Adherence to secondary prophylaxis for acute rheumatic fever and rheumatic heart disease: a systematic review

Background: Optimal delivery of regular benzathine penicillin G (BPG) injections prescribed as secondary prophylaxis for acute rheumatic fever (ARF) and rheumatic heart disease (RHD) is vital to preventing disease morbidity and cardiac sequelae in affected pediatric and young adult populations. However, poor uptake of secondary prophylaxis remains a significant challenge to ARF/RHD control programs. Objective: In order to facilitate better understanding of this challenge and thereby identify means to improve service delivery, this systematic literature review explored rates of adherence and factors associated with adherence to secondary prophylaxis for ARF and RHD worldwide. Methods: MEDLINE was searched for relevant primary studies published in the English language from 1994-2014, and a search of reference lists of eligible articles was performed. The methodological quality of included studies was evaluated using a modified assessment tool. Results: Twenty studies were included in the review. There was a range of adherence to varying regimens of secondary prophylaxis reported globally, and a number of patient demographic, clinical, socio-cultural and health care service delivery factors associated with adherence to secondary prophylaxis were identified. Conclusion: Insights into factors associated with lower and higher adherence to secondary prophylaxis may be utilized to facilitate improved delivery of secondary prophylaxis for ARF and RHD. Strategies may include ensuring an effective active recall system, providing holistic care, involving community health workers and delivering ARF/RHD health education

Adherence rates and risk factors for suboptimal adherence to secondary prophylaxis for rheumatic fever

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 = 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

Rare Sarcomatoid Carcinoma of the Liver in a patient with no history of Hepatocellular Carcinoma: A Case Report

Sarcomatoid carcinoma is a rare malignant tumor of unknown pathogenesis characterized by poorly differentiated carcinoma tissue containing sarcoma-like differentiation of either spindle or giant cell and rarely occurs in the gastrointestinal tract and hepatobiliary-pancreatic system.1 Primary hepatic sarcomatoid carcinoma accounts for only 0.2 % of primary malignant liver tumors, and 1.8% of all surgically resected hepatocellular carcinomas.2 The majority of hepatic sarcomatoid carcinoma cases appear to occur simultaneously with hepatocellular or cholangiocellular carcinoma.3 The preferred treatment for hepatic sarcomatoid carcinoma is surgical resection and the overall prognosis is poor.4 This case depicts a 62-year-old female whom underwent initial resection in 2010 of a cavernous hemangioma. Seven years after her initial diagnosis she developed what was initially felt to be local recurrence of the hemangioma but additional diagnostic workup with a liver biopsy confirmed primary hepatic sarcomatoid carcinoma

Sharing success - understanding barriers and enablers to secondary prophylaxis delivery for rheumatic fever and rheumatic heart disease

Background: Rheumatic fever (RF) and rheumatic heart disease (RHD) cause considerable morbidity and mortality amongst Australian Aboriginal and Torres Strait Islander populations. Secondary antibiotic prophylaxis in the form of 4-weekly benzathine penicillin injections is the mainstay of control programs. Evidence suggests, however, that delivery rates of such prophylaxis are poor. Methods: This qualitative study used semi-structured interviews with patients, parents/care givers and health professionals, to explore the enablers of and barriers to the uptake of secondary prophylaxis. Data from participant interviews (with 11 patients/carers and 11 health practitioners) conducted in four far north Queensland sites were analyzed using the method of constant comparative analysis. Results: Deficits in registration and recall systems and pain attributed to injections were identified as barriers to secondary prophylaxis uptake. There were also varying perceptions regarding responsibility for ensuring injection delivery. Enablers of secondary prophylaxis uptake included positive patient-healthcare provider relationships, supporting patient autonomy, education of patients, care givers and healthcare providers, and community-based service delivery. Conclusion: The study findings provide insights that may facilitate enhancement of secondary prophylaxis delivery systems and thereby improve uptake of secondary prophylaxis for RF/RHD

