Risk Of Acute Rheumatic Fever Research Articles

The effects of sugar in drinking water on Streptococcus pyogenes colonisation in a murine nasopharyngeal infection model

The number of sugar-sweetened beverages consumed per day has been associated with an increased risk of acute rheumatic fever, an autoimmune disease triggered by superficial Streptococcus pyogenes infection. To explore if there could be a biological basis for this association, we used a mouse model of S. pyogenes nasopharyngeal colonisation combined with a dietary intervention. We observed an increased bacterial load in the nasopharynx of mice receiving sucrose drinking water post-infection, suggesting that high sucrose intake promotes S. pyogenes growth and/or survival. This provides new insight into the potential biological basis behind the association seen in humans.

Changes in the frequency and clinical features of acute rheumatic fever in the COVID-19 era: a retrospective analysis from a single center.

SUMMARYOBJECTIVE:Coronavirus disease 2019 (COVID-19) pandemic resulted in significant changes in the frequency of many diseases. In this study, we aimed to investigate the changes in the frequency and clinical features of acute rheumatic fever (ARF) in this period and determine the effect of health measures taken against COVID-19 on this change.METHODS:The cases with initial attack of ARF between January 2016 and March 2022 in Ataturk University, Division of Pediatric Cardiology, were determined from the clinic’s database, and case per month ratios were calculated for each period, retrospectively. Also the frequency of the clinical manifestations was compared among patients before and during the outbreak.RESULTS:Frequency of the major clinical manifestations among patients before and during the outbreak was similar. On average, the number of cases reported per month in the years 2016, 2017, 2018, and 2019 are, respectively, 1.75, 2, 2.25, and 2.58. In the first 3 months of 2020, the average number of cases reported per month was 3.67. After the advent of the pandemic, in the period from April to December 2020 and from January to September 2021, an average of 0.56 and 0.22 cases were reported per month, respectively. The frequency of clinical features between patients diagnosed before and during the outbreak was similar.CONCLUSIONS:Our results indicated an important decrease in frequency of ARF, but no change in the clinical features of the disease during the COVID-19 pandemic. It is thought that this is the result of health measures taken for COVID-19. Children with an increased risk of acute rheumatic fever should be encouraged in terms of wearing mask, social distance, and cleaning, especially during the seasons when upper respiratory tract infections are common. Thus, a permanent decrease in the incidence of ARF and its recurrences may be achieved.

Roadmap to incorporating group A Streptococcus molecular point-of-care testing for remote Australia: a key activity to eliminate rheumatic heart disease.

Roadmap to incorporating group A Streptococcus molecular point-of-care testing for remote Australia: a key activity to eliminate rheumatic heart disease.

Population pharmacokinetic study of benzathine penicillin G administration in Indigenous children and young adults with rheumatic heart disease in the Northern Territory, Australia.

Benzathine penicillin G (BPG) is the cornerstone of secondary prophylaxis to prevent Streptococcus pyogenes infections, which precede acute rheumatic fever (ARF). The paucity of pharmacokinetic (PK) data from children and adolescents from populations at the highest risk of ARF and rheumatic heart disease (RHD) poses a challenge for determining the optimal dosing and frequency of injections and undermines efforts to develop improved regimens. We conducted a 6 month longitudinal PK study of young people receiving BPG for secondary prophylaxis. Throat and skin swabs were collected for microbiological culture along with dried blood spot (DBS) samples for penicillin concentrations. DBSs were assayed using LC-MS/MS. Penicillin concentration datasets were analysed using non-linear mixed-effects modelling and simulations performed using published BMI-for-age and weight-for-age data. Nineteen participants provided 75 throat swabs, 3 skin swabs and 216 penicillin samples. Throat cultures grew group C and G Streptococcus. Despite no participant maintaining penicillin concentration >20 ng/mL between doses, there were no S. pyogenes throat infections and no ARF. The median (range) observed durations >20 ng/mL for the low- and high-BMI groups were 14.5 (11.0-24.25) and 15.0 (7.5-18.25) days, respectively. Few patients at highest risk of ARF/RHD receiving BPG for secondary prophylaxis maintain penicillin concentrations above the target of 20 ng/mL beyond 2 weeks during each monthly dosing interval. These PK data suggest that some high-risk individuals may get inadequate protection from every 4 week dosing. Future research should explore this gap in knowledge and PK differences between different populations to inform future dosing schedules.

