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Aim: Secondary prophylaxis with 3–4 weekly benzathine penicillin G injections is necessary to prevent disease morbidity and cardiac mortality in patients with acute rheumatic fever (ARF) and rheumatic heart disease (RHD). This study aimed to determine secondary prophylaxis adherence rates in the Far North Queensland paediatric population and to identify factors contributing to suboptimal adherence. Methods: A retrospective analysis of data recorded in the online RHD register for Queensland, Australia, was performed for a 10‐year study period. The proportion of benzathine penicillin G injections delivered within intervals of ≤28 days and ≤35 days was measured. A multi‐level mixed model logistic regression assessed the influence of age, gender, ethnicity, suburb, Accessibility and Remoteness Index of Australia class, number of people per dwelling, Index of Relative Socio‐economic Advantage and Disadvantage, Index of Education and Occupation, year of inclusion on an ARF/RHD register and individual effect. Results: The study included 277 children and analysis of 7374 injections. No children received ≥80% of recommended injections within a 28‐day interval. Four percent received ≥50% of injections within ≤28 days and 46% received ≥50% of injections at an extended interval of ≤35 days. Increasing age was associated with reduced delivery of injections within 35 days. Increasing year of inclusion was associated with improved delivery within 28 days. The random effect of individual patients was significantly associated with adherence. Conclusions: Improved timely delivery of secondary prophylaxis for ARF and RHD is needed as current adherence is very low. Interventions should focus on factors specific to each individual child or family unit. [ABSTRACT FROM AUTHOR]

Background. The aim of this study was to investigate the frequency of anemia and hepatotoxicity associated with aspirin use in patients with acute rheumatic fever. Methods. Patients with acute rheumatic fever followed at Erciyes University, Faculty of Medicine, Department of Pediatric Cardiology between 2015-2018 were reviewed retrospectively. Results. A total of 286 patients with acute rheumatic fever were analysed. Aspirin treatment was started in 53 of the 286 patients (18.5%) due to arthritis. The mean age of the patients who used aspirin was 10.7 ± 2.5 years. Aspirin-induced hepatotoxicity developed in 9 (17%) of the 53 patients. Naproxen or ibuprofen was given to these patients as an alternative to aspirin. No side effects occurred in patients receiving naproxen or ibuprofen. In addition, 30% of 53 patients were initially anemic. The mean duration of aspirin use in the hepatotoxic patients who had anemia was longer than patients without anemia (p=0.02). Conclusions. Patients with acute rheumatic fever should be closely monitored for aspirin hepatotoxicity. When aspirin hepatotoxicity develops, naproxen or ibuprofen treatment can be used safely. [ABSTRACT FROM AUTHOR]

Rheumatic heart disease (RHD) is prevalent in sub-Saharan Africa, where the capacity for diagnosis and evaluation of disease severity and complications is not always optimal. While the medical history and physical examination are important in the assessment of patients suspected to have RHD, cardiovascular imaging techniques are useful for confirmation of the diagnosis. Echocardiography is the workhorse modality for initial evaluation and diagnosis of RHD. Cardiovascular magnetic resonance is complementary and may provide additive information, including tissue characteristics, where echocardiography is inadequate or non-diagnostic. There is emerging evidence on the role of computed tomography, particularly following valve replacement surgery, in the monitoring and management of RHD. This article summarises the techniques used in imaging RHD patients, considers the evidence base for their utility, discusses their limitations and recognises the clinical contexts in which indications and imaging with various modalities are expanding. • Diagnosis of RHD is based on medical history and physical examination; echocardiography is the first-line imaging modality. • Cardiovascular imaging techniques aid with diagnosis and comprehensive evaluation of severity and complications in RHD. • CT and CMR provide additive information above echocardiography but are not always available in resource-poor settings. • Improved understanding of the role of imaging modalities and their complementary role enhances management of RHD patients. [ABSTRACT FROM AUTHOR]

Context: Indigenous children and adolescents in Australia and globally bear the burden of acute rheumatic fever (ARF). It has been virtually eliminated in well-resourced, developed settings. ARF is an autoimmune response to infection with group A Streptococcus. The mainstay of management is long-acting intramuscular penicillin injections to prevent recurrence of ARF and development of rheumatic heart disease (RHD), comprising valvular pathology and attendant complications. In Australia, penicillin injections are currently prescribed every 28 days for 5–10 years after diagnosis of ARF, depending on cardiac involvement. Adherence to this regimen reduces ARF recurrences and RHD progression. ‘Days at risk’ of ARF recurrence are calculated as the number of days after day 28 that an injection is not received. Adherence to the injection schedule has been reported as difficult in most global locations due to the painful nature of the injections, the long timeframes of the prescription, young age of patients, access problems and costs in some locations. The newly updated Australian guideline on the prevention, diagnosis and management of ARF and RHD has a chapter dedicated to secondary prophylaxis. This chapter takes into account cultural considerations and advises on ways to minimise pain and distress of injections in children such as pain gate strategies, distraction techniques and concurrent injection of local anaesthetic. Issues: Some children continue to find the injection regimen traumatising despite strategies to reduce pain and fear. Clinicians providing the injections to children also find the injecting episodes distressing if pain is not effectively minimised. An Aboriginal Community Controlled Health Service in a remote setting in northern Australia addressed the issue of severe trauma of injection episodes experienced by an Aboriginal boy aged 7 years. Usual strategies were not effective, so advice was sought from an expert anaesthetist at a tertiary hospital. As a result, oral clonidine 3 µg/kg was trialled 45 minutes prior to the penicillin injection. Procedural coaching and monitoring protocols specific to administration of clonidine in children under their care were created by the health service. The initial dose of clonidine was delivered with the child as an inpatient. Lessons learned: Clonidine was successful in reducing pain related distress and facilitating adherence to the penicillin regimen. Subsequent doses were delivered and monitored in a remote setting by nurses. After 18 months, the boy no longer required clonidine due to his increased coping capacity. A second child was recognised with similar trauma and has been taking clonidine for pre-procedural sedation for 6 months with good effect and no adverse effects. An additional child was similarly prescribed clonidine without success. Failure in that instance was attributed to lack of procedural coaching and receiving the initial dose of clonidine in an emergency department in hurried circumstances. Individualised child-focused and culturally appropriate care in remote settings is feasible: in this instance team planning for use of clonidine and procedural coaching when other measures have failed. However, for children with RHD, or other comorbidities, advice from the child’s treating cardiologist is required prior to prescribing clonidine due to possible adverse consequences. These include hypotension and atrioventricular block, which could lead to haemodynamic compromise in the setting of moderate to severe RHD. [ABSTRACT FROM AUTHOR]

