was different than the diagnosis made prior to
consultation. In seven patients there was an immediate recommendation for more
appropriate therapy.
Conclusion: Portable devices can be extremely valuable in the diagnosis and
management of cardiac disease. There should be a greater role for “leapfrog” technology
in providing health care to the developing world.
Background
Cardiac disease is a burgeoning problem in the developing world. While responsible for
approximately 30% of deaths world wide, 80% of those deaths occur in the developing
world.1 In Sub Sahara Africa, ischemic heart disease ranks 8th among the leading causes
of death in men and women, accounting for 10% of all deaths.2,3 The increasing
prevalence of ischemic heart disease has been attributed lifestyle changes stemming from
the adoption of western diets and habits, the increasing burden of diabetes, obesity, and
tobacco use. These changes suggest that ischemic cardiac disease as a health problem will
continue to grow.
Rheumatic heart disease is a substantial health problem that can result in irreversible
heart damage and death. Rheumatic heart disease will continue to be a global problem
unless current prevention initiatives are expanded and sustained. This disease, now rare in
the developed world, remains an important cause of morbidity and mortality in
developing nations, in both adults and school-aged children. Previous estimates state that
more than 15 million people have rheumatic heart disease and that 350,000 people die
each year while many more are left disabled.3 However, a recent study from Nicaragua
has suggested that these data may underestimate the number of people with the disease by
a factor of four to five. This means that between 62 million and 78 million individuals
worldwide may currently have rheumatic heart disease, which could potentially result in
1.4 million deaths per year from rheumatic heart disease and its complications.4 There are
over 1 million estimated cases of rheumatic heart disease in children of ages 5-14.5 In the
developing world, rheumatic heart disease accounts for approximately 60% of
cardiovascular disease in children.6 Accurate diagnosis and effective treatment of
rheumatic heart disease has the potential to have a major impact on health in these
countries. Thus, the management of cardiovascular disease is increasingly important in
countries like Tanzania. In an area of the world where the ratio of doctors to patients is 1
to 25,000 the lack of diagnostic skills can be due to lack of trained personnel but also due
to the lack of diagnostic equipment.7
Echocardiography is an accurate, non-invasive and indispensable tool for the diagnosis
and management of patients with cardiovascular disease. Echocardiography is known to
be more sensitive than auscultation for the detection of pathologic valve disease.
According to Marijon et al. systematic screening with echocardiography, as compared
with clinical screening, reveals a much higher prevalence of rheumatic heart disease.5
However large echocardiographic machines are expensive and not easily portable. This is
particularly problematic in regions with underdeveloped or nonexistent transportation
systems or roadways. Additionally, the equipment is complex and subject to malfunction,
requiring highly technical support for maintenance. Even in regions where the equipment
may be available there are often long delays in servicing these devices which limit their
utility. Portable echocardiography has recently been developed and may allow doctors
and practitioners the ability to gather information and make decisions for patients in areas
where current machines are impractical. The use of portable echocardiography may
result in a change in workflow for doctors by allowing for more information in the initial
physical examination.
“Leapfrog” technology may allow the developing world to skip a generation of
equipment to allow for better diagnosis and treatment of cardiac disease while alleviating
some of the limitations of older equipment stated above. These technologies may thereby
improve patient care in this underserved area. We describe the preliminary results of the
use of a small, PDA sized portable ultrasound in a remote large rural hospital in NorthCentral Tanzania as an example of the application of a “leapfrog” technology.
The device used was a VscanTM (GE Healthcare) pocket size visualization tool
providing black and white anatomic images in realtime. Additional features of the device
include color-coded overlay for real-time blood flow imaging, field-of-view for black and
white imaging (up to 75 degrees with maximum depth of 25 cm), a color flow sector
representing blood flow within an angle of 30 degrees, and a broad-bandwidth phased
array probe (from 1.7 to 3.8 MHz).
Location
Haydom Hospital is a 420 bed hospital in North Central Tanzania serving a referral base
of approximately 2 million persons. The nearest main urban center is Arusha, an 8 hour
drive on rough and sometimes impassable roads. Patients are seen in the hospital as well
as in remote outreach clinics accessed by four wheel drive landcruisers. In many
instances, technicians to service existing ultrasound machines need to be imported from
Europe or South Africa and diagnostic equipment often remains unused and
nonfunctioning for long periods of time.
Patient Population
15 patients were evaluated and included in this report by consulting physicians.
Evaluation included chart review, history, physical examination, and portable
echocardiography. We assessed the effect of this evaluation in establishing a diagnosis
and affecting therapy.