Seasonal variations and risk factors of Streptococcus pyogenes infection: a multicenter research network study.

Background:Streptococcus pyogenes, or Group A Streptococcus (GAS), causes acute pharyngitis and necrotizing fasciitis. Seasonal variations in GAS infections are not robustly characterized. We assessed seasonal variations and risk factors of GAS pharyngitis and ICD-10-diagnosed necrotizing fasciitis.Methods:From the period 2010–2019, we conducted a case–control study using laboratory-confirmed cases of GAS pharyngitis and a descriptive observational study of necrotizing fasciitis using ICD-10 codes. Data were collected from TriNetX, a federated research network. We extracted seasonal (quarterly) incidence rates. We used an autoregressive integrated moving average (ARIMA) model to assess seasonal variations. Demographic characteristics and 1-month outcomes were compared among adults with or without GAS pharyngitis.Results:We identified 224,471 adults with GAS pharyngitis (test-positive) and 546,142 adults without it (test-negative). GAS pharyngitis adults were younger (25.3 versus 30.2 years of age, p < 0.0001), more likely to be Hispanic individuals (10% versus 8%, p < 0.0001) and slightly more likely to be Black or African American individuals (14% versus 13%, p < 0.0001). Propensity score matching found that adults with test-positive cases of GAS pharyngitis had a higher risk of acute rheumatic fever while having no significant differences in risk of intensive care unit admission and mortality compared with test-negative cases. GAS pharyngitis average incidence peaked in the winter while dipping in the summer (0.32 versus 0.18 and 4.07 versus 1.78 per 1000 adults and pediatric patients, respectively). Necrotizing fasciitis diagnoses were highest during summer (0.032 per 1000 adults). There was a significant ARIMA seasonal variation in the time series analysis for adult and pediatric GAS pharyngitis (p < 0.0001 and p = 0.014, respectively). Necrotizing fasciitis diagnosis was not associated with seasonal variation (p = 0.861).Conclusion:Peaks in GAS pharyngitis occur in the winter months. ICD code–based necrotizing fasciitis did not show a quarterly seasonal variation.

Population Pharmacokinetic Study of Benzathine Penicillin G Administration in Indigenous Children and Young Adults With Rheumatic Heart Disease in the Northern Territory, Australia

Benzathine penicillin G (BPG) is the cornerstone of secondary prophylaxis to prevent Streptococcus pyogenes infections which precede acute rheumatic fever (ARF). The paucity of pharmacokinetic (PK) data from children and adolescents from populations at the highest risk of ARF and rheumatic heart disease poses a challenge for determining the optimal dosing and frequency of injections and undermines efforts to develop improved regimens.

Prevalence and predicting factors of Group A beta-hemolytic Streptococcus carrier state in primary schoolchildren.

Introduction:Transmission of Group A Streptococcus from asymptomatic children to their surrounding carries a risk of acute rheumatic fever in susceptible people.Aim and Objectives:We aimed to investigate the prevalence and predictors of GAS carrier state and evaluate the antibiotic sensitivity pattern of GAS in Jakarta, Indonesia.Material and Methods:We enrolled 201 asymptomatic schoolchildren (6–12 years) using stratified random sampling from a primary school in Jakarta. None of the children had a history of rheumatic fever or rheumatic heart disease. All participants underwent physical examination, and laboratory tests include complete blood count, erythrocyte sedimentation rate, C-reactive protein, antistreptolysin O titer, and throat swab culture.Results:The prevalence of GAS carrier was 13.9% (95% confidence interval: 9.2%–18.6%) in our study. On multivariate analysis, tonsillar enlargement was found to be the only predicting factor of GAS carrier (P = 0.03). GAS was sensitive to penicillin G, erythromycin, vancomycin, clindamycin, chloramphenicol, azithromycin, and tetracycline in 100%, 89%, 86%, 75%, 68%, 68%, and 32% of patients, respectively.Conclusion:The GAS carrier state is common among school-age children affecting approximately 13.9% children. Tonsillar enlargement is a significant finding predictive of GAS carrier state. All isolates are still sensitive to penicillin and mostly sensitive to erythromycin but are increasingly resistant to tetracycline.