Acute rheumatic fever (ARF) is a sequela of streptococcal infection—typically following 2 to 3 weeks after group A streptococcal pharyngitis—that occurs most commonly in children and has rheumatologic, cardiac, and neurologic manifestations. Rheumatic heart disease (RHD) refers to the long-term cardiac damage caused by either a single severe episode or multiple recurrent episodes of ARF. Secondary prophylaxis with regular intramuscular injections of benzathine penicillin G (BPG) is a key component to prevent ARF and RHD recurrent. This study aimed to evaluate the secondary prophylaxis effectiveness based on the profile of clinical manifestations and blood laboratory findings. The data were collected by interviews, complete blood counts, the anti-streptolysin titer O (ASTO) analysis, the C-reactive protein Assay, electrocardiography, and echocardiography. Data were analyzed using SPSS 18, and the results were presented as the percentage frequency. The samples were 63 patients with ARF and RHD who get secondary prophylaxis, consisting of 32 males (50.8%) and 31 females (49.9%). The echocardiography examination showed that valve regurgitation was more common than valve stenosis, indicating longer P-R interval in 49 subjects (77.7%). Sixty subjects (92.2%) received secondary prophylaxis with BPG injection, and three subjects (4.8%) got Erythromycin oral. The main factor of secondary prophylaxis adherence is pain and injection disliking. [ABSTRACT FROM AUTHOR]

Objective: Acute rheumatic fever is a childhood disease that is still important in terms of both morbidity and mortality due to heart valve involvement in adulthood. The aim of this study was to emphasize the importance of acute rheumatic fever in our clinic and the importance of acute rheumatic fever in terms of morbidity and mortality in cases diagnosed in the last year. Materials and Methods: A retrospective evaluation was made of 34 patients newly diagnosed with acute rheumatic fever in the Paediatric Cardiology Polyclinic of Suleyman Demirel University Training and Research Hospital between August 2017 and Febraury 2020. Results: The study included thirty four patients newly diagnosed with acute rheumatic fever in the Pediatric Cardiology outpatient clinic of Suleyman Demirel University Research and Training Hospital between August 2017 and February 2020. The patients comprised 18 males with a mean age of 10.5 years and 16 females with a mean age of 11.8 years. The youngest patient was diagnosed at the age of 5 years. Severe carditis findings were determined in 4 patients (2 female, 2 male), all of whom were hospitalized and steroid treatment was started. In 2 patients with moderate carditis, 15 with mild carditis, and 11with arthritis and no carditis, aspirin treatment was adminestered. In 2 patients diagnosed with Sydenham's chorea, only haloperidol treatment was applied because the acute phase reactants were normal. Conclusion: Acute rheumatic fever is a disease that starts in childhood and can cause morbidity and mortality at a later age in terms of carditis sequelae. Turkey is in the group of high risk countries for acute rheumatic fever so it should be kept in mind for patients presenting with arthritis. Diagnosis and treatment of throat infections due to group A beta hemolytic streptococcus is important. [ABSTRACT FROM AUTHOR]

Aim: Acute rheumatic fever (ARF) most commonly presents in children aged 5-14 years old. Lifelong rheumatic heart disease (RHD) can result. This study investigated time trends in ARF and RHD using inpatient data from the Royal Children's Hospital, Melbourne (RCH).Methods: A retrospective cohort study covering the period 1937-2013 was conducted using records from RCH, a quaternary paediatric hospital in Melbourne, Victoria, Australia. Patient data were identified using RCH classification of diseases coding for ARF or RHD for years <1952. For the period 1952-1987, this system was used in addition to identifying International Classification of Disease (ICD) discharge codes that corresponded to ARF or RHD. From 1988-2013, only ICD codes were used to identify patient data. Descriptive epidemiological analyses were performed, including incidence rate calculations using historical census population denominator data. Analyses focussed on children in the peak age group.Results: Among children aged five to 14 years, a total of 4337 RCH admissions with ARF/RHD occurred for 3015 patients. A sharp decline in first ARF/RHD hospitalisations at RCH occurred from 1959, following a peak mean annual incidence rate during 1944-1947 of 40.1/100 000 children (95% confidence interval (CI): 36.6-43.9; P < 0.05). Over 1996-2013, the mean annual incidence rate was 1.6/100 000 (95% CI: 1.3-1.8) and reached 2.3/100 000 (95% CI: 1.3-3.7) in 2005.Conclusion: The burden of ARF and RHD treated at RCH declined following the 1940s, mirroring changes seen in North America and Europe. Despite this, inpatient treatment for these conditions continued to be provided right up until the end of the study period. [ABSTRACT FROM AUTHOR]

Objectives: Immediate result of PTMC in juvenile (5-12 years) rheumatic mitral stenosis. Study Design: Observational descriptive and retrospective study. Place and Duration of Study: Institute of Cardiology, Multan from 2009 to Jun 2020. Methodology: This is an observational descriptive and retrospective study carried out at Institute of Cardiology, Multan from 2009 to Jun 2020. Patients with clinical evidence of significant mitral stenosis were undergone transthoracic echocardiography. Mitral stenosis was defined as mitral valve area <1.0 cm2. Mean mitral valve gradient was calculated by mitral valve inflow velocities. Patients with Wilkins score <8 were included. Patients with significant MR, left atrial or atrial appendage clot, infective endocarditis, significant aortic regurgitation or any other indication for bypass surgery were excluded. Patients with Wilkins score >8 were also excluded from the study. Variables recorded on a performa were age, weight, left atrial size, mean mitral valve gradient, preprocedure MR. Reduction of mitral valve mean pressure gradients to less than <50% of the initial value was defined as success (without significant or moderate MR). After the procedure, variables recorded on performa were mean left atrial pressures in mmHg (on angio), mean mitral valve gradients and degree of MR (mild, mild to moderate, moderate or severe MR) on transthoracic echocardiography. Paired t-test of significance (p<0.05) was evaluated using SPSS (version 20). Results: Forty three juvenile patients were included the in the study (2009 to June 2019). Mean age was 10.8 ± 1.4 (range 7-12) years. Mean weight was 28.9 ± 5.2 (20-37) kg. Mean mitral valve gradient (on TTE) before the procedure was 20 ± 6 mmHg. Mean left atrial size and mean area of mitral valve were 42 ± 5 mm and 0.8 ± 0.2 cm2 respectively. Balloon sizes used were 26 mm (n=19) and 24 mm (n=24). After PTMC, mean mitral valve reduced to 7 ± 2 mmHg (p<0.005) and left atrial pressure to 18 ± 7 mmHg. Post procedure transthoracic echocardiography showed 4.7% (n=2/43) patients developed moderate to severe or severe MR. So the success rate was 95.3% (n=41/43). Conclusion: PTMC is safe and effective procedure for juvenile patients with mitral stenosis. Long term follow-up is needed to find out period of re-intervention/surgery free duration from the time of PTMC. [ABSTRACT FROM AUTHOR]