Case Summaries
Patient #1
45 year-old female presented with chest pain, vomiting, cough, and edema for 4 months.
The initial physical examination demonstrated a pulse of 68 beats per minute, blood
pressure of 100/80 mmHg and the patient was afebrile. There were physical signs of a
right-sided pleural effusion and some rales at the left lung base. The diagnosis was
congestive cardiac failure. The patient was treated with Captopril and Furosemide. This
resulted in improvement in symptoms and edema.
Physical examination by the consulting cardiologists confirmed the right pleural effusion,
cardiomegaly, and a third heart sound. Portable echocardiography demonstrated
biventricular enlargement, diminished contraction with an ejection fraction of the left
ventricle of approximately 25%. Therapeutic recommendations were to continue
Furosemide, Captopril, and to consider adding Digoxin.
Initial Diagnosis: Congestive heart failure.
Final Diagnosis: Congestive heart failure due to left ventricular systolic dysfunction.
Impact: Medication recommendation
Patient #2
A 69 year-old man presented with unexplained edema. The preliminary diagnosis of
cirrhosis and possible heart failure was made.
Consulting physical examination showed no signs of heart failure. Portable
echocardiography demonstrated normal cardiac function and no cardiac abnormalities.
Initial Diagnosis: Cirrhosis and possible heart failure.
Final Diagnosis: No cardiac abnormalities.
Impact: Refined Diagnosis
Patient #3
A 70 year-old man presented with dyspnea and palpitations. A chest x-ray was obtained
and demonstrated a right-sided pleural effusion and possible right lower lobe pneumonia
or atelectasis. The heart appeared large on x-ray. The initial impression was of possible
cardiomegaly and congestive heart failure.
Consulting physical examination demonstrated no definite cardiac abnormality. Portable
echocardiography was entirely normal without cardiac abnormality. Therapeutic
recommendation was to treat for pneumonia with appropriate diagnostic testing.
Initial Diagnosis: Possible cardiomegaly and congestive heart failure.
Final Diagnosis: No cardiac abnormalities.
Impact: Refined Diagnosis
Patient #4
A 90 year-old man presented with recent onset of dyspnea, cough, and peripheral edema.
The patient’s history included fatigue and peripheral edema as well as shortness of breath
and generalized body weakness. Physical examination on admission demonstrated a
pulse of 92 beats per minute and blood pressure of 110/70 mmHg and a soft systolic
murmur. Chest X-ray demonstrated cardiomegaly and pulmonary congestion. The
diagnosis of congestive heart failure was made. Treatment with Furosemide resulted in
no improvement in symptoms or peripheral edema.
Consulting physical examination demonstrated elevated right atrial pressure, clear lungs,
cardiomegaly, a paradoxically split-second heart sound, a soft apical systolic murmur,
and a third heart sound. Portable echocardiography showed biventricular enlargement
and decreased right and left ventricular systolic function with elevated right-ventricular
pressure based on straightening of the interventricular septum, confirming the initial
diagnosis of congestive cardiac failure. Our therapeutic recommendation was to consider
Furosemide, Captopril, and Digoxin, the standard treatment for congestive heart failure in
this clinic.
Initial Diagnosis: Congestive heart failure.
Final Diagnosis: Confirmed congestive heart failure due to right ventricular systolic
dysfunction.
Impact: Medication recommendations
Patient #5
An 18 year-old boy presented with severe dyspnea. Physical exam demonstrated normal
right atrial pressure, cardiac enlargement, and systolic and diastolic heart murmurs. A
diagnosis of congestive heart failure was made.
Consulting physical examination confirmed the presence of systolic and diastolic
murmurs. Portable echocardiography demonstrated severe mitral regurgitation and mild
aortic insufficiency consistent with rheumatic heart disease. The patient had been treated
with ACE inhibitors and Digoxin. Our recommendation was to treat primarily with
diuretics since ventricular function was normal.
Initial Diagnosis: Congestive cardiac failure.
Final diagnosis: Rheumatic valve disease.
Impact: Altered Diagnosis and medication recommendations.
Patient #6
An 80 year-old man presented with chest pain, cough, and chronic edema. Physical
examination demonstrated hypertension, increased venous pressure and a murmur
suggesting mitral regurgitation. The lungs were clear. A diagnosis of congestive heart
failure was made. Therapy with Furosemide, Captopril, and Digoxin was begun.
