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Most important indicators for cardiac risks are your personal health history. Age, hereditary factors, weight, cigarette smoking, blood pressure, and diabetes. Certain other factors like High-sensitivity C-reactive protein (hs-CRP) Homocysteine, Lipoprotein A Lp(a) and Fibrinogen also have some role in predicting your cardiac risks.
Rheumatic Fever
Definition
•Diffuse non suppurative inflammatory disease of connective tissue as a sequalae to Group A beta hemolytic streptococcal infection of the throat by rheumatogenic strains, primarily involving heart, blood vessels, joints, subcut. tissue and CNS
Magnitude of Pattern
•Common cause of CV morbidity and mortality in underdeveloped and developing countries
•Less in developed world
Prevalence of RHD in school children
•
•
•
•
6 / 1000 (5 CITIES – 1 Cm2)
Aetiopathogenesis
Incompletely understood
•Non suppurative sequelea to ‘GAS’
•Repeated infection important
•Genetic predisposition ?
•Autoimmunity – Antigenic mimicry between st.cell wall component and human myocardium, valvular glycoprotein etc.
•Delayed immune response to infection with group.A beta hemolytic streptococci.
•After a latent period of 1-3 weeks, antibody induced immunological damage occur to heart valves, joints, subcutaneous tissue & basal ganglia of brain
Determinants
•Severity of throat infection
–Severe exudative infection - upto 3%
–Mild sporadic – 0.5 to 1%
•Immune response (ASO) – 1 to 5%
•GAS persisting in throat
•Previous RF : many times
•Established RHD – very high
–Recurrence rate – 50% - 1st year
10% after 5 years
Pathologic Lesions
•Fibrinoid degeneration of connective tissue,inflammatory edema, inflammatory cell infiltration & proliferation of specific cells resulting in formation of Aschoff nodules, resulting in
-Pancarditis in the heart
-Arthritis in the joints
-Aschoff nodules in the subcutaneous tissue
-Basal gangliar lesions resulting in chorea
•Rheumatic fever licks the joint & bites the heart
Incubation period
•1 to 5 weeks
•Shortest for Arthritis
•Longest for Chorea
Clinical features
Commonest age – 5- 15 years
Arthritis
•Migratory polyarthritis
•Mainly - major joints, no residual deformity
•Usually mild in young children esp. <>
•Prominent in older children and adolescents
•Occur upto 30%, more in girls
•May appear even 6 m after the attack of RF
•Clumsiness, deterioration of handwriting, emotional lability or grimacing of face
•Clinical signs- pronator sign, jack in the box sign, milking sign of hands
•Occur in 2 %
•Painless, pea-sized, palpable nodules:- 0.5 - 2 cm, mainly over extensor surfaces of
joints, spine, scapulae & scalp
•Typically appear > 3 wk after the onset
•Always associated with severe carditis
•Rarely seen in our population -.5 to 2%
•Transient, serpiginous, non-itchy, pale center with red irregular margin, mainly trunks/ limbs
•Often associated with carditis
Carditis - Pancarditis
Endocarditis – Valvulitis, Mitral & /or aortic
•Significant murmur – MR, AR, Carey Coombs
Myocarditis
Cardiomegaly–Clinical, X-Ray CCF, Prolonged PR, relative Tachycardia, Soft S1, S3
Pericarditis
•Pericardial rub ± effusion
Diagnosis of RF
•No single symptom
•No single sign
•No single lab test
Revised Jones Criteria for Guidance in Diagnosis
•1994 – by Dr. T. Duckett Jones
•Modified by AHA in 1956, 1965, 1982, 1992
•1987 – WHO study group accepted 1982 AHA criteria
Revised Jones Criteria, AHA 1992
Major:
Carditis
Arthritis
Chorea
Erythema marginatum
Subcutaneous nodules
Minor:
Clinical: Arthralgia
Fever
Lab: level of acute phase reactants –ESR & C-reactive protein
Prolonged PR interval
Essential criteria:
Evidence of antecedent group A Streptococcal infection
Diagnosis of rheumatic fever highly probable
If
Two major criteria
or
One major & two minor criteria
With
Essential criteria satisfied
Relaxation of Criteria
•Chorea as sole manifestation (other causes excluded)
•Insidious onset / Late onset carditis
•Established RHD
–One major criteria
–Fever with arthralgia + increased acute phase reactants
If evidence of recent GAS infection present
Acute Carditis in Chronic RHD often difficult
•New murmur
•Sudden increase in heart size
•Recent onset CHF
•Pericardial rub
•Erythema marginatum / Subcutaneous nodules
Previous carditis – recurrence of RF ® Carditis almost always present
Supportive evidence of Streptococcal infection
•ASO + others
•Throat culture – positive
•Recent scarlet fever
•History of sore throat – commonest viral
Laboratory Findings
•High ESR, Elevated C-reactive protein
•Anemia, leucocytosis
•ECG - prolonged PR interval, non specific ST-T changes rarely heart blocks
•2D Echo cardiography - valve edema, mitral regurgitation, LA &
Streptococcal antibody tests
ASO - most commonly used
•> 200 IU suggestive, rising titre in 2 to 4 wks
•Peaks in 4to 6 wks , remain high for 4 to 6 wks and comes down
•Sensitivity- 80%
•Specificity low – skin infection, other strep. Inf.