Although acute poststreptococcal glomerulonephritis (APSGN) and acute rheumatic fever (ARF) are well-known complications of group A streptococcus infection, concomitant occurrence of both diseases is rare. We report an 11-year-old Japanese girl with primary Sjögren's syndrome complicated by acute renal failure about 2 weeks after the onset of pharyngitis. Although histopathological findings of the kidney were not confirmative, APSGN was suggested by the spontaneous recovery of her renal function, typical latent period with high levels of antistreptolysin O and low serum levels of C3 but not of C4. In addition, cardiac hypomotility and regurgitation of the 4 valves progressed in the convalescent phase of APSGN, which was accompanied by elevation of serum C-reactive protein and plasma brain natriuretic peptide (BNP) levels. Myocarditis was suggested by delayed gadolinium-enhancement of cardiac walls on cardiac magnetic resonance imaging. She was diagnosed with APSGN and ARF and was treated with a combination of short course prednisolone and prophylactic penicillin G. There is no relapse of renal or cardiac symptoms during 6 years follow-up. Unexpected elevation of plasma BNP in a convalescent stage of APSGN suggests the development of ARF. Underlying Sjögren's syndrome (SS) may modify the histopathological findings and make it difficult to differentiate APSGN from CTD-associated nephritis such as lupus nephritis (LN) even by renal biopsy. [ABSTRACT FROM AUTHOR]

The objective of the study is to evaluate the efficacy of corticosteroids in Sydenham chorea. This is a retrospective observational study. Clinical information of children with Sydenham chorea were collected. Outcome of Sydenham chorea was evaluated in consideration of presence or absence of corticosteroid therapy. Thirty patients were enrolled. A total of 15 were treated with prednisone, 15 received symptomatic drugs or no treatment. Patients who were treated with prednisone showed faster improvement (4 vs 16 days; p = 0.002) and shorter median time of remission (30 vs 135 days; p < 0.001).Conclusion: Our study showed that corticosteroid therapy is an effective treatment of Sydenham chorea.What is Known:• Steroid treatment in Sydenham chorea is widely used but it is not standardized.• Few manuscript report a beneficial use of steroids in Sydenham chorea if compared with no treatment.What is New:• Steroid treatment seems to be effective in both clinical remission and clinical improvement of symptoms among patients with Sydenham chorea.• Steroid treatment seems to be superior to conventional treatment. [ABSTRACT FROM AUTHOR]

Group A Streptococcus (GAS) pharyngitis is a key initiator of acute rheumatic fever (ARF). In New Zealand, ARF cases occur more frequently among persons of certain ethnic and socioeconomic groups. We compared GAS pharyngitis estimates (1,257,058 throat swab samples) with ARF incidence (792 hospitalizations) in Auckland during 2010-2016. Among children 5-14 years of age in primary healthcare clinics, GAS pharyngitis was detected in similar proportions across ethnic groups (≈19%). Relative risk for GAS pharyngitis was moderately elevated among children of Pacific Islander and Māori ethnicities compared with those of European/other ethnicities, but risk for ARF was highly elevated for children of Pacific Islander and Māori ethnicity compared with those of European/other ethnicity. That ethnic disparities are much higher among children with ARF than among those with GAS pharyngitis implies that ARF is driven by factors other than rate of GAS pharyngitis alone. [ABSTRACT FROM AUTHOR]

Background: Acute rheumatic fever (ARF) continues to be a public health problem in low- and middle-income countries. Because there is no specific laboratory test for the exact diagnosis of ARF, the diagnosis is made by the modified Jones criteria. Periostin is an extracellular matrix protein which has been shown to be expressed during remodelling, mechanical stress and tissue repair. There are no data on the relationship between periostin and ARF. Aim: To evaluate serum periostin levels in patients with ARF and investigate its usefulness as a biomarker for diagnosing and monitoring the efficacy of treatment. Methods: Serum periostin levels were estimated in 31 patients with ARF and compared with a control group of 25 healthy patients. The control group comprised patients referred to the outpatient clinic for further evaluation of cardiac murmur, palpitations or chest pain. Patients who were diagnosed with any other cardiac or systemic illness after detailed systemic and cardiac examination were excluded. Results: The mean (SD) age at diagnosis was 12.1 (3.3) years in the patient group, 48.4% of whom were male. There were no significant differences in age or gender between patients and controls. All the study patients had various degrees of carditis, 58.1% had arthritis and 9.6% had Sydenham chorea. Mean (SD) serum periostin levels in patients with ARF on admission [58.4 (13.9) ng/mL] were significantly higher than in the control group [35.1 (10.7) ng/mL, p < 0.01] and were also significantly decreased in the patient group after treatment [35.1 (13.1) ng/mL, p < 0.01]. There was no significant difference in serum periostin levels regarding the severity of carditis in the patient group while patients with any severity of carditis had significantly higher periostin levels than the controls (p < 0.01). Periostin levels were significantly correlated with ESR and CRP values before treatment, but this correlation was detected for only ESR after treatment. For the initial diagnosis of ARF, a serum periostin level of 53.45 ng/mL was found to be the cut-off point with 80.6% sensitivity and 100% specificity. Conclusion: There was a significant increase in serum periostin levels in patients with ARF and a reduction after adequate treatment which was independent of the severity of carditis. Periostin may be a biomarker which acts as an acute phase reactant in ARF. [ABSTRACT FROM AUTHOR]

Acute rheumatic fever (ARF) and its sequelae, Rheumatic heart disease (RHD), contribute significantly to the cardiovascular morbidity and mortality in developing countries. Generally considered a disease of poverty and poor socio-economic conditions, RHD affects the population at the most productive phase of their life. The diagnostic criteria for ARF have been constantly updated to improve the sensitivity. The diagnosis of ARF was entirely clinical however, recently echocardiographic evidence has been added as a major criterion. The disease seems to be on the decline in India, but recent studies using echocardiography have shown high prevalence of RHD among school children. The focus of management has been on prompt recognition and treatment of streptococcal pharyngitis and preventing recurrences of ARF with long-term antibiotic prophylaxis. However, emphasis should be placed on the appropriate management of patients with established RHD, in order to limit the RHD related mortality. [ABSTRACT FROM AUTHOR]

Rheumatic heart disease (RHD), affecting approximately 32 million people all over the world is one of the major causes of cardiovascular morbidity and mortality especially in developing countries. In this ongoing pilot study, we aim to investigate the prevalence of both definitive and borderline RHD in Turkey as a developing country. A total of 386 healthy young individuals (45 female, 341 males) who applied to our Cardiology Clinic for being military personnel coming from different regions of Turkey in the year 2015, were recruited for our study. 2012 World Heart Federation (WHF) criteria for echocardiographic assessment and diagnosis of RHD were used. Study population was classified into one of the three groups as normal, borderline RHD and definitive RHD. The three groups were similar in terms of baseline characteristics and laboratory findings. Definitive and borderline RHD were found in 11 (2,9%) and 29 (7,5%) individuals, respectively. Abnormal thickening of the anterior mitral valve leaflet (AMVL) was found statistically significant between the normal and the RHD groups (3.1±0.6 vs 4.2±0.9, p [Med-Science 2018; 7(1.000): 186-190]

