Rheumatic Heart Disease

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain major causes of heart failure, stroke and death among African women and children, despite being preventable and imminently treatable. From 21 to 22 February 2015, the Social Cluster of the Africa Union Commission (AUC) hosted a consultation with RHD experts convened by the Pan-African Society of Cardiology (PASCAR) in Addis Ababa, Ethiopia, to develop a 'roadmap' of key actions that need to be taken by governments to eliminate ARF and eradicate RHD in Africa. Seven priority areas for action were adopted: (1) create prospective disease registers at sentinel sites in affected countries to measure disease burden and track progress towards the reduction of mortality by 25% by the year 2025, (2) ensure an adequate supply of high-quality benzathine penicillin for the primary and secondary prevention of ARF/RHD, (3) improve access to reproductive health services for women with RHD and other non-communicable diseas...

Certifico que el presente trabajo fue desarrollado bajo mi dirección por ________________________________ ha sido revisada prolijamente, autorizando la presentación de esta monografía de grado la cual cumple con todas las normas internas requeridas por la Unidad Educativa FAE Nº4 -Manta Manta, 12 de diciembre del 2014 ___________________________ Tutor de Monografía de Grado ii AUTORIA ( NOMBRE ) estudiante, declaro bajo juramento que el trabajo aquí descrito es de mi autoría; y que, previamente no ha sido presentada por otro estudiante; y, que se han consultado las referencias bibliográficas que se incluyen en este documento, las ideas, pensamientos, opiniones y la información de esta investigación monografica son de única responsabilidad del autor. __________________________ 3ro de Bachillerato "B"

in the pathophysiology of various disease processes, Genes of the interleukin-1 (IL-1) gene cluster localincluding septic shock, hypertension, rheumatoid arized on chromosome 2q13 are implicated in many physthritis, inflammatory bowel disease, and insulin-depeniological and pathophysiological processes. We presdent diabetes mellitus (Dinarello and Wolff, 1993). Reent here a high-resolution physical map of this region cently, mice deficient in IL-1b-converting enzyme were between markers D2S2008 and D2S43/PAX8. An inteshown to be resistant to endotoxic shock, and their thygrated YAC/PAC contig and a partial transcriptional mocytes displayed an altered pathway of apoptosis (Li map were constructed by STS-content mapping using . The interleukin-1 recepthe CEPH YAC library and three PAC libraries. A total tor antagonist is a specific competitive inhibitor of inof 3 YACs, 34 PACs, and 56 STSs were integrated: 33 terleukin-1 activities since it binds to IL-1 receptors newly generated probes to PAC end sequences, 9 polybut elicits no cytoplasmic signaling cascade. All three morphic and 4 nonpolymorphic markers, 5 known genes have been mapped within a 430-kb genomic fraggenes, 4 expressed sequence tags, and 1 pseudogene. ment (Nicklin et al., 1994) and to a 620-kb interval on Within the map, a complete PAC contig of ú1 Mb enhuman chromosome 2q13 (Spurr et al., 1994; Hildecompasses the IL-1 gene cluster and PAX8, a paired- brandt et al., 1995, 1996).

Objective: To assess the effectiveness of aquatic physical therapy in the treatment of fibromyalgia. Review methods: The studies were separated into groups: Group I -aquatic physical therapy × no treatment, Group II -aquatic physical therapy × land-based exercises and Group III -aquatic physical therapy × other treatments. Results: Seventy-two abstracts were found, 27 of which met the inclusion criteria. For the functional ability (Fibromyalgia Impact Questionnaire), three studies were considered with a treatment time of more than 20 weeks and a mean difference (MD) of -1.35 [-2.04; -0.67], P = 0.0001 was found in favour of the aquatic physical therapy group versus no treatment. The same results were identified for stiffness and the 6-minute walk test where two studies were pooled with an MD of -1.58 [-2.58; -0.58], P = 0.002 and 43.5 (metres) [3.8; 83.2], P = 0.03, respectively. Conclusion: Three meta-analyses showed statistically significant results in favour of the aquatic physical therapy (Fibromyalgia Impact Questionnaire, stiffness and the 6-minute walk test) during a period of longer than 20 weeks. Due to the low methodological rigor, the results were insufficient to demonstrate statistical and clinical differences in most of the outcomes.

