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Rheumatic Fever, Stroke and Accidents Dr. Pracheth R. Rheumatic Fever • Introduction • Problem Statement • Epidemiological factors • Diagnosis • Prevention Introduction • Febrile disease-connective tissue heart, joints • Initiated by throat infection: Group A Beta Haemolytic Streptococci • Crippling disease • Premature death Problem Statement • World: Developing countries • India: 1 million cases • Streptococcal : 1-3% Agent factors • Agent: preceded by sore throat; Group A: M type 5 • Carriers: high Host and environmental • Age: childhood, adolescence • Initial attack young: valvular lesions • Sex: Equal, prognosis bad: females • Socio-economic status • High risk : slums, closed community, children-5 to 15 years Clinical features • Fever • Polyarthritis: large joints-ankle, knee, elbow, wrist • Carditis: pericardium, myocardium, valves • Tachycardia, murmurs, enlarged heart, heart failure • Nodules: small, painless, non-tender • Brain: abnormal, jerky, purposeless movement • Skin: rash Major manifestations • Carditis • Polyarthritis • Chorea • Erythema marginatum • Subcutaneous nodules Minor manifestations • Clinical: fever, polyarthralgia • Elevated ESR, leukocyte count Supporting evidence (45 days) • ECG: prolonged PR interval • Elevated ASO antibody • Positive throat culture • Rapid antigen test: Group A streptococci Definitions • Primary RF: two major or one major and two minor + Group A streptococcal infection • Established rheumatic heart disease: two minor + Group A streptococcal infection Primary prevention • Identify streptococcal infection: treat penicillin • Not feasible • Concentrate: high risk-school children • Swab not there: directly treat • 1.2 million benzyl penicillin: adults • 600,000 units: children • Single injection • Oral penicillin: 10 days Secondary prevention • More practical • Identify those having RF • One IM injection: Benzathine Benzyl Penicillin at interval of 3 weeks • At least 5 years/18 years of age-later • Carditis: 10 years/25 years- longer • Severe valvular disease: life-long treatment • One problem: patient compliance Non-medical measures • Improve living conditions • Socio-economic conditions Evaluation • Survey school children • Find out prevalence Stroke • Definitions • Problem statement • Epidemiology • Control Definition • Rapidly developed clinical signs of focal disturbance, neurological functions • More than 24 hours • No apparent cause other than vascular Problem statement • 6.1 million worldwide deaths,10.8% of all deaths • Highest risk of death: first few weeks • Survive: disability • India: comparatively less • Younger adults • Rheumatic Heart Disease • Ischaemic Stroke • CNS infections: bacterial, TB meningitis • 1.54 cases/1,000 Risk factors • Hypertension: cerebral thrombosis, haemorrhage • Other factors: Cardiac abnormalities: left ventricular hypertrophy, cardiac dilation Diabetes, dyslipidemia Obesity Smoking OCPs. Transient Ischaemic Attack • Focal, reversible, neurological deficit • Sudden onset • Less than 24 hours • Tend to recur • Warning sign of stroke Host factors • Age: Rises with age India: 1/5th below 40 years • Gender: Males>females • Personal history: CVD/diabetes Control • Tissue Plasminogen Activator IV • Address risk factors • NPCDCS Accidents • Definition • Problem statement • Epidemiology • Prevention • Domestic accidents Definition • Unexpected, unplanned occurrence-injury • WHO: unpremeditated event: recognizable damage Problem Statement • World: 4th leading cause • India: Mechanization, awareness, poor implementation- safety Road Traffic Accidents • 1.3 million deaths-world, higher: young age • Half: vulnerable road users • 90% deaths: low, middle income countries • India: 4.4 lakh accidents, 22.4% : two wheelers Human factors • Age, sex, education • Medical conditions • Fatigue • Psychosocial: Lack experience, risk taking, impulsiveness Defective judgement, delay : decision, aggressiveness • Lack of body protection Helmets, safety belts Environmental factors • Road: Defective, narrow roads Defective lay-out: cross-roads Poor lighting, lack of familiarity • Vehicle: Excessive speed, old vehicles, large number, overloaded • Bad weather • Mixed traffic ( slow, fast moving, pedestrians, animals) Human Environmental Prevention • Data collection: Basic reporting system Studies: risk factors, circumstances, chain of events Police: investigate Without: implementation not effective • Safety education Prevention • Promote safety measures: Seat belts, helmets Leather boots: protect lower legs Children: front seat ? Door locks, proper vehicle design • Alcohol: 50-80mg/100 ml. Prevention • Primary care: Emergency care: accident site, transport, hospital Accident Services Organization Trauma care hospitals • Eliminate causative factors: Improve roads, speed limits, provision of fire guards, marking danger points Prevention • Law enforcement: Driving tests, medical fitness, enforce speed limits, seat belt, helmets, check blood alcohol conc, road side breath test, periodic re-examination - over 55 • Rehabilitation services: • Accident research: Accidentology Drowning • Respiratory impairment from submersion/ immersion of • • • • liquid 306,000 people died: drowning Numbers exclude floods, boating, water transport mishaps 3rd leading cause of unintentional injury India : 43% of world’s drowning deaths Risk factors • Age: under 5 years • Gender: males> females • Access to water: fishing • Others: infants unsupervised, unsafe/overcrowded transport, alcohol use, unfamiliar with local water risks Prevention • Engineering methods to remove hazard • Legislation to enforce prevention • Education: individuals, communities • Laws, regulations: safety checks transport, alcohol Burns • Definition: Injury to skin/ organic tissue: caused by heat, radiation, electricity, friction or contact with chemicals • Problem: Majority: low, middle income countries, • Half: South East Asia Risk factors • Gender: females • Age: children • Socio-economic: low, middle income • Other: occupations-exposure to fire, poverty, overcrowding, medical conditions: epilepsy, alcohol, smoking, inadequate safety measures for LPG Prevention • Address hazards for specific burn injuries, education: vulnerable populations, train: first aid • First aid: Do’s Remove clothes, irrigate burns Use cool running water: reduce temperature of burns Roll on ground, blanket Wrap in clean cloth/ sheet Don’t’s • Don’t start before ensure your safety • Don’t apply: paste, oil, haldi • No ice • Not open blisters • Not apply any matter directly to wound • Avoid prolonged cooling with water. Falls • 424,000 fatal falls: every year. 2nd leading cause – unintentional injuries after road traffic • Over 80%: low, middle income countries • Risk factors: Occupations at elevated heights Alcohol/substance use Socio-economic factors Underlying medical conditions: neurological/cardiac Unsafe environment Prevention • Screen living environment: risk of falls • Address clinical factors • Environmental modification of homes • Assistive devices: physical impairments • Muscle strengthening/ balance training • Education Poisoning • 252,000 deaths • India: 28,012 deaths • Accidental ingestion of kerosene Snake bite • Neglected issue • Outcome: depends on species , area of body bitten, amount of venom injected, health condition of victim • Neurotoxic: respiratory paralysis • Cytolytic: tissue destruction by digestion, haemorrhage due to heamolysis First aid • National Snake Bite Protocol, 2007 Reassure Immobilize like fractured limb Remove clothes : constrict bitten limbs Do not incise / manipulate bitten site Transport to medical facility Antivenom: IV, works by binding and neutralizing venom enzymes Questions • Epidemiology and prevention of accidents (6 marks) • Domestic accidents (3 marks) • Prevention of rheumatic fever (3 marks) • Stroke in young (3 marks) • Risk factors for stroke (3 marks) Summary THANKS