Aim. To study the main epidemiological manifestations of GAS infection in Russia and to assess the scale ofthe problem. Materials and methods. A retrospective epidemiological analysis of official statistical reporting data (f. 2, f. 12) about the incidence and prevalence of the most significant. forms of group A streptococcal infection in 2009 - 2016 was performed. Results. There was a slight decrease in the total incidence of GAS infection in the Russian Federation. On the average, 1.8 million people fell ill every year, of which 600,000 were children aged 0 - 14. There was no reliable trend in incidence of acute rheumatic fever (ARF) in 2009 - 2016 (2.0 per 100 000 population). The risk group is adolescents. The main proportion is adults (64%). In recent years the incidence of rheumatic heart disease (RHD) increases significantly (t=3.8, p

Background: Rheumatic heart disease (RHD) continues to create havoc in the developing countries even decades after its discovery. It is entirely preventable through primordial, primary, and secondary level intervention. Secondary prevention is a reasonable treatment option in patients in India, but it suffers due to poor adherence which remains the main impediment to its implementation. The aim is to study the compliance with benzathine penicillin as secondary prophylaxis in RHD patients and to establish the patient-related factors for adherence and reasons for missing of doses. Materials and Methods: This is a cross-sectional study of RHD patients presenting to our institute. The demographic data, clinical history, and details of penicillin prophylaxis were noted. The patient was labeled as compliant or noncompliant depending on frequency and duration of prophylaxis as prescribed. Potential factors between the two groups have been analyzed by univariate and binary logistic regression. Results: The study cohort of 500 patients consisted of 261 compliant and 239 noncompliant patients. Average age of presentation was 29 ± 13 years with females outnumbering the males. Noncompliance with secondary prophylaxis was more prevalent among male (P = 0.003), low socioeconomic class (P = 0.0009), uneducated (P = 0.000018), and the rural population (P = 0.025) while those with previous history of rheumatic fever (RF) were found to be more compliant (P = 0.04). Recurrences of RF were more common in those not on regular prophylaxis (P = 0.011). The most common reason cited for noncompliance was the absence of proper counseling followed by a sense of well-being, injection site pain and financial constraints. Conclusion: Compliance with secondary penicillin prophylaxis is essential to ensure eradication of RHD. Education about the importance and necessity of prophylaxis would improve compliance. A close patient and health personnel relationship is important in improving adherence to secondary prophylaxis.

Abstract Background Rheumatic heart disease (RHD) is a chronic cardiac condition with an infectious aetiology, causing high disease burden in low-income settings. Affected individuals are young and associated morbidity is high. However, RHD is relatively neglected due to the populations involved and its lower incidence relative to other heart diseases. Methods and results In this narrative review, we describe how RHD care can be informed by and integrated with models of care developed for priority non-communicable diseases (coronary heart disease), and high-burden communicable diseases (tuberculosis). Examining the four-level prevention model (primordial through tertiary prevention) suggests primordial and primary prevention of RHD can leverage off existing tuberculosis control efforts, given shared risk factors. Successes in coronary heart disease control provide inspiration for similarly bold initiatives for RHD. Further, we illustrate how the Chronic Care Model (CCM), developed for use in non-communicable diseases, offers a relevant framework to approach RHD care. Systems strengthening through greater integration of services can improve RHD programs. Conclusion Strengthening of systems through integration/linkages with other well-performing and resourced services in conjunction with policies to adopt the CCM framework for the secondary and tertiary prevention of RHD in settings with limited resources, has the potential to significantly reduce the burden of RHD globally. More research is required to provide evidence-based recommendations for policy and service design.

Abstract Background Acute rheumatic fever (ARF) rates have declined to near zero in nearly all developed countries. However, in New Zealand rates have not declined since the 1980s. Further, ARF diagnoses in New Zealand are inequitably distributed--occurring almost exclusively in Māori (the indigenous population) and Pacific children--with very low rates in the majority New Zealand European population. With ARF diagnosis, secondary prophylaxis is key to prevent recurrence. The purpose of this study was to identify the perceived enablers and barriers to secondary recurrence prophylaxis following ARF for Māori patients aged 14–21. Methods This study took a systems approach, was informed by patient voice and used a framework method to explore potential barriers and enablers to ongoing adherence with monthly antibiotic injections for secondary prophylaxis. Qualitative interviews were conducted with 19 Māori ARF patients receiving recurrence prophylaxis in the Waikato District Health Board region. Participants included those fully adherent to treatment, those with intermittent adherence or those who had been “lost to follow-up.” Results Barriers and enablers were presented around three factors: system (including access/resources), relational and individual. Access and resources included district nurses coming to patients as an enabler and lack of income and time off work as barriers. Relational characteristics included support from family and friends as enablers and district nurse communication as predominantly a positive although not enabling factor. Individual characteristics included understanding, personal responsibility and fear/pain of injections. Conclusion This detailed exploration of barriers and enablers for ongoing secondary prophylaxis provides important new information for the prevention of recurrent ARF. Among other considerations, a national register, innovative engagement with youth and their families and a comprehensive pain management programme are likely to improve adherence to ongoing secondary prophylaxis and reduce the burden of RHD for New Zealand individuals, families and health system.

Background: Acute rheumatic fever (ARF) and post-streptococcal reactive arthritis (PSRA) are immune-mediated consequences of group A streptococcal pharyngitis. ARF has declined in developed nations. No prevalence survey of PSRA has been conducted. This study evaluated the incidence and characteristics of ARF and PSRA in Japanese children. Methods: From 2010 to 2015, ARF and PSRA were evaluated using clinical data retrospectively collected by chart review from 528 hospitals. Results: From 323 hospitals (61% response rate), 44 cases of ARF and 21 cases of PSRA were reported. Patients with ARF and/or PSRA were mainly from large cities in Japan. The mean age of ARF occurrence was 8.5 years, and the ratio of female/male patients was 16:28. Major manifestations in the acute phase included carditis, 27 cases (61.4%); polyarthritis, 22 cases (50%); erythema marginatum, 7 cases (15.9%); Sydenham chorea, 3 cases (6.8%); and subcutaneous nodules, 1 case (2.3%). Twenty-one (58.3%) patients had migratory arthritis. During the follow-up period, 6 patients (13.6%) showed mild carditis. For PRSA, the mean age was 8.2 years, and the ratio of female/male patients was 12:9. Six (28.6%) patients had monoarthritis, and 4 (19%) patients had migratory arthritis. No patient had carditis. Conclusions: Although ARF and PSRA are rare in the Japanese pediatric population, substantial numbers of patients with both conditions were identified in this study. We observed a high incidence of arthritis and carditis in ARF patients. No PSRA case was complicated with carditis. General pediatricians need to have updated information about ARF and PSRA, even in industrialized countries.