Subvalvular preservation is beneficial in patients undergoing mitral valve replacement, especially in degenerative mitral regurgitation. Its feasibility and benefit is less evident in rheumatic disease. Our aim was to study the impact of preservation techniques in rheumatic patients and determine risk factors for mortality.Five hundred sixty-six rheumatic patients undergoing mitral valve replacement between 1996 and 2006 have been included. One hundred fifty-six patients had complete excision of the subvalvular apparatus (group 1), 248 had preservation of the posterior leaflet (group 2), and 162 had total chordal preservation (group 3). Echocardiography was performed preoperatively, at discharge, at 1 year, and at late follow-up.Reduction of ventricular volume was greater in groups 2 and 3, especially if previous mitral regurgitation or mixed disease were present. In mitral stenosis, valve resection caused postoperative increase of volume. Ventricular ejection and pulmonary hypertension had better outcome with valve preservation. Valve resection was associated with late mortality (hazard ratio, 2.64; p < 0.05), and complete chordal preservation was protective (hazard ratio, 0.31; p = 0.13). Actuarial survival (130 months) was better in group 3: 77.18% ± 0.04%, 85.38% ± 0.03%, and 93.22% ± 0.02%, respectively (p < 0.01 group 1 versus group 3). Group 1 exhibited more low cardiac output syndrome (p < 0.01) and more patients in New York Heart Association functional class III and IV at last follow-up: 17.8% versus 3.9% and 2.0% (p < 0.001).Complete chordal preservation is possible in a large percentage of rheumatic patients. Greater decrease of ventricular volume is obtained for mitral regurgitation. In mitral stenosis, subvalvular preservation may avoid postoperative ventricular dilatation. Consequently, ventricular ejection, pulmonary hypertension, and clinical outcomes may improve with time.

The differentiation of mouse T H 17 cells requires transforming growth factor β and iL-6, whereas human naive T cells can develop into T H 17 cells in the presence of iL-1β and iL-23 alone, transforming growth factor β having an indirect role in their development via the selective inhibition of T H 1 cell expansion. in both mice and humans, a late developmental plasticity of T H 17 cells towards the T H 1 lineage has been shown. Mainly based on mouse gene knockout studies, T H 17 lymphocytes have been found to have a pathogenic role in several autoimmune disorders; however, whether human autoimmune disorders, including rheumatoid arthritis (rA) and psoriasis, are prevalently T H 1-mediated or T H 17-mediated, is still unclear. research suggests that both T H 1 and T H 17 cells are involved in rA pathogenesis, raising the possibility that interventions that target both the iL-23-iL-17 (T H 17) and the iL-12-interferon γ (T H 1) axes might be successful future therapeutic approaches for rA.

In 2011, the European League Against Rheumatism (EULAR) published recommendations regarding the vaccination of children with rheumatic diseases. These recommendations were based on a systematic literature review published in that same year. Since then, the evidence body on this topic has grown substantially. This review provides an update of the systematic literature study of 2011, summarizing all the available evidence on the safety and immunogenicity of vaccination in paediatric patients with rheumatic diseases. The current search yielded 21 articles, in addition to the 27 articles described in the 2011 review. In general, vaccines are immunogenic and safe in this patient population. The effect of immunosuppressive drugs on the immunogenicity of vaccines was not detrimental for glucocorticosteroids and methotrexate. Biologicals could accelerate a waning of antibody levels over time, although most patients were initially protected adequately. Overall, persistence of immunological memory may be reduced in children with rheumatic diseases, which shows the need for (booster) vaccination. This update of the 2011 systematic literature review strengthens the evidence base for the EULAR recommendations, and it must be concluded that vaccinations in patients with rheumatic diseases should be advocated.

To identify optimum international normalized ratio (INR) levels and required warfarin doses and anticoagulation-related complications in patients following mechanical prosthetic valve replacement. Five hundred and seven patients were prospectively followed up for 10 years (2008.5 patient-years). Anticoagulation-related complications were classified into hemorrhage and thromboembolism. Two hundred and ninety-two (57.6%) were males and 215 (42.4%) were females with a mean age of 29.5 +/- 11.32 years. A total of 268 (52.9%) patients had mitral, 96 (18.9%) had aortic and mitral, and 76 (15%) had aortic valve replacement (AVR). Valves implanted totaled 345 (68%) ball and cage, 126 (24.9%) bileaflet, and 36 (7.1%) single disc. There were 10,669 total visits, with mean INR 2.6 +/- 0.59 and mean warfarin 5.17 +/- 1.6 mg. Sixty-four (3.2% per patient-years) events occurred during follow-up, of which 23 (1.13% per patient-years) events were due to thromboembolism and 41 (2.04% per patient-yea...