The Utility of Rapid Group A Streptococcus Molecular Testing Compared with Throat Culture for the Diagnosis of Group A Streptococcal Pharyngitis in a High-Incidence Rheumatic Fever Population.

Group A streptococcus (GAS) causes significant morbidity and mortality in New Zealand and is responsible for invasive disease and immune sequelae, including acute rheumatic fever (ARF). Early treatment of GAS pharyngitis reduces the risk of ARF. In settings with a high burden of GAS disease, a rapid GAS pharyngitis diagnostic test with a strong negative predictive value is needed to enable prompt and accurate treatment. This prospective study compares the Xpert Xpress Strep A molecular test (Cepheid) to throat culture and a second molecular method, the BioGX group A streptococcus-open system reagent (OSR) for BD Max for the diagnosis of GAS pharyngitis. Throat swabs were collected from the emergency department and wards of Middlemore Hospital, New Zealand. The BioGX group A streptococcus OSR for BD Max contributes to the composite gold standard of throat culture or both molecular methods positive. Basic demographic, clinical, and laboratory data were collected. Two hundred five out of two hundred fourteen swabs were suitable for analysis. Of those, 28/205 (13.7%) were GAS culture positive, 45/205 (22%) Xpert Xpress Strep A positive, and 38/205 (18.5%) BioGX positive. Compared to culture, the sensitivity, specificity, and positive and negative predictive values of the Xpert Xpress Strep A molecular test were 100%, 90.4%, 62.2%, and 100%, respectively. Compared to the composite gold standard, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 100%, 95.8%, 84.4%, and 100%, respectively. Seventeen samples were Xpert Xpress positive but culture negative; 6 of these 17 swabs represent true positives with evidence of recent GAS infection. Ten samples were culture negative but both Xpert Xpress and BioGX positive. The Xpert Xpress Strep A molecular test is highly sensitive with a strong negative predictive value and rapid turnaround time. It can be safely introduced as a first-line test for throat swabs in a high-incidence ARF population.

Primary prevention of acute rheumatic fever.

Acute rheumatic fever (ARF) is an abnormal immune reaction following Streptococcus pyogenes (Strep A) infection of the throat, and likely the skin. Primary prevention is the prompt and appropriate antibiotic treatment of StrepA infection, and it can reduce the risk of developing ARF and subsequent rheumatic heart disease. This article explores current recommendations for primary prevention of ARF in Australia. People at increased risk of ARF should beoffered empirical antibiotic treatment of Strep A infections to reduce this risk. People at increased ARF risk include young Aboriginal and Torres Strait Islander people in remote Australia as well as those with a personal or family history of ARF and people from migrant communities in urban areas, including Māori and Pacific Island people. Risk-stratified primary prevention can reduce the inequitable burden of ARF and rheumatic heart disease in Australia.

Sudden Cardiac Arrest in an American Indian Infant

Sudden Cardiac Arrest in an American Indian Infant

Analysis of knowledge about acute granular pharyngitis among Tiruchirapalli school children and their parents: connotation for preventing further complications

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Identification and appropriate treatment for the streptococcal pharyngitis decreases the risk of acute rheumatic fever and rheumatic heart disease. By understanding the public perceptions and behaviors related to sore throat is considered as the fundamental for disseminating the health programs to control such diseases. The main objective of this study is to understand the epidemiology and microbiology of acute granular pharyngitis and its treatment in a tertiary care teaching hospital of South India.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This is a prospective and cross-sectional investigation performed by direct interview and written surveys. In this study, school students and their parents were interviewed about the history of sore throats in the last 12 months and treatment received. A focused history and physical examination to detect pharyngitis was conducted and children were referred for follow-up as indicated. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; A total of 1550 and 1450 students from 13 and 14 schools participated in the study respectively, along with their parents. Three hundred and thirty six (21.6%) parents reported their child had at least one episode of sore throat in the previous year, and 326 (21%) of students reported at least one sore throat in the same time period.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Girls were reported to have high level of pharyngitis than boys. Parents have variable knowledge about the frequency of sore throat in their children and its management. These results provide insight into current perceptions and practices related to sore throat and will be used to design public awareness activities aimed at reducing the future risks.&lt;/p&gt;

Public health and economic perspectives on acute rheumatic fever and rheumatic heart disease.