Objective: to investigate the incidence of acute rheumatic fever (ARF), chronic rheumatic heart disease (CRHD), musculoskeletal diseases (MSD), and connective tissue diseases in the pediatric and adult populations of the Arkhangelsk Region (AR) in comparison with the data on Russia and the North-Western Federal District (NWFD) in 2010–2015.Subjects and methods. The total and primary incidence rates of ARF, CRHD, and MSD were analyzed in the pediatric and adult populations of these regions in 2010–2015.Results and discussion. Among the adult population of AR, the total incidence of ARF was low (7 cases in 2010 and none in 2015), which is comparable with the data in the whole of Russia. No recurrences of ARF were registered in the AR. Among the adult population of AR, the total incidence of CRHD fell by 28% in 2010 to 2015. The similar trend was also observed in the whole of Russia. Patients newly diagnosed with CRHD decreased by 65% in the AR. There was a 14% increase in the total incidence of MSD among the adult population of AR and an 11% decrease in its primary incidence. Since 2010, the total incidence of rheumatoid arthritis (RA), osteoarthritis, spondylopathies (SP), osteoporosis (OP), and systemic connective tissue diseases rose in the AR. There were 22 and 140% increases in the incidence of RA and SP, respectively; the number of reactive arthritis cases decreased by 17.2% in the adults and increased by 7% in the children. This trend in the adults is seen of the whole of Russia (an 8% decrease), although the latter in the AR is not comparable to the All-Russian measures. In the AR, the incidence of OP remains low (50 and 73 per 100,000 population in 2010 and 2015, respectively); this is noted to increase by 46% in the past 5 years; the similar trend was observed in both the whole of Russia and NWFD (7.8 and 8.3%, respectively).

The program for the prevention of acute rheumatic fever (ARF) and recurrent attacks of the disease includes primary and secondary prevention. The basis for the primary prevention of ARF are activities aimed at increasing the level of the body’s innate immunity and adaptive responses to adverse environmental conditions, as well as the timely diagnosis and adequate antimicrobial therapy of group A streptococcus throat infections, such as sore throat and pharyngitis. Secondary prevention aims to prevent recurrent attacks and disease progression in individuals who have experienced ARF and provides regular twenty-four-hour administration of long-acting penicillin (benzathine benzylpenicillin)

Acute rheumatic fever and rheumatic heart disease remain common in the population of South Africa. A recent screening study of asymptomatic schoolchildren in Mozambique and Cambodia makes a compelling case for a shift in the approach to screening for rheumatic heart disease from auscultation to portable echocardiography. Rheumatic heart disease meets all the epidemiological criteria for screening in the South African population. The incorporation of echocardiographic screening programmes into the school health system and in antenatal clinics for the pre-symptomatic diagnosis of rheumatic heart disease could result in the reduction of morbidity and mortality through the early and wide application of secondary antibiotic prophylaxis.

Infection with Group A β-haemolytic Streptococcus, also known as Streptococcus pyogenes, results in various mucosal and skin diseases including pharyngitis. An exaggerated immune response to a single or repeated group A streptococcal (GAS) infection subsequently results in acute rheumatic fever (ARF) and, in the absence of intervention, repeated bouts of ARF may in turn result in progression to RHD, particularly in those ARF patients with cardiac involvement. Addressing GAS pharyngitis through appropriate primary prevention measures and treating all symptomatic GAS sore throats with a course of oral or parenteral penicillin presents an opportunity for the primary intervention of RHD. Failure to eradicate streptococci from the pharynx occurs in about one third of non-treated cases, giving rise to carrier status in those individuals harbouring intracellular GAS and thus representing a potential source of the acquisition of infections for other children and adults. Improved living conditions and access to healthcare during the last century are credited for the considerable decline in the prevalence of ARF and RHD in developed countries. However, a few studies have been reported from within Africa, and in these GAS carriage ranged around 9.0%. In South African studies GAS carriage isolation rates, which range from 1.62% to16.8%, were reported. As regards the prevalence of GAS pharyngitis, it is generally higher in developing countries and impoverished communities within industrialised nations. The most-up-to-date data from South Africa was collected more than 30 years ago with rates then ranging from 23.2% to 45.5%. There are no incidence data on GAS pharyngitis in Africa. This review found that there is a need to document the epidemiology of GAS carriage and GAS pharyngitis in school children of all ages within Africa. Molecular characterisation of strains harboured in the pharynx of carriers and of those isolated during bouts of pharyngitis, will help to identify risk factors associated with carriage in school-aged children and influence the planning and evaluation of management programmes in the screening of pharyngeal carriers and treatment of GAS pharyngitis.

The paper presents the main milestones of a long-term study of the time course of acute rheumatic fever (ARF) in a Russian contingent of patients from different age groups, the results of studying of the clinical types of the disease, developing, and introducing methods for its diagnosis, treatment, rehabilitation and prevention programs. It highlights a path of successes and disappointments in the control of ARF, the way in which every answer is followed by a new question.

Purpose: To describe a rare case of acquired Brown syndrome (ABS) associated with acute rheumatic fever (ARF)., Case Report: a healthy 9-year-old girl developed polyarthritis, carditis, and elevated inflammatory markers 10 days after suffering from a sore throat. She was diagnosed with ARF and was treated with systemic antibiotics and high-dose non-steroidal anti-inflammatory drug (NSAID). After 2 weeks, despite improvement of ARF symptoms, the patient presented with binocular vertical diplopia, periorbital pain, and limited elevation in adduction of the left eye. Imaging revealed a thickened trochlea-superior oblique tendon complex, and ABS due to trochleitis was diagnosed. The patient underwent a successful regional corticosteroid injection as a second-line treatment, and within a month, all signs and symptoms of ABS resolved., Conclusions: ABS is an infrequent yet possible manifestation of ARF., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Myocarditis is an inflammatory disease of the cardiac muscle. Prognosis is most often good but, in some patients, the disease can be fulminant. Our aim with this study was to determine interleukin-9 (IL-9) and interleukin-17 (IL-17) levels in myocarditis cases with different etiologies. Materials and methods: Thirty one patients with myocarditis and 30 healthy controls of similar age and gender without a history of chronic disease were included in the study. All 31 patients were clinically myocarditis. In some of these patients, the cause of myocarditis is acute rheumatic fever or Kawasaki disease. Serum samples of the patients were taken during diagnosis in order to analyze serum IL-9 and IL-17 levels and sedimentation rate, CRP, ASO, pro-BNP, CK-MB, and Troponin-I tests were performed. Results: It was found that IL-17 levels were statistically significant in all acute rheumatic fever, Myocarditis and Kawasaki patients compared to the control group (p = 0.001) and that cut-off was 4.30 pg/mL. This value was determined to be 71% sensitive and 67% specific for IL-17 (AUC = 0.761). Conclusions: Both of the mean and median levels of IL-17 were significantly higher in pediatric patients with myocarditis than in healthy children. Our study made us think that complications of myocarditis and associated morbidity can be prevented by IL17 inhibitors. The high levels of IL17 found in our study may be a reference for future study. [ABSTRACT FROM AUTHOR]

