Rheumatic manifestations in childhood and adolescence

The importance of this subject can hardly be overestimated when one realizes that rheumatism in childhood is responsible for nearly all the cardiac disease in early life and a considerable proportion in adult life, and that cardiac disease is responsbile for a very large share of the death rate of this country. In 1921 the Registrar General found that 11.76% of deaths at all ages and from all causes in England and Wales were due to heart disease and this did not include diseases the vessels. The frequency of the condition is not fully realized, probably because its minor symptoms owing to their apparent triviality are often ignored or ascribed to something else. The traditional belief amongst the general public that children cannot have rheumatism dies hard and often prevents an early diagnosis being made. Only too often does one first see these cases when irreparable damage has already been done to the heart. These considerations, together with the varied clinical manifestations, the unknown etiology and the difficulties of treatment are in the author's at work give him ample scope for studying the disease in its various guises and for ferreting out possible predisposing causes and contributing factors in the etiology. In the following thesis an attempt will be made to put together a few observations on the condition as met with in general practice, and to bring these phenomena into their appropriate relation with one's view of rheumatism as a whole

Rheumatism

Obviously it is beyond the scope of this essay to enter into a full and critical account of all the above various conditions to which the term rheumatism has been in one sense or other applied. Such being,then, both unnecessary and inadvisable, I shall restrict my efforts to the consideration of such common forms of the disease as acute articular rheumatism(including the subacute variety and the affection in children), chronic rheumatism,muscular rheumatism,and gonorrhoeal rheumatism,as well as arthritis deformans

Anemias

LECTURE IN INTERNAL MEDICINE FOR IV COURSE STUDENT

The cardiovascular assessment skills gap in small animal general veterinary practitioners and identification of methods to reduce this

Administration of pimobendan to dogs with preclinical myxomatous mitral valve disease (MMVD) with cardiomegaly (stage B2 mitral valve disease, Atkins et al., 2009) has been shown to extend the asymptomatic period by an average of 15 months, and dogs receiving the drug live significantly longer than those receiving a placebo (Boswood et al., 2016). The identification in general veterinary practice of patients with MMVD who could benefit from this medication relies heavily on the accurate identification of a heart murmur on a physical examination and identification of cardiomegaly, including left atriomegaly, on thoracic radiographs. Little is known about the ability of general practitioners to identify these patients accurately. To investigate this in more detail, practitioner record keeping in relation to cardiovascular parameters, practitioner accuracy in interpretation of cardiac murmurs (Chapter 1) and practitioner accuracy in identification of cardiomegaly and left atriomegaly on thoracic radiographs (Chapter 2) was assessed. To identify methods that might aid the detection of cardiovascular disease in general practice, the value of focused echocardiography was assessed. Record keeping by general veterinary practitioners for important cardiovascular parameters was markedly limited in standard. General practitioners, compared with a referral clinician consensus opinion, agreed substantially on murmur grade (K = 0.7), agreed perfectly on murmur timing (K = 1.0) and moderately on the site of maximum intensity of murmurs (K = 0.5). These findings would suggest that practitioners are able to accurately grade a heart murmur and therefore could potentially correctly select patients who would benefit from further investigation, confirming the cause of the murmur as MMVD and therefore potentially benefit from medication. However due to poor record keeping, the loss of information may prevent the identification of patients in early stages of heart disease or patients who might benefit from further cardiovascular investigation. When assessing thoracic radiographs for changes associated with MMVD (Chapter II), general practitioners were found to have a high level of accuracy in the detection of patients with marked generalised cardiomegaly (median number of images correctly identified was 100%) and patients with no left atrial enlargement (median number of images correctly identified was 80%) using subjective methods of assessment. However, their accuracy was lower in detection of those with mild changes (median number of images correctly identified with mild cardiomegaly and mild left atrial enlargement was 66.67%). Whilst practitioners were accurate in their ability to measure a vertebral heart score (VHS), the lack of a clear upper limit for VHS meant that VHS added no significant value in aiding correct diagnosis. Patients in stage B2 MMVD (Atkins et al., 2009) have mild changes on thoracic radiographs, therefore this research suggests that in general practice patients in the early stages of cardiac remodelling, and those who might benefit greatly from medication, may go undiagnosed. This highlights that radiographic examination may not be sufficiently reliable in the evaluation of mild cardiomegaly and emphasizes the need for echocardiography to assist in the detection of patients with B2 MMVD. The introduction of the novel tool of focused echocardiography (Chapter 3) significantly improved general practitioner’s ability to correctly identify cardiac anatomy on echocardiography, detect left atrial enlargement, detect reduced systolic function and detect pericardial effusion (p<0.0001), practically obtain the views required to make these assessments, and improved their confidence in both image interpretation and practical acquisition. In relation to detection of MMVD, following the training course in focussed echocardiography, the mean accuracy of identification of normal left atrial size, a mildly enlarged left atrium and severely enlarged left atrium was 88%. Post training, 95% of practitioners were able to correctly identify a severely enlarged left atrium. These results suggest that the addition of the focused echocardiogram to general practice could aid earlier detection of patients in stage B2 MMVD or greater by detection of left atrial enlargement. These patients could then benefit from an echocardiogram and potentially benefit from the positive effects of pimobendan