Public health and economic perspectives on acute rheumatic fever and rheumatic heart disease.

Contemporary Australian Profile of Rheumatic Fever: Results From Multiple Jurisdictions

Introduction: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) rates among Indigenous Australian communities are among the highest globally, yet no national reliable data exist on the burden. We aim to provide the first quasi-national description of ARF in Australia. Methods: Northern Territory (NT), Queensland, Western Australia and South Australia residents (NSW data forthcoming) with a diagnosis of ARF were identified from person-linked jurisdiction-specific in-patient hospital (ICD codes I00–I02) and ARF register data 2015–2017. ARF records were categorised into 3-month episodes. First-ever ARF was determined through interrogation of register/hospitalisation ARF/RHD dates and by applying a 13.5-year look-back period to hospital data. Age-specific (10-year age groups, 0–54 years), age-standardised first-ever and total ARF incidence rates were calculated by Indigenous status, and sex, with incident rate ratios (IRR) used for comparison across sub-populations. Recurrences per person-years were calculated for first-ever cases. Results: 1401 episodes (91% Indigenous, 55% female, 82% first-ever) pertaining to 1297 people were identified, predominantly from NT (56%) and Queensland (28%). First-ever incidence rates peaked at 5–14 years (46/100,000) and 15–24 years (19/100,000). Compared with non-Indigenous, Indigenous age-standardised first-ever rates (0–54 years) were significantly higher (IRR(all) = 113.7; IRR(females) = 137.7; IRR(males) = 90.8). Total IRRs were even higher. Recurrence rates were highest among females, people aged 5–14 years and NT residents. Conclusion: These findings confirm the unacceptably high risk of ARF among Indigenous Australians. The study provides the first incidence data using integrated/linked data from registers and hospitals, providing a comprehensive baseline from which to assess much-needed multi-sectoral policies to end ARF/RHD in Australia.

Effect of Oral Probiotic Streptococcus salivarius K12 on Group A Streptococcus Pharyngitis: A Pragmatic Trial in Schools.

The aim of this study was to examine effectiveness of oral probiotic Streptococcus salivarius K12 in preventing group A streptococcus pharyngitis in 5- to 14-year-old children at high risk of acute rheumatic fever. New Zealand has high rates of acute rheumatic fever among Māori and Pacific children. Children were already enrolled in a school-based Ministry of Health throat swabbing and treatment program. Children self-identified and reported sore throats daily and were swabbed twice weekly. A total of 1314 children were quasirandomized (based on odd or even birthdates) to receive either K12 (2.5 × 10(9) cfu per lozenge) or placebo lozenges and continued observed daily treatment (in the school week, during school time) for one school year. A total of 801 children (61.0%) reported a sore throat on one or more occasions resulting in 2927 pharyngeal swabs. Of these swabs, 1525 (52.1%) were taken from 411 children receiving K12 and 119 (7.8%) of these were positive for group A streptococcus on routine culture. In addition, 1402 (47.8%) swabs were taken from 390 children receiving placebo and 124 (8.8%) were positive. Overall there was a nonsignificant 11.2% relative reduction in positive swabs among children receiving K12. This relative reduction was greater for older children, 7-9 years of age, 15.6%, and for children 10 years and older, 30.2%. S. salivarius K12 had modest nonsignificant effects on culture-positive sore throats when given at school, during the school day. Based on our pragmatic trial, the routine use of this probiotic in the prevention of pharyngitis associated with GAS detection is not supported.

A repeat audit of primary care management of group A streptococcal pharyngitis in Northland, New Zealand 2016