BACKGROUND: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are the leading causes of acquired diseases in children and young adults in developing countries carrying considerable morbidity and mortality. Rheumatic fever (RF) commonly affects children between 5-15 years old and is rarely seen in < 5 years old. Mitral stenosis (MS) is the most common sequela, as it bears maximum onslaught. In India, few patients follow an unusually rapid course in developing severe MS because of its fulminant nature following attack of ARF. CASE REPORT: Our patient was a 28-month-old girl who had developed severe MS, mitral regurgitation (MR), and pulmonary hypertension (PH) as the sequelae of ARF which she had suffered at the age of 18 months old. CONCLUSION: To the best of our knowledge, this is the youngest reported case of rheumatic MS following ARF after extensive search in the literature. This case highlights the fact that very young population is not immune to ARF contrary to prior belief and therefore, more stringent preventive measures need to be implemented for it and possibility of ARF should be kept in mind while evaluating carditis in a child. [ABSTRACT FROM AUTHOR]

Objective: To describe clinical presentation, electrocardiographic, and echocardiographic characteristics of carditis at the time of diagnosis of acute rheumatic fever (ARF) over a 13-year period.Study Design: A single-center retrospective chart analysis was conducted involving all consecutive patients diagnosed with ARF between 2003 and 2015. Patient age, sex, clinical characteristics, recent medical history for group A streptococcal pharyngotonsillitis and antibiotic treatment, and laboratory, echocardiographic, and electrocardiographic findings were recorded.Results: Of 98 patients (62 boys, mean age 8.81 ± 3.04 years), 59 (60.2%) reported a positive history of pharyngotonsillitis; 48 (49%) had received antibiotic (mean duration of treatment of 5.9 ± 3.1 days), and, among these, 28 (58.3%) had carditis. Carditis was the second most frequent finding, subclinical in 27% of patients. Mitral regurgitation was present in 49 of 56 patients (87.5%) and aortic regurgitation in 36/56 (64.3%) no stenosis was documented.Conclusions: ARF is still present in high-income countries and can develop despite primary prophylaxis, especially when given for a short course. Our findings highlight the need for 10 days of antistreptococcal treatment to prevent ARF. Echocardiography is important because 27% of cases with carditis were subclinical. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to investigate of the role of oxidative stress (OS) in acute rheumatic fever (ARF) and its relationship with the progress of the disease. Methods: Thirty patients with ARF and 31 age–sex‐matched healthy children were enrolled in this study. Serum malondialdehyde (MDA), protein carbonyl (PCO), high‐sensitivity C‐reactive protein (hs‐CRP), cytokines (tumor necrosis factor‐α and interleukin‐6) and total antioxidant capacity (TAC) were measured. The diagnosis of ARF was based on the Jones criteria. Results: Patients with ARF had significantly higher serum MDA, PCO, hs‐CRP and cytokine levels and lower TAC than healthy controls. On Pearson's correlation analysis we found that oxidative stress markers were positively correlated with hs‐CRP and cytokines, while TAC was negatively correlated with MDA, PCO, hs‐CRP and cytokines. The number of valves involved as well as the level of mitral valve involvement was also significantly related to the oxidative stress parameters and TAC. All oxidative stress parameters decreased significantly with anti‐inflammatory therapy while TAC increased. Conclusion: Malondialdehyde and PCO, as biomarkers, as well as hs‐CRP together with the other available diagnostic tools, can be used in the evaluation of patients with ARF. [ABSTRACT FROM AUTHOR]

Rheumatic heart disease, as a result of a single or recurrent episode of acute rheumatic fever (ARF), remains a significant cause of morbidity and mortality in northern and remote Australia; ARF has a peak incidence among 5-14-year-old Aboriginal and Torres Strait Islander children. Long-term regular benzathine penicillin G injections are the only currently successful secondary prevention strategy; however, rates of adherence remain critically low. In contrast, rates of adherence to immunisations on the National Immunisation Program (NIP) Schedule are high, even among this target population. This article compares strategies used to implement and improve ARF secondary prophylaxis with those used in the NIP. Some successful NIP strategies, such as Service Incentive Payment for health providers, home-visiting delivery models and integration into the National Immunisation Register, if applied to ARF secondary prophylaxis have the potential to improve benzathine penicillin G adherence. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the clinical features of children diagnosed as having acute rheumatic fever between June 2015 and November 2018, and the changes observed in patient groups in comparison with data obtained in previous years. The diagnosis of acute rheumatic fever was made using the updated Jones criteria. Material and Methods: The medical records of pediatric patients who were diagnosed as having acute rheumatic fever between June 2015 and November 2018 using the updated criteria, were examined retrospectively. The data of a previous study that used the old criteria were reorganized and the two groups were compared. Results: A total of consecutive 50 patients [22 males (44%)] who presented in the study period and were diagnosed as having first-attack acute rheumatic fever, were included in our study. Carditis was found in 42 (84%) patients. Manifest carditis was found in 24 patients and silent carditis was found in 18 patients. Joint involvement was present in 34 (68%) patients. Accompanying carditis was present in all 14 patients (28%) who were found to have chorea. Erythema marginatum and subcutaneous nodules were not found in our patients. When evaluated in terms of the updated criteria, a diagnosis of rheumatic fever was made with silent carditis+polyarthralgia in two patients, with silent carditis+monoarthritis in two patients, with polyarthralgia in four patients, and with monoarhtritis in one patient in our study. A diagnosis could be made by means of the updated criteria in a total of 9 (18%) patients. When compared with the previous study, an increase in the rate of silent carditis (from 21.8% to 36%) and a reduction in the rate of total carditis (from 92% to 84%) were found. Conclusion: Our results show that the updated Jones criteria prevent under diagnosis of acute rheumatic fever in an important number of patients. [ABSTRACT FROM AUTHOR]

Streptococcus A infections have been associated with immune-mediated sequelae including acute glomerulonephritis, acute rheumatic fever, thrombocytopenia, hemolytic anemia, Henoch-Schönlein purpura, arthritis, uveitis, guttate psoriasis, and erythema nodosum. Available reviews do not report the occurrence of acute poststreptococcal glomerulonephritis in association with one of the mentioned conditions. We performed a systematic review of the literature on extrarenal immune-mediated disorders associated with acute poststreptococcal glomerulonephritis. The principles recommended by the Economic and Social Research Council guidance on the conduct of narrative synthesis and on the Preferred Reporting Items for Meta-Analyses and Systematic Reviews were used. We identified 41 original articles, published after 1965, which reported on 52 patients (34 males and 18 females aged from 1.7 to 57 years, median 9) affected by acute poststreptococcal glomerulonephritis associated with a further poststreptococcal disease: 29 cases with rheumatic fever (17 males and 12 females aged 3.0 to 57, median 17 years), 16 with hematologic diseases such as thrombocytopenia or hemolytic anemia (13 males and 3 females aged 1.8 to 13, median 6.0 years) and seven with Henoch-Schönlein syndrome, reactive arthritis or uveitis (4 males and 3 females aged 1.7 to 14, median 7.0 years). Patients affected by acute poststreptococcal glomerulonephritis associated with acute rheumatic fever were on the average older (P < 0.05) than patients with acute poststreptococcal glomerulonephritis associated with thrombocytopenia, hemolytic anemia, Henoch-Schönlein syndrome, reactive arthritis or uveitis. Five large case series describing 2058 patients affected by acute poststreptococcal glomerulonephritis did not mention its occurrence in association with further immune-mediated disorders. This systematic review points out that acute poststreptococcal glomerulonephritis can be associated, albeit rarely, with rheumatic fever, thrombocytopenia, hemolytic anemia, Henoch-Schönlein syndrome, reactive arthritis, or uveitis. [ABSTRACT FROM AUTHOR]