Others
–Antistreptokinase, Antihyaluronidase
–Anti DNAse, Antistreptozyme(most sensitive)
Throat Culture
•Positive in minority (latency, antibiotic Use)
•About 20 % school children – carrier state
Differential Diagnosis
•Rheumatoid Arthritis
•SLE
•Infective Endocarditis
•Serum sickness
•Gonococcal Arthritis
•Tuberculosis
•Viral myopericarditis
•Leukaemias
Overdiagnosis - Problems
•Trauma + anxiety – parent + children
•Unnecessary prophylaxis – risk
•Missing another disease
Under Diagnosis
No prophylaxis
Risk of reactivation
Natural History of RF
•Period of activity
75% - 6 weeks
90% - 12 weeks
< style="mso-spacerun:yes"> - upto 6 months (Chronic RF)
•Arthritis
> 12 years – 80%
3 to 6 years – 50%
•Carditis
<>
14 to 17 years – 30%
Natural History – RF with Carditis
•Initial attack, no carditis – excellent prognosis
•Initial attack, mild carditis – 70% normal heart after 10 years
•Initial attack, severe carditis – 40% normal heart at 10 years
These drugs have been globally discarded but are available in
Analgin: This is a painkiller
Reason for ban: Bone marrow depression
Brand name: Novalgin
Cisapride: Acidity, constipation
Reason for ban: irregular heartbeat
Brand name: Ciza, Syspride
Droperidol: Anti-depressant
Reason for ban: Irregular heartbeat
Brand name: Droperol
Furazolidone: Antidiarrhoeal
Reason for ban: Cancer
Brand name: Furoxone, Lomofen
Nimesulide: Painkiller, fever
Reason for ban: Liver failure
Brand name: Nise, Nimulid
Nitrofurazone: Antibacterial cream
Reason for ban: Cancer
Brand name: Furacin
Phenolphthalein: Laxative
Reason for ban: Cancer
Brand name: Agarol
Phenylpropanolamine: cold and cough
Reason for ban: stroke
Brand name: D'cold, Vicks Action 500
Oxyphenbutazone: Non-steroidal anti-inflammatory drug
Reason for ban: Bone marrow depression
Brand name: Sioril
Piperazine: Anti-worms
Reason for ban: Nerve damage
Brand name: Piperazine
Quiniodochlor: Anti-diarrhoeal
Reason for ban: Damage to sight
Brand name: Enteroquinol
( Source: Dr C.M. Gulhati, Editor, MIMS
.Whenever we think of cancer,a sort of fear comes up in our mind as it is incurable.Lot of researches are being made in cancer which go to contribute the treatment . When a person has cancer it indicates that, his immune system is weak due to multiple nutritional deficiencies(esp micronutrients).To overcome these deficiencies,change in the the diet and addition of lot of supplements are necessary.
.Diet made of green leafy vegetables (80%)and cooked food(20%) help to put the body in an alkaline environment. Fresh vegetables, juices provide live enzymes that are easily absorbed and reach down to the cellular levels within minutes to enhance the growth of healthy cells. Eat some raw vegetables two to three times a day. ( dark green and dark yellow vegetables like spinach, beans, carrots and other vegetables like cabbage, soybeans, cauliflower, brinjal, onions (red), peppers, garlic, sweet potatoes, tomatoes etc`)
.Unsaturated fat don't contribute to cancer and may in fact have some anticancer properties. Limiting your diet to unsaturated fats, found in plant foods, such as legumes; vegetable oils peanut and canola oil and seafood, such as salmon and tuna, that is high in omega 3 fatty acids can be of great benefit.
.Cancer cells, nourished by sugar and sugar substitutes that are made with aspartamine, better substitute is manuka honey or molasses but only in small amounts.Table salt has a chemical added to make it white in colour.Better alternative is Bragg’s aminos or sea salt. Further, cancer cells feed on mucous.Milk produces mucous especially in the GIT ,by cutting down the milk intake ,cancer cells can be starved. Instead of that, milk substituted with unsweetened soy milk can be used. Avoid tea, coffee, and chocolate, which have high caffeine. Green tea, is a better alternative and it has cancer fighting properties.
.Meat protein is difficult to digest and requires a lot of digestive enzymes, and undigested meat remaining in the intestine may undergo putrefaction ,which results in toxic accumulation. So it is better to eat fish and little chicken rather than beef or pork.More than that Meat contains lot of antibiotics, growth hormones, parasites which are all harmful.
.Supplements (ip6, flor-essence,Essiac,antioxidants,vitamins ,minerals,EFA..)enable the body’s own killer cells to destroy cancer cell. Supplements like vitamin E are known to cause apoptosis or programmed cell death, which is body’s normal method of disposing damaged unwanted cells. Antioxidants prevent free radicals reactions and faulty metabolism in the cell, which makes the cell becoming carcinogenic. They also protect the membrane of intestinal cells. Vitamin A, Betacarotine, Riboflavin, Selenium, Zinc, Foliate, Vitamin E etc. have antioxidant properties.
·Microwaved foods are chemically and molecularly altered,so they are harmful to health.( by reversing the polarity of water molecules in the food and the friction caused by these repeated changes that emits the heat that cooks the food in microwave oven) Besides that, heating food in microwave oven (especially certain food Stuffs that contain fat) using plastics containers release dioxins in to the food ,ultimately to the cells of the body. Dioxins are carcinogenic.
.Water best to drink is purified water or filtered water to avoid known toxins and heavy metals in tap water. Avoid Distilled water, which is acidic
.Cancer cells cannot survive in an oxygenated environment.So exercise regularly .
.Learn to have a loving and forgiving spirit.Anger,hatred, etc put the body in to a stressful and acidic environment . learn to relax and enjoy life.
Links
manuka honey ,Bragg's aminos