INTRODUCTION One of the New Zealand Government's Better Public Services targets was to reduce the rate of acute rheumatic fever (ARF) nationally by two-thirds by 2017. Māori children and young people are disproportionately affected by ARF in the Northland District Health Board region. General practice contributes to ARF prevention in detecting and appropriately treating group A streptococcal (GAS) pharyngitis. An audit in 2012 suggested improvements in adherence to national guidelines were needed. AIM The aim was to reassess general practice adherence to national guidelines for the management of GAS pharyngitis in Northland, New Zealand, following implementation of the national Rheumatic Fever Prevention Programme. METHODS Throat swab and dispensing data were obtained and analysed for children and young people aged 3-20 years who attended general practice in Northland between 1 April and 31 July 2016 and had laboratory-proven GAS pharyngitis. RESULTS Between 2012 and 2016, the number of throat swabs carried out in general practice more than doubled, and amoxicillin was more commonly prescribed. The proportion of GAS pharyngitis patients in general practice not receiving recommended antibiotics, or receiving an inadequate length of treatment or no prescription, has not reduced. There are significant differences in the management of care for Māori and non-Māori patients, with much higher risk of ARF for Māori. Discussion The management of GAS pharyngitis by general practice in Northland remains substandard. Implicit bias may contribute to inequity. Focused engagement with identified subgroups of general practices and practitioners who disproportionately contribute to non-guideline prescribing should be further investigated.

Epidemiology of pharyngitis as reported by Zambian school children and their families: implications for demand-side interventions to prevent rheumatic heart disease

BackgroundPrompt and appropriate treatment of streptococcal pharyngitis decreases the risk of acute rheumatic fever and rheumatic heart disease (RHD). Understanding public perceptions and behaviors related to sore throat is fundamental to inform health programs aimed at eliminating new cases of RHD in endemic regions. We sought to describe the epidemiology of pediatric pharyngitis and its treatment, as reported by children and their parents or guardians in Lusaka, Zambia.MethodsThis was a cross-sectional investigation using interviews and written surveys, nested in a school-based RHD prevalence study. Students and their parents were asked to report number of sore throats in the previous 12 months, treatment received, and type and place of treatment. A focused history and physical examination to detect pharyngitis was conducted and children were referred for follow-up as indicated.ResultsA total of 3462 students from 47 schools participated in the study, along with their parents or guardians. Six hundred and fifty eight (19%) parents/guardians reported their child had at least one sore throat in the previous year, and 835 (24%) of students reported at least one sore throat in the same time period. Girls were reported to have pharyngitis 50% more often than boys, and also made up two-thirds of the total students treated. Approximately two-thirds of children who had at least one episode of pharyngitis during the previous year were also reported to have received some form of treatment. The majority of treatments were received in government clinics (36.6%) and at home (26.3%). Half of treatments included an antibiotic. Nineteen students (0.5%) had clinically-apparent pharyngitis at screening.ConclusionPharyngitis is common among school-aged children and adolescents in Zambia, with females reporting significantly more sore throat episodes than males. Parents/guardians have variable knowledge about the frequency of sore throat in their children, and management of pharyngitis may be suboptimal for many children since more than a quarter were reported to have received treatment without skilled assessment. These results provide insight into current perceptions and practices related to sore throat in Zambia and will be used to design public awareness activities aimed at reducing RHD.

A Clinical Approach to Tonsillitis, Tonsillar Hypertrophy, and Peritonsillar and Retropharyngeal Abscesses.

1. Risa E. Bochner, MD* 2. Mona Gangar, MD*,† 3. Peter F. Belamarich, MD* 1. *Department of Pediatrics, Children’s Hospital at Montefiore, Bronx, NY 2. †Department of Otorhinolaryngology/Head and Neck Surgery, Division of Pediatric Otorhinolaryngology, Albert Einstein College of Medicine, Bronx, NY * Abbreviations: ALPS: : Autoimmune lymphoproliferative syndrome ARF: : Acute rheumatic fever CMV: : Cytomegalovirus CT: : Computed tomography EBV: : Epstein-Barr virus GAS: : Group A Streptococcus HIV: : Human immunodeficiency virus NSAIDs: : Nonsteroidal anti-inflammatory drugs OSA: : Obstructive sleep apnea PFAPA: : Periodic fever, apthous stomatitis, pharyngitis, and adenitis PSGN: : Poststreptococcal glomerulonephritis PTA: : Peritonsillar abscess RADT: : Rapid antigen detection test SDB: : Sleep-disordered breathing T&A: : Tonsillectomy and adenoidectomy Despite established guidelines for group A Streptococcus pharyngitis diagnosis and treatment, pediatricians are overtreating and mistreating sore throat in children. (1) This results in unnecessary antibiotic use and contributes to antimicrobial resistance, increased health care costs, and risk for adverse drug reactions. In addition, controversy exists among pediatricians regarding the indications for tonsillectomy and adenoidectomy in children. After completing this article, readers should be able to: 1. Describe the clinical presentation, differential diagnosis, diagnostic evaluation, and management of tonsillitis/pharyngitis in pediatric patients. 2. Describe the clinical presentation, diagnostic evaluation, and management of peritonsillar abscess in pediatric patients. 3. Describe the clinical presentation, diagnostic evaluation, and management of retropharyngeal abscess in pediatric patients. 4. Describe the indications for tonsillectomy and adenoidectomy in pediatric patients and associated complications. ### Epidemiology Sore throat is a common complaint in children and adolescents. Most cases of pharyngitis are viral and self-limited. Group A Streptococcus (GAS) pharyngitis is the only commonly occurring infectious pharyngitis in which antimicrobial treatment is indicated. Treatment of GAS decreases the risk of acute rheumatic fever (ARF), suppurative complications and transmission of disease, and provides symptomatic relief. GAS pharyngitis accounts for 20%-30% of office visits for sore throats in children. (2) Infection typically occurs in school-age children and adolescents, and is uncommon in children younger than 3 years. GAS pharyngitis occurs most commonly in the winter and early spring months …