Acute rheumatic fever in an adult is a rare entity. We present a 29-year-old man of mixed ancestry, including Native Hawaiian and other Pacific Islander, who presented with a 6-week history of migratory polyarthralgia and fever with a recent history of purulent lower extremity wounds and a remote history of acute rheumatic fever in childhood. The diagnosis of recurrent acute rheumatic fever was confirmed by elevated Antistreptolysin-O titers and Anti-DNase B titers. This case presentation showcases a Native Hawaiian and other Pacific Islander with acute rheumatic fever in both childhood and adulthood following pyoderma infection, with a delay in diagnosis and management for both episodes. The patient had an excellent response to naproxen without developing complications and was restarted on secondary antibiotic prophylaxis. Health care providers in the Pacific region should understand the relationship between pyoderma and acute rheumatic fever in addition to including acute rheumatic fever in the differential diagnosis of polyarthralgia in an adult. [ABSTRACT FROM AUTHOR]

The prolongation in the PR interval on the electrocardiogram is one of the minor criteria of Jones. Abnormal increases in the PR interval lead to hemodynamic impairments caused by atrioventricular asynchrony and is called pseudo-pacemaker or pacemaker-like syndrome in the literature. A 13-yearold boy who had polyarthralgia for six weeks was referred to the emergency room because of syncope while exerting effort. In the electrocardiography, the P wave was regularly seen at the onset of the T wave immediately after the QRS wave with extremely prolonged PR interval and mild tachycardia. Also, 24 hours rhythm Holter recording showed atrioventricular dissociation. The echocardiography revealed findings of severe carditis. Diagnosis of acute rheumatic fever accompanying pacemaker-like syndrome was made. Although the recommendation for marked first-degree atrioventricular block that causes hemodynamic impairment is pacemaker implantation, a significant improvement in the PR prolongation was observed in the short term with anti-inflammatory treatment because the impairment of conduction in the patient was due to inflammation. The pacemaker-like syndrome in a child is being reported for the first time in the literature. [ABSTRACT FROM AUTHOR]

Background: Acute rheumatic fever (ARF) affects millions of children in the third world countries like India. The diagnosis of rheumatic fever is based on the Jones criteria with serological titers, antistreptolysin O titer (ASO), and anti-deoxyribonucleic B (ADB), taken as evidence of recent streptococci infection. There is a lack of recent data available on ASO and ADB titers in children from the Delhi/NCR and thus adequate geographical area-specific cutoffs for the region are not available. Aims and Objectives: The aim of this study is to determine and compare the ASO and ADB antibody titers in children with acute pharyngitis, ARF, rheumatic heart disease (RHD), and in healthy children of the Delhi/NCR region. Materials and Methods: Twenty-six cases of ARF, 51 cases of RHD, 50 cases of acute pharyngitis, and 84 healthy normal children were included in the study. A single ASO and ADB titer measurement was done in these children. Results: The ASO titers was raised in acute pharyngitis – 303 IU/ml (interquartile range [IQR], 142–520 IU/ml) and ARF – 347.5 IU/ml (IQR, 125–686 IU/ml) children in comparison to healthy controls – 163.5 IU/ml (IQR, 133–246.5 IU/ml) and RHD patients – 163 IU/ml (IQR, 98.250–324.500). The ADB titers were highest in ARF patients – 570.5 IU/ml (IQR, 276–922 IU/ml) followed with RHD – 205 IU/ml (IQR, 113.6–456.5), healthy controls – 78.25 IU/ml (IQR, 53.39–128.15 IU/ml), and acute pharyngitis – 75.12 IU/ml (IQR, 64.5–136 IU/ml). The upper limit of normal (ULN) values of ASO and ADB computed from normal healthy children were 262.4 IU/ml and 134.44 IU/ml, respectively, and these can be used as cutoff values for recent streptococcal infection in this geographical area. Conclusions: The median ASO titers in acute pharyngitis group and ARF were significantly raised compared to that of the control group. The ADB titers were raised in ARF and RHD patients albeit the levels were higher in ARF patients. The derived ULN values can be used as cutoff reference. [ABSTRACT FROM AUTHOR]

Background: Benzathine benzylpenicillin G (BPG) is recommended as secondary prophylaxis to prevent recurrence of acute rheumatic fever and subsequent rheumatic heart disease (RHD). Following intramuscular injection, BPG is hydrolysed to benzylpenicillin. Little is known of the pharmacokinetics of benzylpenicillin following BPG in populations at risk of RHD.Methods: We conducted a longitudinal pharmacokinetic study of children and adolescents receiving secondary prophylaxis throughout six monthly cycles of BPG. Dried blood spot samples were assayed with LC-MS/MS. Benzylpenicillin concentrations were analysed using non-linear mixed-effects modelling with subsequent simulations based on published BMI-for-age and weight-for-age data.Results: Eighteen participants contributed 256 concentrations for analysis. None had benzylpenicillin concentrations >0.02 mg/L for the full time between doses. The median duration above this target was 9.8 days for those with a lower BMI (<25 kg/m2), who also had lower weights, and 0 days for those with a higher BMI (≥25 kg/m2). Although fat-free mass was a key determinant of benzylpenicillin exposure after a standard dose of BPG, having a higher BMI influenced absorption and almost doubled (increase of 86%) the observed t½.Conclusions: Few children and adolescents receiving BPG as secondary prophylaxis will achieve concentrations >0.02 mg/L for the majority of the time between injections. The discordance of this observation with reported efficacy of BPG to prevent rheumatic fever implies a major knowledge gap relating to pharmacokinetic/pharmacodynamic relationships between benzylpenicillin exposure and clinical outcomes. [ABSTRACT FROM AUTHOR]

During the acute phase of acute rheumatic fever (ARF), cardiac arrhythmias and conduction disorders may occur. Standard electrocardiogram (ECG) may be insufficient in the cases of possible paroxysmal rhythm or conduction abnormalities. The aim of this study is to evaluate arrhythmias and conduction disorders and benefits of 24-hour Holter ECG on detecting these disorders in children with ARF. Two hundred and ten patients who were diagnosed with ARF during a four -year period, were retrospectively analyzed. Demographic characteristics, clinical, laboratory, and echocardiographic findings of the patients were evaluated. Standard ECG and 24-hour Holter analysis were examined. First (47.8%), second (6.9%) and third degree (4.3%) atrioventricular (AV) blocks, bundle branch blocks (9.8%), intermittent pre-excitation (1.1%), accelerated nodal rhythm (15.2%), supraventricular (10.9%) and ventricular premature contractions (8.7%), as well as supraventricular (3.3%) and ventricular tachycardia (1.1%) were detected with 24 -hour Holter ECG. Frequency of both rhythm and conduction abnormalities were detected higher with Holter ECG than 12-lead ECG, and this was statistically significant (p<0.05). Second degree type II AV block and non-sustained supraventricular tachycardia as well as intermittent complete AV block were detected on 24-hour Holter analysis in patients with normal initial standard ECG. The incidence of rhythm and conduction abnormalities is higher than traditionally known. 24-hour Holter ECG is very helpful to detect especially paroxysmal abnormalities and to determine the more exact incidence of rhythm and conduction abnormalities in patients with ARF. For this reason, we suggest a routine 24-hour Holter ECG analysis in pediatric heart centers for patients diagnosed with ARF. [ABSTRACT FROM AUTHOR]