Consulting physical examination demonstrated a clear chest, possible cardiomegaly, but
no gallop or murmur. Portable echocardiography demonstrated left ventricular
dysfunction with an ejection fraction of appropriately 40% and no other abnormality.
Initial Diagnosis: Congestive heart failure.
Final Diagnosis: Confirmed congestive heart failure due to left ventricular systolic
dysfunction.
Impact: No changes.
Patient #7
A 75 year-old man presented with dyspnea, fatigue, abdominal distention, and diarrhea.
Cardiac examination on admission was reported as unremarkable. He was treated for
typhoid fever at an outside hospital with no improvement. Chest x-ray demonstrated
pleural effusion and possible cardiomegaly. The diagnosis was congestive heart failure.
He was treated with diuretics with some reduction of his peripheral edema but with
persistent abdominal distention.
Consulting physical examination showed no cardiac abnormality. Portable ultrasound
was entirely normal without evidence for cardiac disease. Thus, diuretics were stopped.
Initial Diagnosis: Congestive heart failure.
Final Diagnosis: No cardiac abnormalities.
Impact: Changed diagnosis and medication recommendations.
Patient #8
A 13 year-old boy presented with cough, diarrhea, vomiting, fever, and loss of appetite.
Initial diagnosis was malaria and typhoid fever for which he received Chloramphenicol
and ALU, an antimalarial medication. Chest x-ray one week after admission suggested
the possibility of cardiac disease and he was put on Captopril and Digoxin. Symptoms
were improved.
Consulting physical examination suggested severe mitral regurgitation and moderate
aortic insufficiency. Portable echocardiography demonstrated severe mitral regurgitation
and mild to moderate aortic insufficiency, consistent with rheumatic heart disease. The
therapeutic suggestion was diuresis with less of a role for Captopril or Digoxin because
of normal left ventricular function.
Initial Diagnosis: Malaria and typhoid fever.
Final Diagnosis: Rheumatic heart disease.
Impact: Changed diagnosis and medication recommendations.
Patient #9
A middle-aged man presented with dyspnea. There was a history of uncontrolled
hypertension. Physical examination was largely unremarkable.
Consulting physical examination was essentially unrevealing. Portable echocardiography
demonstrated good ventricular function without significant cardiac abnormality.
Therapeutic recommendation was control of hypertension.
Initial Diagnosis: None.
Final Diagnosis: No cardiac abnormalities.
Impact: Refined diagnosis.
Patient #10
A 53 year-old man presented with dyspnea and edema. No diagnosis had been
established.
Consulting physical examination, revealed a pericardial friction rub. Portable
echocardiography demonstrated a pericardial effusion and enlarged right atrium with no
other abnormality. As a result of the effusion, a work up for tuberculosis, including
drainage of the pericardial fluid, was begun.
Initial Diagnosis: None.
Final Diagnosis: Pericardial effusion, probable tuberculosis.
Impact: Refined diagnosis
Patient #11
A 65 year-old woman presented with dyspnea and fatigue.
Consulting physical examination demonstrated an enlargement of the left breast, elevated
right venous pressure and no other apparent abnormality. Portable echocardiography
demonstrated a pericardial effusion of moderate size and no other abnormality.
Initial Diagnosis: None.
Final Diagnosis: Inflammatory versus malignant left breast disease with pericardial
effusion.
Impact: Refined diagnosis.
Patient #12
A 33 year-old woman presented with vaginal bleeding. She was being worked up for
possible complicated pregnancy. Physical examination by her primary care provider
revealed a heart murmur.
Consulting physical examination demonstrated no abnormality except for a pulmonic
flow murmur. Portable echocardiography was completely normal. The diagnosis
provided was normal cardiac function with a pulmonic flow murmur due to possible
pregnancy and anemia.
Initial diagnosis: Possible cardiac disease complicating pregnancy.
Final diagnosis: Normal cardiac function with pulmonic flow murmur.
Impact: Changed diagnosis.
Patient #13
A 25 year-old man presented with a history of remote pericardial effusion and possible
tuberculosis in 1996. Since 2005, there was a history of fatigue, tachycardia, and
palpitations. No diagnosis had been established.
Consulting physical examination revealed no abnormality except for an early to mid
systolic click and late systolic murmur. Portable echocardiography demonstrated
prolapse of both mitral leaflets without significant regurgitation and no other significant
abnormality.
Initial Diagnosis: None.
Final Diagnosis: Mitral valve prolapse.
Impact: Refined diagnosis.
Patient #14
A young woman (approximately 20 years old) presented with dyspnea and heart
murmurs. The diagnosis was congestive heart failure.