Estimating the risk of acute rheumatic fever in New Zealand by age, ethnicity and deprivation.

In New Zealand, efforts to control acute rheumatic fever (ARF) and its sequelae have focused on school-age children in the poorest socioeconomic areas; however, it is unclear whether this approach is optimal given the strong association with demographic risk factors other than deprivation, especially ethnicity. The aim of this study was to estimate the stratum-specific risk of ARF by key sociodemographic characteristics. We used hospitalization and disease notification data to identify new cases of ARF between 2010 and 2013, and used population count data from the 2013 New Zealand Census as our denominator. Poisson logistic regression methods were used to estimate stratum-specific risk of ARF development. The likelihood of ARF development varied considerably by age, ethnicity and deprivation strata: while risk was greatest in Māori and Pacific children aged 10-14 years residing in the most extreme deprivation, both of these ethnic groups experienced elevated risk across a wide age range and across deprivation levels. Interventions that target populations based on deprivation will include the highest-risk strata, but they will also (a) include groups with very low risk of ARF, such as non-Māori/non-Pacific children; and (b) exclude groups with moderate risk of ARF, such as Māori and Pacific individuals living outside high deprivation areas.

Are minor echocardiographic changes associated with an increased risk of acute rheumatic fever or progression to rheumatic heart disease?

BackgroundThe World Heart Federation criteria for the echocardiographic diagnosis of rheumatic heart disease (RHD) include a category “Borderline” RHD which may represent the earliest evidence of RHD. We aimed to determine the significance of minor heart valve abnormalities, including Borderline RHD, in predicting the future risk of acute rheumatic fever (ARF) or RHD. MethodsA prospective cohort study of Aboriginal and Torres Strait Islander children aged 8 to 18years was conducted. Cases comprised children with Borderline RHD or other minor non-specific valvular abnormalities (NSVAs) detected on prior echocardiography. Controls were children with a prior normal echocardiogram. Participants underwent a follow-up echocardiogram 2.5 to 5years later to assess for progression of valvular changes and development of Definite RHD. Interval diagnoses of ARF were ascertained. ResultsThere were 442 participants. Cases with Borderline RHD were at significantly greater risk of ARF (incidence rate ratio 8.8, 95% CI 1.4–53.8) and any echocardiographic progression of valve lesions (relative risk 8.19, 95% CI 2.43–27.53) than their Matched Controls. Cases with Borderline RHD were at increased risk of progression to Definite RHD (1 in 6 progressed) as were Cases with NSVAs (1 in 10 progressed). ConclusionsChildren with Borderline RHD had an increased risk of ARF, progression of valvular lesions, and development of Definite RHD. These findings provide support for considering secondary antibiotic prophylaxis or ongoing surveillance echocardiography in high-risk children with Borderline RHD.

APSC2015-1148 Are Minor Echocardiographic Changes Associated With an Increased Risk of Acute Rheumatic Fever or Progression to Rheumatic Heart Disease?

APSC2015-1148 Are Minor Echocardiographic Changes Associated With an Increased Risk of Acute Rheumatic Fever or Progression to Rheumatic Heart Disease?