Five and ten year follow-up study of rheumatic patients

Five and Ten Year

Follow-up

Rheumatic

Patients

Role of Climate MILTUN

s. SASLAW,

M.D..

I:.-z.c.c:., F.

Study

of

and Environment*

A.

HERNANDEZ,

HAZEL ELLEN

~I.D., P.A.(:.(:., and

RANDOLPH, M.A. Miami,

C

and

LIMATE

environment

roles in influencing

currence outcome

of rheumatic

tropical ried

fever.

the recurrence

in Miami,

Florida, and

out

long-term

This

study

vironmental

conditions

specially

these

can

to any other heart

information

five years prior to June, (90.2

Special

disease. more

patients

National

Children’s

subjects

supplementary

were the

rates

death

mum of four months, nosis of rheumatic * From

the

fever

Department of

the arm)-,

in

infor-

in which various work, emotional

forth,

current

were

living

in the

in the

outpatient

nursing

were

area

clinic

Cardiac

contacts

Those

Miami

Others were checked

Often

cardiac

posed.

of

Hospital, by private established

or social service units.

school,

thus

neighbor,

encountered

different

from

out in other

and so on. obstacles

similar

areas,

that

The were

investigations

where

the popula-

tion is relati\,rl>, stable.

the

Miami, KESULTS

The group

Research,

of our investigations

I and II.

of patients

are listed

Data are presented followed

heart National 7.54

for the

for over ten years,

for five to ten years, and for the combined The tion

the diag-

or rheumatic

findings

in Tables

from those children Hospital for a mini-

Mrdical

on 92 of whom

accumulated

Children’s

county

carried

and in whom

1956,

were

Man)- types of follo\v-up leads had to be used-m

were contacted to determine their Florida, current medical, socioeconomic, and educational The present investigation is confined status. to information collected \vho had resided at the

National

slightly

Hospita!,

discharged

schooling,

were

re-examined

studies

in

children

recurrences,

so

who

through

and Iowa findings

and

physicians.

is available

the

102

we have

if they desired.

of recur-

hospitalized

Cardiac

cent)

rheumatic

be considered

regions.

formerly

(2)

on 41

data

forms were devised,

findings,

METHODS All

per

and

1756,

adequate

mation.

with rheumatic

to compare

and tropical

per cent)

designed,

Data from these cities provide the neces-

temperate

(85.4

status,

from Boston, New York, Philadelphia, sary

of whom

employed. and

considered: the hospital

a

on the

damage,

were from

ten or more years prior to June,

cart

to the

patients

collected ;

heart

according

discharged

produce

agents,

treatment

information

of

questions concerning

must

therapeutic

groups

48 children

and en-

in patients

conditions

established

climatic

beneficial

prognosis

as potential

Cit)-.

Two (1)

txen

criteria.’

was car-

for the specific

fever or rheumatic under

rence,

these fac-

and

who had suffered at least one attack

If residence

Similar

How

had

Jones

disease was investigated

surroundings

of rheumatic

disease,

disease

of oc-

an area where the climate is

and operated

of children

favorable

rate

favorable.

in

constructed,

important

the frequency

of rheumatic

tors affect

play

Florida

total.

total number of patient-years of observafollowing discharge from the National

Children’s

Cardiac

Hospital,

THE AMERICAN

Miami, JOURNAL

Florida. OF CARDIOLOGY

Saslavv. TABLE

Hernandez,

and

Randolph ‘TAHLE

I

Vital Statistics on 150 Former Rheumatic Patients of National Children’s Cardiac Hospital, Miami. Florida I’vriod of follow-up studL’ ( years 1

Rhrunlatic

IIrvelopments National

II

in

Children’s

124

‘I‘otal

Numbrr

Number of children reached Number

48

92(90

2%)

j I 19 4

‘150

41 (85.4%o,i133(88.7%)

yrars Out-of-state origin (Iut-of-staw return out-of-state origin Florida residents Florida residents throughout

j48h

21 .o

; 24.2 ~

I

1670

j1156

children study

I4

among

i

4

subjects.

involved

~

0

Hospital

44

10

54

20

12

‘32

21

17

: 38

59

22

81

13

11

: 24 I

13

6

19

’

24.2

)-ears

for the

Heart

for the 39

the

of 1,156

period

133

group,

(88.7

per

of

patient-years,

\-ears per patient.

Of the

This

18 were in the

of 20 months

tion;

in

remaining

is statistically

in

signifi-

minimal

86 children

Chil-

of cardiac

No ph>,sical restriction from

revealed

involvement. demonstrated

Thus, little

disease. was necessary

for 81

while 24 more vvere required competitive

tients, 105 (8.5 per cent) normal lives. Of

examina-

examination

(60 per cent)

or no evidence

ahstain

The average age was 19.4 years for

others,

or questionable

cent).