Acute rheumatic fever (ARF) is a multi-systemic disease, in which cardiac involvement is the most serious major manifestation of disease. The aim of this study was to analyse cardiac involvement in children with ARF and his risk factors. It were a retrospective study including all children under the age of 14 years who were hospitalized for ARF in the pediatric department of the CHU Hédi Chaker of Sfax, during a period of twelve years (2010–2022). We collected 50 cases (31 boys and 19 girls). Twenty-two patients (44%) developed cardiac lesions. The mean age at diagnosis was 9.6 years [5–14 years]. A pathological heart murmur was detected in 14 cases (n = 14/22) was classified as mild carditis in 15 cases, moderate carditis in 5 cases and severe in 2 cases. The median follow-up time was 3,3 years. Nineteen patients developed valvular sequelae Risk factors of cardiac lesions was: age more than 8 years, heart murmur, allonged PR, CRP > 100 mg/l and VS > 100 mm. CR is still a public health problem in Tunisia. It is a serious pathology that can cause serious increases in morbidity rates. Thus, we must strengthen preventive strategies. [ABSTRACT FROM AUTHOR]

Rheumatic heart disease (RHD) is a disease of poverty, is almost entirely preventable, and is the most common cardiovascular disease worldwide in those under 25 years. RHD is caused by acute rheumatic fever (ARF) which typically results in cumulative valvular lesions that may present clinically after a number of years of subclinical disease. Therapeutic interventions, therefore, typically focus on preventing subsequent ARF episodes (with penicillin prophylaxis). However, not all patients with ARF develop symptoms and not all symptomatic cases present to a physician or are correctly diagnosed. Therefore, if we hope to control ARF and RHD at the population level, we need a more reliable discriminator of subclinical disease. Recent studies have examined the utility of echocardiographic screening, which is far superior to auscultation at detecting RHD. However, there are many concerns surrounding this approach. Despite the introduction of the World Heart Federation diagnostic criteria in 2012, we still do not really know what constitutes the most subtle changes of RHD by echocardiography. This poses serious problems regarding whom to treat and what to do with the rest, both important decisions with widespread implications for already stretched health-care systems. In addition, issues ranging from improving the uptake of penicillin prophylaxis in ARF/RHD-positive patients, improving portable echocardiographic equipment, understanding the natural history of subclinical RHD and how it might respond to penicillin, and developing simplified diagnostic criteria that can be applied by nonexperts, all need to be effectively tackled before routine widespread screening for RHD can be endorsed.

Acute rheumatic fever (ARF) remains a healthcare challenge. The global burden of ARF in children aged 5–14 years totals 336 thousand of new cases annually. The main symptom of ARF is carditis which determines the severity and outcome of the disease. Heart involvement in the form of isolated myocarditis without valvulitis is not regarded as typical of rheumatic fever. It should be borne in mind that post-streptococcal rheumatic myocarditis may also develop. No less important is the problem of neurological disorders in ARF including PANDAS syndrome. Analysis of the updated (2015) diagnostic Jones criteria showed that their application in Russia is problematic due to large inter-regional differences in the frequency of ARF. Amendments to the existing Russian classification and nomenclature of ARF seem untimely. Adequate primary prevention of rheumatic fever is still based on timely diagnosis and rational antimicrobial therapy of GABHS - tonsillitis/pharyngitis.

Background The effectiveness of a single intramuscular benzathine penicillin G as a secondary prevention of acute rheu- matic fever after 28 days is still controversial. The latest study showed that serum penicillin concentration was below protective level in 4 weeks after a single intramuscular injection. Objective This study was a preliminary study to compare the in- hibiting ability of benzathine penicillin G towards group A Strepto- coccus β -hemolyticus in 21 and 28 days after a single IM injection by using Mueller-Hinton broth method. Methods The inhibiting ability was measured by the serum in- hibitory concentration and serum bactericidal concentration after a single intramuscular injection of benzathine penicillin G 1.2 mil- lion units. Results The subjects were 28 patients, with mean age of 15.5 years (SD 3.4). The numbers of male and female were equal. Mean serum inhibitory concentration in 21 days after a single injection was 926.4 (SD 3080.1) and after 28 days was 1540.9 (SD 4275.1), which was not significantly different (p=0.0662). Mean serum bac- tericidal concentration in 21 days after IM injection was 1579.6 (SD 4265.7) and in 28 days was 2417 (SD 6849.4) and it was not statistically different (p=0.2276). Conclusion This study concluded that there was no significant difference in the inhibiting ability of benzathine penicillin G to- wards group A Streptococcus β -hemolyticus between 21 and 28 days after a single intramuscular injection

Acute rheumatic fever (ARF) is an inflammatory collagenous tissue disease which shows its cardinal signs in joints, heart, skin and nervous system while affecting whole connective tissue system more or less. This study was conducted in order to investigate the clinical pattern and severity of ARF, echocardiographic findings and the course of the patients with heart valve involvement by studying the clinical and laboratory aspects of the patients diagnosed with ARF according to updated Jones criteria. The study included 214 patients diagnosed with ARF for the first time between January 2005 and May 2008. All patients were scanned with doppler echocardiography (ECHO) between certain intervals. Severity of carditis was grouped into 3 groups of mild, moderate and severe. The frequency of carditis was 57.9%, arthritis was 73.4%, chorea was 11.7% and erythema marginatum was 0.9% but no subcutaneous nodules. Recovery was observed in 22% of the cases of isolated aortic insufficiency (AI), 50% of the cases with isolated mitral insufficiency (MI) and 80% of the cases with mitral and aortic insufficiencies together (MI+AI). Recovery in isolated MI was significantly much more than recovery in isolated AI. However, recovery in AI was significantly much more than in MI in cases of mitral and aortic insufficiencies together. In conclusion, ARF is a cause of acquired and preventable heart disease and it can be reversed through right diagnosis and appropriate treatment. Isolated mitral insufficiency, isolated aortic insufficiency and both mitral and aortic insufficiency are observed during a valvular disease. Remission among valvular diseases are most commonly in those with mitral insufficiency and remissions in both mitral and aortic insufficiency occur most commonly in aortic ones. Regular prophylaxis is the key element for long term prevention of patients with ARF.