java barcode reader api ACUTE RHEUMATIC FEVER & RHEUMATIC HEART DISEASE in Objective-C

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ACUTE RHEUMATIC FEVER & RHEUMATIC HEART DISEASE
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ESSENTIALS OF DIAGNOSIS
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Uncommon in the United States (approximately 2 cases/100,000 population); more common (100 cases/100,000 population) in developing countries Peak incidence ages 5 15 years Diagnosis based on Jones criteria and confirmation of streptococcal infection May involve mitral and other valves acutely, rarely leading to heart failure
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Rheumatic fever is a systemic immune process that is a sequela to -hemolytic streptococcal infection of the pharynx Pyodermic infections are not associated with rheumatic fever Signs of rheumatic fever usually commence 2 3 weeks after infection but may appear as early as 1 week or as late as 5 weeks In recent years, the disease has become quite uncommon in the United States, except in immigrants; however, there have been reports of new outbreaks in several regions of the United States The peak incidence is between ages 5 and 15 years; rheumatic fever is rare before age 4 years or after age 40 years Rheumatic carditis and valvulitis may be self-limited or may lead to slowly progressive valvular deformity The characteristic lesion is a perivascular granulomatous reaction with vasculitis The mitral valve is attacked in 75 80% of cases, the aortic valve in 30% (but rarely as the sole valve), and the tricuspid and pulmonary valves in under 5% of cases
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B Minor Criteria
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These include fever, polyarthralgias, reversible prolongation of the PR interval, and an elevated erythrocyte sedimentation rate or CRP Supporting evidence includes positive throat culture or rapid streptococcal antigen test and elevated or rising streptococcal antibody titer
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There is nonspecific evidence of inflammatory disease, as shown by a rapid sedimentation rate High or increasing titers of antistreptococcal antibodies (antistreptolysin O and anti-DNase B) are used to confirm recent infection; 10% of cases lack this serologic evidence
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The diagnostic criteria first described by Jones were updated in 1992 The presence of two major criteria or one major and two minor criteria establishes the diagnosis
Heart Disease
CMDT 2008
Differential Diagnosis
Rheumatic fever may be confused with the following: rheumatoid arthritis, osteomyelitis, endocarditis, chronic meningococcemia, systemic lupus erythematosus, Lyme disease, sickle cell anemia, surgical abdomen, and many other diseases
residual valvular disease, it can be stopped at 10 years after the episode If carditis has occurred with residual valvular involvement, it should be continued for 10 years after the last episode or until age 40 years if the patient is in a situation in which reexposure would be expected
A Penicillin
The preferred method of prophylaxis is with benzathine penicillin G, 12 million units intramuscularly every 4 weeks Oral penicillin (200,000 250,000 units twice daily) is less reliable
Complications
CHF occurs in severe cases In the longer term, the development of rheumatic heart disease is the major problem Other complications include arrhythmias, pericarditis with effusion, and rheumatic pneumonitis
B Alternatives for Penicillin-Allergic Patients
If the patient is allergic to penicillin, sulfadiazine (or sulfisoxazole), 1 g daily, or erythromycin, 250 mg orally twice daily, may be substituted The macrolide azithromycin is similarly effective against group A streptococcal infection If the patient has not had an immediate hypersensitivity (anaphylactic-type) reaction to penicillin, then cephalosporin may also be used
Treatment
A General Measures
The patient should be kept at strict bed rest until the temperature returns to normal (without the use of antipyretic medications) and the sedimentation rate, plus the resting pulse rate, and the ECG have all returned to baseline
B Medical Measures
1 Salicylates The salicylates markedly reduce fever and relieve joint pain and swelling They have no effect on the natural course of the disease Adults may require large doses of aspirin, 06 09 g every 4 hours; children are treated with lower doses 2 Penicillin Penicillin (benzathine penicillin, 12 million units intramuscularly once, or procaine penicillin, 600,000 units intramuscularly daily for 10 days) is used to eradicate streptococcal infection if present Erythromycin may be substituted (40 mg/kg/d) 3 Corticosteroids There is no proof that cardiac damage is prevented or minimized by corticosteroids A short course of corticosteroids (prednisone, 40 60 mg orally daily, with tapering over 2 weeks) usually causes rapid improvement of the joint symptoms and is indicated when response to salicylates has been inadequate
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