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Prevention of rheumatic fever recurrences
EDITOR'S COLUMN
Prevention of rheumatic fever recurrences
I N
A R E C E N T
paper,
Lim
and
rences. At the present time 3 prophylactic regimens are commonly used: monthly intramuscular injections of 1,200,000 units of benzathine penicillin G, oral penicillin, 200,000 units twice daily, or sulfadiazine, 0.5 to 1 Gm. once a dayY The first regimen is foolproof and the most effective? The 2 oral regimens are somewhat less reliable because they depend on the cooperation of the patient. In comparison with a regimen in which penicillin is given whenever signs of an upper respiratory infection develop, the standard prophylactic measures recommended by the American Heart Association have distinct advantages. Rheumatic children, who often have had long bouts of illness, tend not to report minor symptoms. Furthermore, rheumatic recurrences frequently follow subclinical streptococcal infections which would not be treated. 4 The majority of upper respiratory infections are of viral rather than of streptococcal origin2 Therapeutic doses of penicillin, therefore, would be given unnecessarily at frequent intervals. T h e generally accepted methods for the prevention of recurrences of rheumatic fever, therefore, are preferable to a regimen of intermittent therapy given only when signs of an upper respiratory infection are detected.
Wilson 1
have compared daily oral prophylactic penicillin with therapeutic doses of penicillin given for 10 days for every upper respiratory infection as a means of preventing rheumatic recurrences. Data on a total of 213 patients followed for a 6 year period are presented: 110 received continuous daily prophylactic penicillin and 103 intermittent penicillin therapy. The patients in the 2 groups, however, were not matched carefully in regard to number of rhemnatic attacks, cardiac lesions, or age or interval since the last attack. Furthermore, some of the patients were switched from one group to another. A larger number of recurrences were observed in the group on continuous daily prophylactic penicillin than in the group receiving intermittent penicillin therapy. Since the patients in the latter group were older and the interval since the last attack was longer, however, the comparison is not valid. The authors themselves state that if these factors are taken into consideration the rate of recurrence shows no significant difference between the 2 groups. In any study of rheumatic patients, unless cases are matched as closely as possible in every way, the significance of the results is open to question. It is now well established that prophylaxis for the prevention of streptococcal infections reduces the incidence of rheumatic recur-
A N N G. K U T T N E R , M.D.
847
84 8
Editor's column
REFERENCES
1. Lim, Wan Ngo, and Wilson, M. G.: Comparison of the Recurrence Rate of Rheumatic Carditis Among Children Receiving Penicillin by Mouth Prophylactically or on Indication, New England J. Med. 262: 321, 1960. 2. American Heart Association. Committee on Prevention of Rheumatic Fever and Bacterial Endocarditis: Prevention of Rheumatic Fever and Bacterial Endocarditis Through Control of Streptococcal Infections, Circulation 11: 317, 1955. 3. Feinstein, A. R., Wood, Harrison F., Epstein, Jeanne E., Taranta, Angel% Simpson, Rita,
]une 1960
and Tursky, Esther: Controlled Study of Three Methods of Prophylaxis Against Streptococcal Infection in Population of Rheumatic Children. II. Results of First Three Years of Study Including Methods for Evaluating Maintenance of Oral Prophylaxis, New England J. Med. 260: 697, 1959. 4. Miller, J. M.: Prophylaxis of Rheumatic Fever and Rheumatic Heart Disease, New England J. Med. 260: 220, 1959. 5. Dingle, J. H., Badger, G. F., Filler, A. E., Hodges, R. G., Jordan, W. S., and Rammelkamp, C. H.: Study of Illness in Group of Cleveland Families, Am. J. Hyg. 58: 16, 1953.
The superior child." selective precocity F O R T H E third successive year, Bobby Fischer, 16-year-old Brooklyn schoolboy, won the United States chess championship. He has now equaled the record made by Reshevsky who scored 3 straight victories in 1936, 1938, and 1940. As in music and mathematics, precocity is not infrequent among the great masters of chess. Samuel Reshevsky learned the game at 3 ~ years of age and at the age of 8 defended himself ably against some of America's best players. Jos6 Capablanca, who wrested the world championship from Emanuel Lasker, learned to play at 4 years of age. Paul Morphy, one of the great chess masters of all times, began his career at 12 years of age and quickly overcame all opponents in his native New Orleans. Chess playing is unique among the great skills in that it can be acquired without book learning. Reuben Fine, an author of several books on chess, states that he never read a book on the subject until he became a master. Emanuel Lasker, who retained the world championship for 27 years, rarely looked at a book on chess, although he read widely in other fields, particularly mathematics and philosophy.
Precocity in chess, as in music and mathematics, requires a high order of general intelligence, opportunity to see the game played, strong motivation, and a combination of mental qualities especially suited to the subject at hand. Unlike music, chess does not "run in families." It is notable that in chess, as in musical composition, no woman has ever achieved a place of high eminence. The unique feature of young Fischer's career is the speed with which he has risen to the top in the chess world. T a u g h t by his 10-year-old sister, he began to play chess at 6 years of age, but it was not until he was 13 that he began to take the game seriously. Since then he has made chess history. None of the precocious chess players of the past reached the heights attained by Fischer at so early an age. At 15 he won the title of International Grand Master, the highest position open to a chess player next to World Champion. At 16 years of age he is regarded by m a n y as one of the 90 best players in the world and as a probable future contender for the world championship. Already his plays show the quality of greatness. HARRY BAKWIN, M.D.
