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Acute rheumatic fever
Case Study 2
Therapeutic management of Acute rheumatic fever involves three strategies: management
of the attack, current infection, and further attacks and infections. Evidence for the treatment
of acute rheumatic fever using corticosteroids and aspirin were originated from randomized
trials before the use of echocardiography. Today, corticosteroids such as corticotrophin and
intramuscular cortisone are not commonly used in the management of ARF (Coffey et al.,
According to Cochrane review, aspirin, corticosteroids, Prednisone, and immunoglobulin
did not reduce the risks of heart valve attacks as they had no significant difference. There has
been published use of naproxen 13 and methylprednisone 14 to treat acute inflammation in
rheumatic patients (M Kevat et al., 2017). The introduction of penicillin and bed rest to the
patient has also been proposed.
The pharmacotherapeutic measures to prevent ARF recurrence involve the
proper identification and adequate administration of antibiotics for GAS tonsillopharyngitis.
The diagnosis of group A GAS pharyngitis is based on diagnostic results based on the culture
of the throat of the patient. Due to the nature of the patient, from the aboriginal, penicillin is
used as the treatment since it is cost-effective, efficacy, and intense spectrum of activity in
the patient's body (Cilliers & Sadiq, 2021).
Secondary prevention is done to prevent the risk of developing recurrences through
continuous prophylaxis of antimicrobial, which depends on the time since the attack, patient's
age, cardiac assessments, and risks for GAS infection (Cilliers & Sadiq, 2021).
Maternal safety and efficacy and risks to the foetus through anticoagulation
therapy have to be considered during pregnancy. When vitamin K crosses the placenta, it can
cause pregnancy loss, deficits in neurodevelopment and fetal bleeding, and teratogenicity.
The risk of embryopathy warfarin can be reduced by discontinuation of vitamin K antagonists
before week 6 of pregnancy (James et al., 2017). Clinical trials for direct oral thrombin and
Xa inhibitors such as rivaroxaban, edoxaban, apixaban, and dabigatran were excluded
because they are likely to cross over to the placenta their risks in the reproductive health are
Reports have shown successful use of fondaparinux in pregnant women because they
cross to the placenta in small quantities, which involve later exposure in the second trimester
of pregnancy. For the risk-benefit approach, LMWH, UFH, and danaparoid are used because
they are safe for the foetus and do not cross the placenta. For thromboembolism prevention
and treatment, unfractionated heparin UFH is used during pregnancy. Women using low
molecular weight heparin have lower risks for bleeding incidences, osteoporosis, and
complications as it is safer compared to UFH. LMWHs are primarily eliminated by excretion
of the renal system but may accumulate in pregnant women with renal dysfunction. This
treatment is not recommended for nonpregnant women with renal impairment based on the
glomerular filtrate, which should significantly not be lower than 30ml/min. In renal impaired
patients, the accumulation of LMWH differs according to the type according to different
research results. The consensus among the reviewed documents shows that the preferred
anticoagulant for treatment and management of VTE in pregnant women is LMWH.
In clinics, women on long-term receipt of vitamin K antagonist therapy and oral
anticoagulants have to be advised by the physicians about the risks of the medication of fetus
before the occurrence of pregnancy to ensure proper management of the fetal risks. For renal
dysfunction patients, UFH is preferred.
To reduce the risks of warfarin embryopathy, women must be advised to perform regular
pregnancy tests by substituting with LMWH during the first six weeks of pregnancy. UFH
and LMWH have to substitute vitamin K antagonists before the achievement of pregnancy to
reduce risks of miscarriage but increase the cost of heparin therapy injections (James et al.,
2017). Warfarin embryopathy occurs due to exposure after six weeks of pregnancy.
Therefore, women on long-term Xa inhibitor therapy must be swapped with LMWH
immediately after confirmed pregnancy to minimize the embryopathy risks.
Atrial fibrillation is an electrical disease of the heart's upper chambers. It increases risks
for other disorders and risks of the heart, such as stroke. This makes the heart have many
heartbeats, up to hundreds every minute. which interfere with the contraction of the atria in
the plumbing of blood. In case the patient undergoes surgery, AF causes heart surgery
complications. If untreated, it causes hypertension which eventually may lead to more severe
and risky complications (Knight et al., 2019).
This leads to decreased plumbing blood, leading to a pool with the heart due to the
passive flow of blood. In some patients, it has no symptoms, while in others, there is a wide
range of symptoms. Like for the patient, there was an increased heartbeat, blood pressure, and
difficulty in breathing due to AF. It puts the patient at increased risk of exposure to extra
heart disorders and affected rhythm. It might resolve or be permanent depending on the
patient (Knight et al., 2019). Complications involve the early warnings of stroke, including
blurred vision and headaches, of which the risk increases with the increased age of the
patient. Other risks of AF are heart problems, high blood pressure, and diabetes of which
were reported from the patient's data.
To control the risks by lowering them, blood thinners and change of lifestyles such as
healthy weight, regular exercise, and low salt diet to reduce hypertension help a lot.