To prevent infective endocarditis (IE), Australian guidelines recommend providing prophylactic antibiotics to Indigenous patients with rheumatic heart disease (RHD) prior to procedures which may cause bacteremia. In northern Australia RHD remains prevalent. We aimed to determine whether RHD is associated with an increased risk of IE, which risk factors are associated with IE, and the incidence and aetiology of IE.

Background: Congestive cardiac failure (CCF) has emerged as a major public health problem worldwide and imposes an escalating burden on the health care system. Objective: To determine the causes and mortality rate of CCF in the University of Port Harcourt Teaching Hospital (UPTH), south Nigeria, over a five-year period from January 2001 to December 2005. Methods: A retrospective study of CCF cases were identified from the admission and discharge register of the medical wards of UPTH and the case notes were retrieved from the medical records department and analyzed. Results: There were 423 patients: 242 males and 181 females. Their ages ranged from 18 to 100 years with a mean of 54.4 ± 17.3. The commonest causes of CCF were hypertension (56.3%) and cardiomyopathy (12.3%). Chronic renal failure, rheumatic heart disease, and ischemic heart disease accounted for 7.8%, 4.3%, and 0.2% of CCF, respectively. Peripartum heart disease was rare despite being commonly reported in northern Nigerian females. Eighteen patients died from various complications with a mortality rate of 4.3%. Conclusion: The burden of CCF in the Niger Delta is mainly attributed to hypertension. Efforts should be geared towards hypertension awareness, detection, treatment, and prevention in the region.

By the dawn of this modern era of science, the prime challenge of physician is cardiovascular diseases (CVD). According to World Health Organization (WHO), CVDs are the number one cause of death globally. An estimated 17.5 million people died from CVDs in 2005, representing 30% of all global deaths. Over 80% of CVD deaths take place in low-and middleincome countries like Bangladesh. By 2015, almost 20 million people will die from CVDs, mainly from heart disease and stroke and they will remain the single leading causes of death. 1 CVD is caused by disorders of the heart and blood vessels, and includes coronary heart disease, stroke, hypertension, peripheral artery disease, rheumatic heart disease,

Introduction: infective endocarditis is an infection of the endocardial lining of the heart mainly associated with congenital and rheumatic heart disease. Although it is a rare disease in children, it is associated with high morbidity and mortality; death due to infective endocarditis has been reported to be as high as 26% in sub-Saharan Africa. Methods: this was a retrospective review of routinely collected data from patient records. Results: a total of 40 children (71% female) with 41 episodes of infective endocarditis admitted to a general paediatric ward in Addis Ababa, Ethiopia between 2008 and 2013. Age ranged from 7 months to 14 years, with a median of 9 years (Inter quartile Range: 7-12 years). Rheumatic and congenital heart diseases were underlying risk factors in 49% and 51% of cases respectively. Congestive heart failure, systemic embolization and death occurred in 66%, 12% and 7.3% respectively. Death was associated with the occurrence of systemic embolization (P-value=0.03). Conclusion: rheumatic heart disease was an important predisposing factor for infective endocarditis in Ethiopian children. Late presentations of cases were evidenced by high proportion of complications such as congestive heart failure. A low rate of clinically evident systemic embolization in this study may be a reflection of the diagnostic challenges. High proportion of prior antibiotic intake might explain the cause of significant BCNE. Preventive measures like primary and secondary prophylaxis of rheumatic fever may decrease the associated morbidity and mortality. Early detection and referral of cases, awareness creation about indiscriminate use of antimicrobials, and proper history taking and documentation of information recommended.

Chronic musculoskeletal (MS) syndromes are some of the most common and debilitating diseases in the United States. These syndromes range from conditions such as osteoarthritis (OA) and rheumatoid arthritis (RA) to more vague but common problems such as fibromyalgia, fibrositis, myalgias, and arthralgias. OA alone affects nearly 10% of the population over 60 years of age, resulting in an average of 3.5 physician visits and 3.7 million hospitalizations per year.1s, 2o The economic impact of these diseases results in billions of dollars spent on medications, physical therapy, and surgery and millions of lost work days every year.22 For individuals who do not die of more lethal diseases such as cardiovascular disease, stroke, or cancer, arthritis and MS syndromes often become major obstacles to quality life in later years.