Prevention of rheumatic fever recurrences
I N
A R E C E N T
paper,
Lim
and
rences. At the present time 3 prophylactic regimens are commonly used: monthly intramuscular injections of 1,200,000 units of benzathine penicillin G, oral penicillin, 200,000 units twice daily, or sulfadiazine, 0.5 to 1 Gm. once a dayY The first regimen is foolproof and the most effective? The 2 oral regimens are somewhat less reliable because they depend on the cooperation of the patient. In comparison with a regimen in which penicillin is given whenever signs of an upper respiratory infection develop, the standard prophylactic measures recommended by the American Heart Association have distinct advantages. Rheumatic children, who often have had long bouts of illness, tend not to report minor symptoms. Furthermore, rheumatic recurrences frequently follow subclinical streptococcal infections which would not be treated. 4 The majority of upper respiratory infections are of viral rather than of streptococcal origin2 Therapeutic doses of penicillin, therefore, would be given unnecessarily at frequent intervals. T h e generally accepted methods for the prevention of recurrences of rheumatic fever, therefore, are preferable to a regimen of intermittent therapy given only when signs of an upper respiratory infection are detected.
Wilson 1
have compared daily oral prophylactic penicillin with therapeutic doses of penicillin given for 10 days for every upper respiratory infection as a means of preventing rheumatic recurrences. Data on a total of 213 patients followed for a 6 year period are presented: 110 received continuous daily prophylactic penicillin and 103 intermittent penicillin therapy. The patients in the 2 groups, however, were not matched carefully in regard to number of rhemnatic attacks, cardiac lesions, or age or interval since the last attack. Furthermore, some of the patients were switched from one group to another. A larger number of recurrences were observed in the group on continuous daily prophylactic penicillin than in the group receiving intermittent penicillin therapy. Since the patients in the latter group were older and the interval since the last attack was longer, however, the comparison is not valid. The authors themselves state that if these factors are taken into consideration the rate of recurrence shows no significant difference between the 2 groups. In any study of rheumatic patients, unless cases are matched as closely as possible in every way, the significance of the results is open to question. It is now well established that prophylaxis for the prevention of streptococcal infections reduces the incidence of rheumatic recur-
A N N G. K U T T N E R , M.D.
847
84 8
Editor's column
REFERENCES
1. Lim, Wan Ngo, and Wilson, M. G.: Comparison of the Recurrence Rate of Rheumatic Carditis Among Children Receiving Penicillin by Mouth Prophylactically or on Indication, New England J. Med. 262: 321, 1960. 2. American Heart Association. Committee on Prevention of Rheumatic Fever and Bacterial Endocarditis: Prevention of Rheumatic Fever and Bacterial Endocarditis Through Control of Streptococcal Infections, Circulation 11: 317, 1955. 3. Feinstein, A. R., Wood, Harrison F., Epstein, Jeanne E., Taranta, Angel% Simpson, Rita,
]une 1960
and Tursky, Esther: Controlled Study of Three Methods of Prophylaxis Against Streptococcal Infection in Population of Rheumatic Children. II. Results of First Three Years of Study Including Methods for Evaluating Maintenance of Oral Prophylaxis, New England J. Med. 260: 697, 1959. 4. Miller, J. M.: Prophylaxis of Rheumatic Fever and Rheumatic Heart Disease, New England J. Med. 260: 220, 1959. 5. Dingle, J. H., Badger, G. F., Filler, A. E., Hodges, R. G., Jordan, W. S., and Rammelkamp, C. H.: Study of Illness in Group of Cleveland Families, Am. J. Hyg. 58: 16, 1953.
The superior child." selective precocity F O R T H E third successive year, Bobby Fischer, 16-year-old Brooklyn schoolboy, won the United States chess championship. He has now equaled the record made by Reshevsky who scored 3 straight victories in 1936, 1938, and 1940. As in music and mathematics, precocity is not infrequent among the great masters of chess. Samuel Reshevsky learned the game at 3 ~ years of age and at the age of 8 defended himself ably against some of America's best players. Jos6 Capablanca, who wrested the world championship from Emanuel Lasker, learned to play at 4 years of age. Paul Morphy, one of the great chess masters of all times, began his career at 12 years of age and quickly overcame all opponents in his native New Orleans. Chess playing is unique among the great skills in that it can be acquired without book learning. Reuben Fine, an author of several books on chess, states that he never read a book on the subject until he became a master. Emanuel Lasker, who retained the world championship for 27 years, rarely looked at a book on chess, although he read widely in other fields, particularly mathematics and philosophy.
Precocity in chess, as in music and mathematics, requires a high order of general intelligence, opportunity to see the game played, strong motivation, and a combination of mental qualities especially suited to the subject at hand. Unlike music, chess does not "run in families." It is notable that in chess, as in musical composition, no woman has ever achieved a place of high eminence. The unique feature of young Fischer's career is the speed with which he has risen to the top in the chess world. T a u g h t by his 10-year-old sister, he began to play chess at 6 years of age, but it was not until he was 13 that he began to take the game seriously. Since then he has made chess history. None of the precocious chess players of the past reached the heights attained by Fischer at so early an age. At 15 he won the title of International Grand Master, the highest position open to a chess player next to World Champion. At 16 years of age he is regarded by m a n y as one of the 90 best players in the world and as a probable future contender for the world championship. Already his plays show the quality of greatness. HARRY BAKWIN, M.D.