The

was not found in .54 patients

at the time of follow-up

32

(65 per cent),

at the National

to their

Two occurred

(8 per cent)

difference

damage

information

total numl)er of deaths was nine (6.8 per cent of 133). The remaining 124 children spent dren’s Cardiac Hospital. (in 1956) of these subjects

oldrr

cant (p < 0.01).

4

and 670 for the

Together,

in the entire on

is 486.5

group,

a total

of 9.3

available

1959

i

26 children

Florida.

I

150 children

JUNE,

18

Of a total of 20 recurrences,

22

8

in the senior

an avcragc

lb

homes in states outside Florida.

an average was

20(16yo/,‘1 2

group of 78 (18 per cent) who returned

Cardiac

85 junior

124

7(180/o) 1

1 12

group,

(44 per cent), Children’s

~ 39

85

ones.

I ‘)8

31

Over 10

13(15%‘,) 1

Physical wstrictions Noor ComprtitiolI eseluded Moderate to lnarkrd

younger

the

‘I‘otal

I

Heart damagr None Minimal or questionable Moderate to marked

the

’ 1 67

of childrrnj

Numbrr of rrcurrencrs Florida residents Non-Florida residents

deceased - (7.6%) 3(4 9%) 9 (6.8%) Time in hospital (85 childrrn)l(39 childrenI’i(l24 children) 5 4 -6 months 3 2 ! 19 9 6-l 2 months 10 I Over 12 100 / 72 months 28 Average stay j 20.0 ~ 20.1 (months) I o .O Average= age (1956) Number of patient

of

Hospital

Period of follow-up study (years) 5 -10

Number of children in hospital ovtT 4 months 102

Expatlents

Cardiac

16 females

sports.

Of

were capable

in the older

group

124

to pa-

of living (average

age 24 years) 11 are married and 7 of these 11 have alreadv~ borne children without diffi-

756

Long-term Of the 37 female

cult)-. group

(average

age

patients

19 years),

and 2 have borne children. In the five- to ten-year tending

secondary

graduated. school 81

In

the

frotn

school,

older The

high

50

school.

108 (87 per

27 are

the

have

gainfully

employed;

30 are

schools;

at-

27

high in

in

the

are

Hospital

have

variety auto

of the National

of

established

man?

medical

chemist,

publishing

per

ported

director,

an

teacher,

and

television

)-ears,

DISCUSSION

quency

of

lower

in the

National

heart

damage

Children’s

Florida

(Table

reported

from

III),

than

in

New

York,

The

attributed

result

to the being

similar

rate

of selection

treated

in

Miami,

may

City

I

Data

be

Death Total cases

while

onlv

Boston2 York3

Philadelphia4 Iowa Cityb$ Miami5

* More than minimal. 3.3 years. of observation,

1,000

413 537 266 133

when in-

Within

formerly

hospitalized to their

former

in Florida.

The

18 per cent prr

cent

in Florida. be

to

recurrences;

at

of the rccur-

occurred

appears

among A sojourn

protective

permanent

against rcsidcncc

protection.

III

Disease

as Reported

rate

From

Various

Cities Heart

RKLltT~IlCCS

damage*

I %

%

Pt

%

I>+

~-

I

New

rccur-

returned

up residence

the

3.3 a\‘-

low

closely.

in

Florida

covers

onI\.

in the prcscnt

remained 8

of

those taking

increases

in contrast

Heart

some sufTercd

rheumatic

of milder

on Rheumatic

man)-

16 IT-

of 10.3

Cit!,

significant

more

of patients

while

rences,

TABLE Comparative

group

rate

This

more

studied

of that

investigation

child.

vestigation

homes,

groups

per

our

of rccurrcnce

arc

rate

The

so

a period.

than

in Iowa

lvith

and vvith

duration

period

I~~comcs even

out-of-staters

Philadelphia.

low death

9.3 )cars

this instittttion,

Miami,

sources.

as cotnparcd rate

parents

lower

I)!, .Jackson’

after illness.

children

of short

olrscr\,ation

average

onlv

active

=\ recurrence

other

art

children

for so long

is considerably from

scrics

homrs tnany

and

a to

lift-saving

to send

the 20 episodes the

of the

Hospital,

Boston,

fre-

substantially

expatients

Cardiac

and Iowa City. Mortality Rate: illnesses

were

124 rheumatic

and

their

residents,

has hos-

cotnc

in our

of chronic

home,

per cent found

psy-

to

rheumatic

or illnesses

from

cent

operator,

rate,

local

Recurrmce Rat?:

en-

radar

recurrence

to Icavc or years

symptoms

rence rate,

Other

rcfrom

the

desperate

deaths

vvcrc reluctant

far away

corps-

other

the

of sickness:

allowed

last

group.

for

craging

death

a

this

Except

physician,

as

among

mild

in

reaching

period

been

A fc\v of the

physicians

ser\icetnan.