Consulting physical examination demonstrated murmurs of mitral stenosis, mitral
regurgitation, and aortic regurgitation. Portable echocardiography revealed a severely
enlarged left atrium, severe rheumatic mitral stenosis, mild mitral regurgitation, and
moderate aortic regurgitation. There was good left ventricular function, and a
significantly enlarged right ventricle and right atrium with an interventricular septum
which suggested significant elevation of right ventricular pressures. Our diagnosis was
rheumatic mitral and aortic valve disease with pulmonary hypertension. Our therapeutic
recommendation was to manage the patient with diuretics and mitral valve surgery if
surgery could be made available.
Initial Diagnosis: Congestive heart failure.
Final Diagnosis: Rheumatic heart disease.
Impact: Changed diagnosis and medication recommendations.
Patient #15
A 12 year-old girl was admitted to the pediatric ward with fever, dyspnea, and chest
pain. Admission physical exam reported an uncomfortable girl with dyspnea and a “heart
murmur”. Chest radiography demonstrated an enlarged heart and pulmonary congestion.
Her initial diagnosis was congestive heart failure due to acute rheumatic fever, and she
began therapy with diuretics. She responded poorly to this therapy.
Consulting physical exam revealed a pericardial friction rub rather than a valvular heart
murmur. Bedside echocardiography confirmed a significant pericardial effusion.
Pericardiocentesis was performed under ultrasound guidance and revealed a bloody,
purulent fluid. The patient had a significant clinical improvement following the
aspiration. Diuretics were stopped, and intravenous fluids and antibiotics were started for
presumed acute bacterial pericarditis
Initial Diagnosis: Congestive Heart Failure/Rheumatic heart disease
Final Diagnosis: Acute bacterial pericarditis with pericardial tamponade
Impact: Changed diagnosis and medication recommendations.
Thus, of the 15 patients seen, definitive cardiac diagnosis was established for all and in
11 patients the final diagnosis was different than the diagnosis made prior to consultation
and echocardiographic study. In seven patients there was an immediate recommendation
for more appropriate therapy.
Discussion
In this study, we demonstrate the value of portable echocardiography combined with
clinical consultation for the management of cardiac disease in rural Tanzania. Cardiac
disease is a burgeoning problem in the developing world including Sub-Saharan Africa.
Rheumatic valvular disease and infectious cardiomyopathy remain significant causes of
cardiac pathology and as lifestyle and diet change, coronary disease is becoming more
prevalent. Difficulties in patient management can be attributed to difficulties in initial
diagnosis and treatment which are hindered by a lack of trained personnel and a lack of
diagnostic tools. The latter issue can be addressed with careful planning and the use of
“leapfrog technology.”
Leapfrog technology refers to skipping over a generation of equipment and taking
advantage of new technologies including the growing trend in technology towards
smaller, more portable devices. The most obvious example in the developing world is the
use of cellular telephones and internet access provided by cell phone service providers.
With the advent of wireless communications, the developing world has been able to
obviate (“leapfrog”) the need for expensive placement of telephone or fiber optic lines.
This has allowed remote areas to become more accessible. Given the success of leapfrog
technologies in telecommunications, it seems reasonable to apply similar strategies to the
arena of medical devices.
Donation of unused medical equipment has been a major aspect of traditional mission
trips. Devices such as ventilator, anesthesia, or advanced imagine machines are often
donated by Western hospitals once they have become obsolete or replaced by newer
versions. While well intentioned, the problem with such an approach is that if (and more
often when) these devices break, a technician is required to travel in from the west or
from the regional urban centers far from remote hospitals to first diagnose and then fix
the problem. In the intervening weeks and months the machine is left unused. Thus, the
donation of these devices has little long term impact on the health of these populations.
Portable devices such as the hand held echocardiographic machines used in the present
report avoid the economic burden of calling in technicians and are relatively inexpensive
to purchase and service. If such a device breaks, it can be easily shipped to repair centers
with minimal cost. The portability of the device used in this report is suited to remote
areas often encountered in developing nations, which results in the ability to offer care to
more patients, including those seen in outreach clinics.
This case series supports the premise that portable echocardiography can be effectively
utilized to provide meaningful care.
Conclusion
“Leapfrog” technologies, such as portable echocardiography, are valuable tools for
providing care to remote, poorly accessible regions of the world. We present our case
series of cardiac patients from a rural hospital in Tanzania where portable
echocardiography was critical in providing cardiac care to 15 patients. We believe this is
just one example of the many possible applications of leapfrog technologies in the
developing world.
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