Mario Spagnuolo

Natural history of rheumatic aortic regurgitation. Criteria predictive of death, congestive heart failure, and angina in young patients.

The medical courses of 174 young patients with aortic regurgitation were followed prospectively for a median of 10 years. The data were analyzed by life-table methods; congestive failure and angina, as well as death, were considered as end points, since the occurrence of the former is considered sufficient indication for aortic valve replacement. Thirty-one patients developed the triad of moderate or marked left ventricular enlargement, two or three electrocardiographic abnormalities, and abnormal blood pressure. Thirty-three percent of these patients either died or had failure or angina within 1 year, 48% within 2 years, 65% within 3 years, and 87% within 6 years from the acquisition of the triad. The 71 patients with none of the above features had uneventful courses. Of the 71 patients with one or two features only seven either died (three) or became symptomatic. These data are useful for patient selection for surgery before symptoms appear.

POST-STEROID PANNICULITIS

Excerpt The great majority of untoward effects of steroid therapy follow one of two general patterns. Some of them, such as sodium retention, osteoporosis, and decreased resistance to infections, a...

Chronic rheumatic fever.

Excerpt Rheumatic fever has often been described in the past as a chronic disease (2) or as a disease of long duration (3). These descriptions were based on long-term follow-up studies of children ...

Risk of rheumatic-fever recurrences after streptococcal infections. Prospective study of clinical and social factors.

Abstract The rheumatic-fever recurrence rate per streptococcal infection was studied in 393 patients in whom 711 streptococcal infections and 123 recurrences developed. Factors were evaluated for their relation to the recurrence rate by means of statistical technics that allowed testing the significance of a given factor while holding the others constant; thus, each factor was evaluated independently from the others. Symptoms of pharyngitis (sore throat and fever) were significantly associated with a high recurrence rate, whereas magnitude of rise in antistreptolysin-O titer was not. Young age and, particularly, short interval since the preceding rheumatic attack, were also significantly associated with a high rate of recurrence, as were existing rheumatic heart disease, number of previous attacks and oral (rather than parenteral) administration of drug prophylaxis. The effects of overcrowding, yearly family income, welfare status, rheumatic fever in siblings and ethnic group were not significant.

Sore throats, streptococcal infections, and prevention of rheumatic fever

Abstract Recent advances in laboratory and clinical investigation have shown the constant association of acute rheumatic fever with Group A beta-hemolytic streptococcal infections. Attempts to prevent rheumatic fever are accordingly aimed at eradication of Streptococci. This is an elusive target because there are no routine, simple clinical or laboratory indications of streptococcal infection. Patients with streptococcal infections may have sore throats but often are asymptomatic or have non-specific upper respiratory symptoms. Tests for Streptococci in the throat can be done easily but show only that the organism is present; they do not prove it is the causing infection. Antibody measurements can detect infection, but these tests are complex, cumbersome, and often require long delays to await acquisition of the sequential specimens required for demonstrating a change in titer. In preventing first attacks of rheumatic fever, physicians must find and then eradicate asymptomatic or atypical streptococcal infections as well as those that produce sore throats. Oral or parenteral penicillin, in adequate dosage , is the agent of choice for this purpose. Sulfonamides should not be employed therapeutically; erythromycin provides a feasible alternative when the use of penicillin is precluded. The major features used in deciding whether infection is present are a sore throat, and exudate, together with laboratory evidence of streptococcal infection. In preventing recurrent attacks of rheumatic fever in susceptible patients, physicians cannot rely on attempts to find and then treat streptococcal infections because the risk of missing asymptomatic infections is too great. Therefore, prevention of rheumatic recurrences requires continuous antimicrobial prophylaxis. At present, the most effective agent is a monthly injection of long-acting parenteral benzathine penicillin. The most effective oral agent to date has been sulfadiazine, 1.0 gram daily. Although it is currently recommended that all rheumatic patients maintain prophyl-axis indefinitely, rational considerations suggest that more finite durations can be planned for some patients on the basis of age, cardiac status, and length of time elapsed since the previous rheumatic attack.

The Pattern of Symptoms, Pre-Treatment Interval, and Prognosis of Acute Rheumatic Fever

Excerpt In a recent re-appraisal of the clinical patterns of acute rheumatic fever (1), we decided to examine the now traditional belief that residual heart disease is prevented by early treatment....

Annuloplasty in Children and Young Adolescents with Severe Rheumatic Mitral Insufficiency

Eleven patients aged 8 to 15 years underwent measured asymmetrical annuloplasty for severe mitral regurgitation in the years 1961 through 1966. They had had a total of 20 attacks of acute rheumatic fever. The intervals between the last attack of acute rheumatic fever and operation ranged from 2 to 8 years. The criteria for surgery were congestive failure and progressive cardiac enlargement. Using the hydraulic formula of Gorlin, a mitral annuloplasty was tailored to the size of each patient so that insufficiency was eliminated without producing hemodynamically significant stenosis.In this group of 11 children there has been one death. The majority of our 11 patients reacquired murmurs of mitral regurgitation. Satisfactory results, however, are not dependent on complete hemodynamic correction. All patients have improved remarkably and have sustained this improvement up to 7 years. These results suggest that mitral annuloplasty should be the operation of choice in children with severe mitral regurgitation.

Single weekly doses of oral sulfamethoxypyridazine in preventing recurrences of rheumatic fever

A single weekly dose of sulfamethoxypyridazine (SMP), 3.0 Gm., provided rheumatic children and adolescents with higher blood levels of the drug through most of the week than peak values after single daily doses of sulfadiazine, 1.0 Gm. When tested in a program of prophylaxis against recurrences of rheumatic fever, the repetitive weekly dose of SMP was maintained continuously with about the same degree of fidelity given to a daily oral sulfadiazine regimen. The SMP regimen seemed more effective than daily sulfadiazine for preventing streptococcal infections but not for preventing rheumatic recurrences. Although no significant adverse effects of SMP were noted, the reports of severe reactions in other circumstances have discouraged further clinical trials with long‐acting sulfonamide preparations. When newer and safer long‐acting sulfonamides become available, their value in antirheumatic prophylaxis should be explored.