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Rheumatic fever is still one of the major public health problems in Egypt and the developing countries. It is characterized by a high tendency to recur following streptococcal infections. The use of long acting penicillin for prophylaxis against strep infections was a good achievement in this field, yet, recurrences have been reported in patients following monthly prophylactic programs. Clinical experience in Alexandria have shown for a long time that giving penicillin every 2 weeks is followed by less recurrences of rheumatic fever. Recently, reports came showing that effective penicillin levels are not maintained except for 2 to 3 weeks after the injection. In the present study, we compared two regimens of prophylaxis with 190 patients in the 2-weekly regimen, and 170 patients in the 4-weekly regimen being followed up for 2 consecutive years. Two hundred and sixty nine streptococcal infections occurred during this period. Although the streptococcal infection rate was equal in both groups, the rheumatic fever recurrence rate and the RF attack rate were significantly higher in the group of patients on the 4-weekly schedule. The results of this study have shown the superiority of the 2-weekly schedule in the adequate control of RF recurrences. We suggest that this schedule should be implemented for secondary prophylaxis of rheumatic fever in Egypt and other areas with severe RF.

To determine the effect of ventricular function, size of ventricular septal defect (VSD), and endocrine function on linear growth in children with VSD, we studied 88 children with VSD over a period of 1 year. Growth was assessed by determining the height standard deviation scores (HtSDS) and growth velocity (GV) every 4 months. Two hundred age-matched normal children served as controls for the growth data. Endocrine evaluation was performed in 30 randomly selected children with VSD, and 20 age-matched children with constitutional delay of growth (CSS). Growth hormone (GH) response to clonidine provocation was evaluated and circulating free thyroxine (FT4) and insulin-like growth factor-I (IGF-I) concentrations measured. Echocardiographic evaluation of the different cardiac parameters including shunt size and shunt fraction (Qp/Qs) was performed using a colour-coded echodoppler. The HtSDS, body mass index (BMI), and mid-arm circumference (MAC) of children with VSD were significantly decreased compared to those for the normal control group. The dietary intake evaluated by the recall method, appeared to be adequate in the majority of these children (83/88). IGF-I concentrations were reduced in children with VSD (87.5 +/- 29 ng/ml) versus normal age-matched children (169 +/- 42 ng/ml). Basal and clonidine-stimulated GH concentrations were significantly higher in children with VSD (4.6 +/- 2.1 microg/l and 28.8 +/- 7.9 microg/l respectively) versus controls (17.8 +/- 4.2 microg/l). In these patients (n = 88) the HtSDS was correlated negatively with the size of the shunt (r = -0.793, p < 0.001), shunt fraction (Qp/Qs) (r = -0.76, p < 0.001), pulmonary mean gradient (r = -0.4, p = 0.006), and pulmonary maximum velocity (r = -0.32, p = 0.02). Growth velocity (GV) was correlated negatively with pulmonary maximum gradient (r = -0.3, p = 0.02), pulmonary maximum velocity (r = -0.37, p = 0.007), and pulmonary stroke volume (Qp) (r = -0.345, p = 0.01). The BMI and IGF-I concentrations were correlated significantly with the size of the shunt (r = -0.453, p < 0.01), Qp/Qs (r = -0.432, p < 0.01), HtSDS (r = 0.565, p < 0.01), and BMI (r = 0.435, p < 0.01). It appears that in patients with VSD, the size of the left-to-right shunt and the abnormal hemodynamics in the pulmonary circulation are important factors in the etiology of impaired growth. It is suggested that the hypermetabolic status of these patients compromise nutrition and this decreases IGF-I synthesis with subsequent slowing of linear growth and weight gain.

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