The

onI>.

from

earl!,

effort.

executive,

sociologist,

secretary,

music

pharmacist,

holrcvrer,

ha\-e

months

medical

treated

cases,

thr

permitted

draftsman,

lawyer,

research

optometrist,

chologist,

clerk,

worker,

during patients

were

author,

patients

the children

many

in a wide

ill some

of parents to srparatc thetnsclvcs lvith active rheumatic fever

college

Cardiac

accountant,

barber,

factory

nurse,

thetnselves

:

occupations

mechanic,

gineer,

Children’s

III

Armed

Forces. Expatients

scvcrel>.

Florida

or are

attending

5 are

pital few

still

Forty-six

the

prevented

graduated

attained

Fever Patients

luctancc children

ahead\

31 are

With educations.

married

have

group

satisfactory

professional

to

localities.

group,

attaining or

in the younger

total

cent)

of Rheumatic

6 arc

group,

schools:

graduates.

Follow-up

20.3 12.1 281

’



~

6.8

individually t All& va 1ues are compared 6 These figures include 9 deaths.

28 73 63 19.2 15 0

~

1

<0 001
60.7 79.5 59.2

I

’

It

-1

~~~~~

1


35.3

with corresponding

data

THE AMERICAN

from Miami.

JOURNAL

1 Period

OF CARDIOLOGY

Hernandcz,

Saslaw. Careful leading

inspection

of

to a number

in some

instances

physical

trauma

favoring

illness

the

at Irast, and

had

previously

even

the slightest

there an

,group

provides

rheumatic

in subjects

dren’s ings Often

Carcliac

Hospital

for 20 months, miles.

severit!-

or

when

nized

c;rrdiac

Those

who

and

with of the

tained?

in

age in Miami-treated ably indeed

JUNE, 1959

with

In the total

in Miami

and

severe

were checked

children the results

or in rccoghome

areas.

desired

than

to visit

data

of heart compares

reported

pa-

average,

rechecking

the frequency

pa-

who had

here. to accumulate

illnesses

wcrc

com-

of the National

not

Miami,

Florida,

the li\~

of these

b!- a period

of con\aIcs-

arca.

v\-rre available

on 02 of the

and

ten-year

41 of the

133. the death

rate

five-

patients.

was less than

7

per crnt. Of the 124 survivors

l,i)

information,

ably

16 per cent

Heart

14) (S}

by a

Many-

their

Data group,

rences,

cardiac

was performed

cross-sectional

we believe

)-ear

or

in this tropical

damage,

in onl) The

more

death

rate,

and heart damage, with

on vz;hom \vc have

had

recurrences. than

31 per cent ofthe

similar

reports

physical

of

Others

studies

Hospital,

v\hcthcr

wet-c influenced

care

re-

average

physician

Cardiac

obsc~vcd

or

ten-year

minimal.

\vas

124 sur\-ivors.

frequent)*

of

rccuf-

all compare

ver) favor-

from

centers.

other

were

their

privatel!?

clinics

more

cent

from

of 1,000 patients

beyond

our clinic were rc-examined In \-ic\v of the tendency tients

Chil-

were

of physicians.

either

\zrre

was

physicians.

Evaluation

them.

cardiologists,

subjects

and

National

at a distance

seen by the same

first recommended by

of

disease

parents

occasionally

group

figure

to be separated

of follow-up

heterogeneous were

and

duration.

at time

tients

the

Children’s

(2)

evidence

physicians,

to our institution;

\vere

of the

of these

Therefore,

sent cvcntuallv

of

and

on 102 and 48 expatients

to determine

on the basis of the find-

children

more

conditions

with

Five-

(1)

pletcd

follow-up

heart

at

physicians

to allow

home

status

half Initial

recommendations

both

(if

incidence

our

by northern accepted

luctant

about

areas.

were

and

in

or rheumatic

primarily

patients

The

damage

other

fever

judged

factors

episode

susceptibility.

a rate

in

that

sufficient

to the

occurred)

heart

ohscrvcd

\vas

initial

Incident ?f Heart Damage:

permanenr

e\.ents

indicate

exposure

to cause

none

historical

of recurrences

and Randolph

obdam-

favor-

elsebl-here.

REFERENCES 1.

kUTSTEIN,

Il.

11..

et

(11.:

Jones

criteria

(modified)

for ,gidance in the diagnosis of rheumatic AZlo/l. Conce~fc Cardiovas. Dir. 24: 271> 1955.

fever.

2. JONES. ‘I‘. D. and BLAND, E. F.: Rheumatic fever and heart disease: Completed ten year observaTr. A. Am. Physicims 57 : tion on 1000 patients. 267, 1942. 3. WILSON, M. G., LINGG, C., and CROXFORD, G.: Statistical studies bearing on problems in the classification of heart disease: III. Heart disease itrn. Heart J. 4: 164, 1928. in children. The first few years of rheumatic 4. ASH. R.: .?m. Heart J. 36: 89, 1948. in childhood.

infection

5. JA~KSOR. R. I..: KELI.Y, H. G., ROHRET, C. H., and DUANE, .J. M.: Rheumatic fever recurrences in children without sulfonamide prophylaxis: An evaluation of environmental factors. J. Pediat, 31: 390, 1947.