Methotrexate in Rheumatoid Arthritis

Over the past few years 'low dose pulse' methotrexate has gained increasing popularity as an effective treatment for refractory rheumatoid arthritis. Methotrexate has been shown to be better than placebo in controlled clinical trials. These studies showed methotrexate to be relatively safe and efficacious with treatment up to six months duration. Methotrexate seems to maintain its anti-rheumatic activity for at least two years, and is well tolerated over long periods of time. However, patients controlled on methotrexate for up to 40 months of continuous therapy have been shown to flare within four weeks of ceasing methotrexate, suggesting that the disease is suppressed rather than eliminated

A liver fibrosis cocktail? Psoriasis, methotrexate and genetic hemochromatosis

BACKGROUND: Pathologists are often faced with the dilemma of whether to recommend continuation of methotrexate therapy for psoriasis within the context of an existing pro-fibrogenic risk factor, in this instance, patients with genetic hemochromatosis. CASE PRESENTATIONS: We describe our experience with two male psoriatic patients (A and B) on long term methotrexate therapy (cumulative dose A = 1.56 gms and B = 7.88 gms) with hetero- (A) and homozygous (B) genetic hemochromatosis. These patients liver function were monitored with routine biochemical profiling; apart from mild perivenular fibrosis in one patient (B), significant liver fibrosis was not identified in either patient with multiple interval percutaneous liver biopsies; in the latter instance this patient (B) had an additional risk factor of partiality to alcohol. CONCLUSION: We conclude that methotrexate therapy is relatively safe in patients with genetic hemochromatosis, with no other risk factor, but caution that the risk of fibrosis be monitored, preferably by non-invasive techniques, or by liver biopsy

The Use of Suppressive Agents for the Treatment of Rheumatoid Arthritis

This paper addresses the issue of slow-acting anti-rheumatic drugs as well as complementary therapies

Novel technology for the measurement of newborn and infant heart rate

© 2017 Ajay KevatBackground: Monitoring heart rate in newborns and infants is crucially important in guiding resuscitation and medical care. Established methods for heart rate assessment of these children have inherent drawbacks. In recent years, novel methods for assessing neonatal and infant heart rate have been developed, with varying levels of evaluation conducted. Digital stethoscopes may provide a better means of heart rate assessment for newborns and infants. Aim: The aim of this thesis was to comprehensively review existing established and novel technologies used to monitor newborn and infant heart rate, and compare new digital stethoscope technology with the gold standard, electrocardiogram (ECG). Methods: This thesis (a) outlines the definition and importance of heart rate in medicine, presented in the context of a review of cardiac anatomy and physiology relevant to understanding this vital sign and aspects of its measurement in neonates and infants; (b) presents a narrative review of established methods for monitoring heart rate; (c) expands the scope of this review from established to emerging methods for monitoring heart rate with a systematic literature review of novel methods for newborn and infant heart rate assessment; (d) describes original research using a prototype digital stethoscope attached to a smart device containing software for detecting and displaying heart rate in real-time that was conducted on infants in the neonatal intensive and special care setting, as well in the delivery room setting using an improved version of the device and software. Results: A review of the literature analysing methods of assessing neonatal and infant heart rate found strengths as well as significant weaknesses in the various methods in clinical use or in development. In the neonatal unit, a prototype digital stethoscope and smartphone device for assessing heart rate had a mean difference (±2 standard deviations) of 7.4 (48.5) beats per minute (bpm) when compared to the gold standard of electrocardiography. The mean (interquartile range) time to first digital stethoscope heart rate display was 4.8 (1 to 7) seconds, and the device failed in 12.3% of use attempts. Repeating the comparison in the delivery room setting using an updated algorithm and new hardware, Bland-Altman analysis revealed a smaller mean difference (±2 standard deviations) between the digital stethoscope and electrocardiography of 0.2 (-18 to +18) bpm including crying periods (Figure 23), and 1.0 (-11 to +12) bpm excluding crying periods. The improved digital stethoscope took a median (interquartile range) of 7 (5 to 11.5) seconds after application to display a heart rate. It failed to detect heart rate in 37% of cases, all of which were in crying infants. Conclusion: A digital stethoscope and smart device with software can rapidly detect neonatal and infant heart rate. In the delivery room, device failure primarily occurred during infant crying, with improved accuracy during non-crying periods