Rosen KM: Sites of conduction disease in aortic stenosis. Ann Intern Med 87~275, 1977. 7. Rasmussen K, Thomsen PEB, Bagger JP: HV interval in calcific stenosis. Relation to left ventricular function and effect of valve replacement. Br Heart J 5282, 1984. 8. Friedberg CK, Donoso E, Stein WG: Nonsurgical acquired heart block. Ann NY Acad Sci 111:835, 1964. 9. Lev M: The normal anatomy of the conduction system in man and its pathology in A-V block. Ann NY Acad Sci 111:817, 1964. 10. Partain JO, Sydnor JB: Nonsurgical complete heart block associated with aortic stenosis: The importance of correct diagnosis. AM HEART J 75:180, 1968. 11. Friedberg CK: Disturbances in conduction: Heart block and bundle branch block.

The aim of this project is to implement the heart disease prediction application. Many people all over the world like nearly 60% of the world's population are now-a-days suffering from heart disease. Heart Disease Prediction system is an android application which helps the users for the easy prediction, prevention and curing of the disease. An android application gets the disease name as the output based on the data provided by the user or patient. Android application is also used to get the preventive measures like nearby doctor details, hospitals details and location for hospitals. Proposed system consists of an intelligent system which works on the machine learning algorithms like KNN. The data entered by the user is compared with some existing standard datasets to get probability. KNN used to find the probability.

Osteoporosis (OP) is a well documented complication of some rheumatic diseases. Rheumatoid arthritis (RA) represents the paradigm of bone loss which occurs both locally (iuxta-articular OP and bone erosions) and systemically (generalized osteoporosis and fractures). Both local and systemic bone loss in RA are mainly due to an imbalance in the RANKL/OPG ratio produced by pro-inflammatory cytokines. There is sub- stantial evidence that bone loss does occur also in systemic lupus erythematosus, ankylosing spondylitis and scleroderma. The pathogenesis of bone loss is multifactorial, with disease-dependent and disease-independent factors. Glucocorticoids represent the single most important risk factor for OP, even at low dose, and are associated with a significant increase in fracture risk. Functional impairment, hypovitaminosis D due to lack of sun exposure, disease activity and drugs, such as immunosuppressant and anticoagulants, also play a role.

Mitral regurgitation affects more than 2 million people in the USA. The main causes are classified as degenerative (with valve prolapse) and ischaemic (ie, due to consequences of coronary disease) in developed countries, or rheumatic (in developing countries). This disorder generally progresses insidiously, because the heart compensates for increasing regurgitant volume by left-atrial enlargement, causes left-ventricular overload and dysfunction, and yields poor outcome when it becomes severe. Doppler-echocardiographic methods can be used to quantify the severity of mitral regurgitation. Yearly mortality rates with medical treatment in patients aged 50 years or older are about 3% for moderate organic regurgitation and about 6% for severe organic regurgitation. Surgery is the only treatment proven to improve symptoms and prevent heart failure. Valve repair improves outcome compared with valve replacement and reduces mortality of patient with severe organic mitral regurgitation by abo...

The heart is a complex, dynamic three-dimensional structure that contains many chambers, vessels, and valves. To identify the orientation of these structures and their connected relations, the examiner mentally constructs a three-dimensional picture. In the 1970s, Matsumoto et al. 1-2 began to research threedimensional echocardiography; many investigators have further developed this technique. 3-9 In the past several years, we have studied the imaging method and clinical application of static three-dimensional transesophageal echocardiography and have achieved success. 1°-17 With the rapid development of modern computers, the image processing time has been markedly shortened from hours to minutes, and the quasi-real-time stereo images with gray-scale and volume display can be obtained. Dynamic threedimensional echocardiography can show the configuration, thickness, location, and space relations of cardiac structures and the heart's structural and physiologic motion. Some investigators recommend naming this the "four-dimensional echocardiography" (4DE) to distinguish it from the three-dimensional echocardiography that can display only the static three dimensions of space (width, height, and length). This technique is new and developing and has enormous potential for diagnosing cardiovascular diseases and has aroused interest among many investigators, ls-25 We recently used TomTec Echo-Scan Systems (Boulder, Colo.) and HP SONOS 1500 (Hewlett-Packard Company, Andover, Mass.) to reconstruct 4DE images in 138 subjects. 26,27 This