The leading cause of postmenopause osteoporosis is estrogen deficiency, the
primary cause of bone metabolic diseases. For treatment, hormone replacement therapy, HRT
is used to preserve the mineral density of the bones.STEAR treats symptoms of vasomotor,
osteoporosis, and vaginal atrophy as HRT. SERMs like bazedoxifene and raloxifene maintain
bone mineral density, therefore, reducing osteoarthritis fracture risks (Stavroglou et al.,
2020). Women above the age of 50 of aboriginal descent can be affected with
postmenopausal osteoporosis and fractures. The food and drug administration, FDA has
recommended HRT as the best treatment of osteoporosis based on evidence of data collected
on menopause communities. According to the recent view and recommendations from the
regulatory agencies, HRT usage has to be revised because evidence has shown that the
appropriate dose has to be individualized (Stavroglou et al., 2020). The risk-benefit approach
is only successful if the caregiver can discuss with the individual patients. Results have
shown more significant HRT results in the treatment and prevention of post and
perimenopausal osteoporosis through strong protective effects.
The result shows that the z score is 1.2 standard deviations below the mean of the average
population. This result shows that the aboriginal population has a high prevalence of Sandy's
problem. Osteoporosis is a skeletal disease that involves an increase of fracture risks and
reduced bone strength, leading to high morbidity, mortality, and increased healthcare costs,
which the aboriginal communities can not achieve. Bisphosphonates are used to treat
osteoporosis, of which studies have indicated a reduction in fracture risks in women in
postmenopause with more excellent safety records. The challenges of using bisphosphonates
involve the appropriate therapy for patients, monitoring of the therapy, drug discontinuation,
disputed effects of medication, fear, and management of possible side effects.
To manage osteoporosis, the affordability, past drug experience, preferences of
the patient, and consideration of available information are required to achieve the risk-benefit
approach for biphosphonates usage on the treatment of osteoporosis. Patients with kidney
disease with glomerular filtration of less than 30ml/ min have less safety and efficacy of the
biophosphonates profile as the label advises against the usage. For these patients, limited
sources have indicated effective and safe usage of bisphosphonates as chronic stage 4 are
prohibited against its usage. In stage 5 patients, no labels have indicated the safety and
effectiveness of the usage of bisphosphonates on osteoporosis treatment; therefore, referral to
specialist physicians is to be considered.
In old patients, the antifructure effect of bisphosphonates is limited because a limited
number of older patients were used in the research trials. This group only focuses on post
hoc, which is considered safe and effective in controlling fall risks by ensuring muscle
strengthening, balance training, reduction of sedation exposure, hypertension, and
Coffey, P. M., Ralph, A. P., & Krause, V. L. (2018). The role of social determinants of health
in the risk and prevention of group A streptococcal infection, acute rheumatic fever and
rheumatic heart disease: a systematic review. PLoS neglected tropical diseases, 12(6),
M Kevat, P., M Reeves, B., R Ruben, A., & Gunnarsson, R. (2017). Adherence to Secondary
Prophylaxis for Acute Rheumatic Fever and Rheumatic Heart Disease: A Systematic Review.
Current cardiology reviews, 13(2), 155-166.
Cilliers, A., & Sadiq, M. (2021). Management of Acute Rheumatic Fever. In Acute
Rheumatic Fever and Rheumatic Heart Disease (pp. 55-67). Elsevier
James, A. H., Bates, S. M., Bauer, K. A., Branch, W., Mann, K., Paidas, M., ... & Konkle, B.
A. (2017). Management of hereditary antithrombin deficiency in pregnancy. Thrombosis
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Georgiopoulos, G., Tsiachris, D., Kordalis, A., Kontogiannis, C., Spartalis, M., Pietri, P., ...
& Stefanadis, C. (2019). Pharmacotherapeutic strategies for atrial fibrillation in
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Knight, B. P., Novak, P. G., Sangrigoli, R., Champagne, J., Dubuc, M., Adler, S. W., ... &
Mansour, M. (2019). Long-term outcomes after ablation for paroxysmal atrial fibrillation
using the second-generation cryoballoon: final results from STOP AF post-approval
study. JACC: Clinical Electrophysiology, 5(3), 306-314.
Stavroglou, A., Tsikouras, P., Grapsa, A., Trypsiannis, G., Both, A., Anthoulaki, X., ... &
Tsaroucha, A. (2020). The Contribution of Hormone Replacement Therapy in
Postmenopausal Women to Prevent Periodontal Disease. Journal of Women's Health and
Development, 3(2), 135-147. https://www.fortuneonline.org/articles/the-contribution-ofhormone-replacement-therapy-in-postmenopausal-women-to-prevent-periodontaldisease.html?url=the-contribution-of-hormone-replacement-therapy-in-postmenopausalwomen-to-prevent-periodontal-disease
Eastell, R., Rosen, C. J., Black, D. M., Cheung, A. M., Murad, M. H., & Shoback, D. (2019).
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