Objectives: To present the systematic literature review (SLR), which formed the basis for the European League Against Rheumatism (EULAR) evidence-based recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases (AIIRD). Methods: AIIRD, vaccines and immunomodulating drugs, as well as eight key questions were defined by the multidisciplinary expert committee commissioned by EULAR for developing the recommendations. A SLR was performed using MedLine through October 2009 and including data from meta-analyses, systematic reviews, randomized trials, and observational studies, excluding case series with ≤ 5 participants. Articles in English and regarding patients ≥ 16 years of age, were eligible. Results: Several vaccine-preventable infections (VPI) occur more often in AIIRD-patients and most vaccines are efficacious in AIIRD-patients, even when treated with immunomodulating agents, except rituximab. There does not appear to be an increase in vaccination-related harms in vaccinated patients with AIIRD in comparison with unvaccinated patients with AIIRD. However, these studies are underpowered and therefore not conclusive. Conclusion: Based on the current evidence from the literature, recommendations for vaccination in patients with AIIRD were made. However, more research is needed in particular regarding incidence of VPI, harms of vaccination and the influence of (new and established) immunomodulating agents on vaccination efficacy.

Will vaccination raise the incidence of autoimmune diseases, what is the impact of increasingly crowded vaccination schedules, the vaccination in age groups and the risk of coincidental temporal association? All these issues are still under debate. However, for the time being, to avoid confusion in the medical community and the media, we have to adhere to guidelines established consensually by experts while ensuring a strict surveillance and reporting possible side effects. Recommendation for vaccination in patients with autoimmune inflammatory rheumatic diseases (AIIRD) based on the currently available evidence and expert opinion were recently formulated by an EULAR task force. Major recommendations for AIIRD include: i) vaccination should ideally be administered during stable disease; ii) influenza vaccination and pneumococcal vaccination should be strongly considered; iii) vaccination can be administered during the use of DMARDs and TNFinhibitors, but before starting rituximab; iv) live attenuated vaccines should be avoided whenever possible in immunosuppressed patients; v) BCG vaccination is not recommended.

Background: Various modifi cations of the Erythrocyte Sedimentation Rate (ESR) determination have been suggested since the original Westergren procedure that has been adopted as the gold standard by the International Council for Standardization in Haematology (ICSH). Recently, an automated method, (Alifax Test 1), based on a technique completely different from Westergren, has been introduced. Material and methods: In this comparative study, ESR of blood from 680 patients with various rheumatic diseases was determined on both Test 1 and the StaRRsed automated ESR analyser which performs measurements in accordance with ICSH specifi cations. Furthermore the robustness of the new technique was evaluated. Results: Direct correlation of Test 1 and StaRRsed measurements confi rmed the results of previous studies: an overall correlation coeffi cient of R ϭ 0.90. However, further statistical analysis showed that, depending on the instrument that was used, in 78 samples (i.e. 11.5%) the results could lead to different treatment suggestions. Furthermore it appeared that several procedural factors could infl uence the fi nal Test 1 outcome. Conclusions: Due to its sensitivity for procedural variations, Test 1 measurements should be carried out under strictly standardized conditions. Especially at the higher ESR levels the Test 1 technique is, however, not a reliable alternative for the ICSH approved 'Westergren' method.

Keywords. Rheumatic heart disease; Mitral valve regurgitation; Mitral valve stenosis; Aortic valve regurgitation; Aortic valve stenosis * Tel.: +61 2 93820770; fax: +61 2 93820792. E-mail address: [email protected]. This makes it more difficult to maintain continuity of care for patients with chronic rheumatic heart disease who live in these areas. Limited specialist outreach services also means that echocardiography is often not available since this procedure requires a skilled sonographer or cardiologist/physician to perform the studies. The ability to perform regular Echocardiographic studies in patients with chronic rheumatic heart disease is essential and the recent availability of portable cardiac ultrasound units has been a major step forward. However, the units are expensive, often more than $100,000 and require skilled operators, who are not always available, either medical or technical.

Pediatric rheumatic diseases with predominant musculoskeletal involvement such as juvenile idiopathic arthritis (JIA) and juvenile dermatomyositis(JDM) can cause considerable physical functional impairment and significantly affect the children's quality of life (QOL). Physical function, QOL, health-related QOL (HRQOL) and health status are personal constructs used as outcomes to estimate the impact of these diseases and often used as proxies for each other. The chronic, fluctuating nature of these diseases differs within and between patients, and complicates the measurement of these outcomes. In children, their growing needs and expectations, limited use of age-specific questionnaires, and the use of proxy respondents further influences this evaluation. This article will briefly review the different constructs inclusive of and related to physical function, and the scales used for measuring them. An understanding of these instruments will enable assessment of functional outcome in clinical studies of children with rheumatic diseases, measure the impact of the disease and treatments on their lives, and guide us in formulating appropriate interventions.

Atrial fibrillation is the most common arrhythmia in the United States, whose incidence is greatest in the elderly population. This rhythm disorder can be paroxysmal or chronic and is associated with a range of clinical conditions from palpitations and dyspnea to stroke and death. In ...

Chronic musculoskeletal (MS) syndromes are some of the most common and debilitating diseases in the United States. These syndromes range from conditions such as osteoarthritis (OA) and rheumatoid arthritis (RA) to more vague but common problems such as fibromyalgia, fibrositis, myalgias, and arthralgias. OA alone affects nearly 10% of the population over 60 years of age, resulting in an average of 3.5 physician visits and 3.7 million hospitalizations per year.1s, 2o The economic impact of these diseases results in billions of dollars spent on medications, physical therapy, and surgery and millions of lost work days every year.22 For individuals who do not die of more lethal diseases such as cardiovascular disease, stroke, or cancer, arthritis and MS syndromes often become major obstacles to quality life in later years.

Atrial fibrillation is a complication of mitral valve stenosis that causes several adverse neurologic outcomes. Our objective was to establish a mathematical model to predict the risk of atrial fibrillation in patients with mitral stenosis. Of 819 patients with mitral stenosis who were screened, 603 were enrolled in the study and grouped according to whether they were in sinus rhythm or atrial fibrillation. Demographic, echocardiographic, and hemodynamic data were recorded. Logistic regression models were constructed to identify the relative risks for each contributing factor and calculate the probability of developing atrial fibrillation. Receiver operating characteristic curves were plotted. Two hundred (33%) patients had atrial fibrillation; this group was older, in a higher functional class, more likely to have suffered previous thromboembolic events, and had significantly larger left atrial diameters, lower ejection fractions, and lower left atrial appendage emptying flow veloc...

Objectives. In the past, treatment options for ankylosing spondylitis (AS) have been limited, and the introduction of new treatments such as infliximab will have a noticeable impact on health-care budgets. The objective of this study was therefore to assess the current burden of the disease and estimate the cost-effectiveness of infliximab treatments. Methods. A cross-sectional retrospective observational study of resource

Objetivo: Avaliar o perfil imunológico e a expressão gênica de endotelina-1 em valvas mitrais de pacientes com febre reumática, originados de um serviço de referência em cirurgia cardiovascular. Métodos: Este foi um estudo quantitativo, observacional e transversal. Trinta e cinco indivíduos (divididos em quatro grupos) participaram do estudo, 25 deles com doença cardíaca reumática crônica, além de 10 controles. A média de idade da amostra estudada foi de 34,5 anos. Dezessete (48,58%) dos indivíduos eram homens, e 18 (51,42%) eram mulheres. Foram medidas algumas citocinas inflamatórias (TNF-α, IL-4 e IL-10) e coletadas 10 valvas mitrais de pacientes que se submeteram a primeira troca valvar para determinação da expressão gênica de endotelina-1 pelo PCR real-time. Resultados: Entre os grupos estudados (pacientes e controles), observou-se diferença estatisticamente significante em rela-Rev Bras Cir Cardiovasc | Braz J Cardiovasc Surg Rev Bras Cir Cardiovasc 2014;29(1):25-30 Leão SC, et al. -IL-10 and ET-1 as biomarkers of rheumatic valve disease Rev Bras Cir Cardiovasc | Braz J Cardiovasc Surg Rev Bras Cir Cardiovasc 2014;29(1):25-30 Leão SC, et al. -IL-10 and ET-1 as biomarkers of rheumatic valve disease Rev Bras Cir Cardiovasc | Braz J Cardiovasc Surg Rev Bras Cir Cardiovasc 2014;29(1):25-30 Leão SC, et al. -IL-10 and ET-1 as biomarkers of rheumatic valve disease

Tel.: +61 2 9382 0770; fax: +61 2 9382 0792. E-mail address: [email protected] (W. Walsh). vices and major hospitals. (2) Follow-up care often poses many difficulties because of geographical, cultural and other barriers. (3) Medication adherence is often difficult because of the many other daily problems facing Aboriginal and Torres Strait Islander families-for instance, in some situations long-term warfarin therapy may be problematic and this will have a significant impact on the type of valve surgery that can be performed.