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GP ACRRM > Aboriginal Health > Flashcards

Aboriginal Health Flashcards

1
Q

In which population groups should Strongyloidiasis be considered

A

Residents of endemic areas (tropical and subtropical Aboriginal communities), immigrants, refugees, veterans of WWII and Vietnam War, workers and travelers returning from endemic areas

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2
Q

How is a strongyloides infection caught

A

Larvae penetrate skin -> bloodstream -> pulmonary capillaries -> alveolar space -> ascend bronchial tree -> swallowed by host -> small intestine

There mature into worms -> penetrate mucosa -> lay eggs which hatch into larvae -> penetrate colonic wall or perianal skin and re-enter body via autoinfective cycle

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3
Q

Pathognomic sign of strongyloidiasis

A

Larva currens
Erythematous wavy lesions that appear and move rapidly (2-10cm/h)
Usually on trunk or buttocks

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4
Q

Signs and symptoms of strongyloidiasis

A

Highly variable, depending on site and number of worms, Can include:
Dyspnoea/lung symptoms
Prutirtus, recurrent rash/urticaria
Diarrhoea, wasting, epigastric pain, melaena
Gram-negative sepsis
Eosinophilia

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5
Q

Diagnosing strongyloidiasis

A

Acute or dissmeinated disease: faecal OCP
Chronic infection: serology (strongyloides IgG ELISA)
Intermittent eosinophilia in 10-70% of chronic cases

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6
Q

Management of strongyloidiasis in immunocompetent patients

A

Ivermectin 200 microg/kg with fatty food stat on day 1 and repeated 7-14 days later

OR Albendazole 400mg with fatty food BD fo 3 days then repeat after 7-14 days (lower cure rate, only used if ivermectin unsuitable e.g. due to concurrent Loa loa infection)

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7
Q

Management of strongyloidiasis in immunocompromised patients

A

Ivermectin 200microg/kg orally with fatty food on days 1, 2, 15, 16
Seek ID advice as may required longer courses of therapy

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8
Q

Strongyloides prophylaxis prior to commencing immunosuppression for patients at risk

A

If serology positive: ivermectin 200microg/kg orally with fatty food once weekly for 2 doases

If serology negative (from remote ATSI communities): ivermectin 200 microg/kg orally with fatty food as single dose

Ongoing primary prophylacis every 3 months recommended for patients requiring significant immunosuppression and returning to endemic communities

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9
Q

Criteria for cure of chronic strongyloidiasis

A

Negative serology
Negative faeces OCP
No symptoms

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10
Q

Peak age for acute rheumatic fever

A

5-20y

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11
Q

High risk groups for acute rheumatic fever

A

Those living in RF-endemic setting
ATSI people living in rural or remote setting
ATSI, Maori and Pacific islander peoples living in overcrowded housing OR of low SE status
Personal history of ARF/RHD and aged <40y

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12
Q

Primordial prevention of ARF

A
  • washing of hands and bodies with soap and water
  • wash clothing and bedding in a manner that kills lice and scabies (>50deg or tumble dried >40 min)
  • reduce overcrowding
  • reduce hazards that cause skin trauma (i.e clean and tidy yards)
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13
Q

Primary prevention of ARF

A

Recognise strep A throat and skin infections early in high risk populations
Early treatment
- throat: IM BPG or PO PMP (inferior)
- skin: IM BPG or PO cotrimoxazole (non-inferior)

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14
Q

Presentation of ARF in Australia

A

High rate in Australia of arthritis being the only major manifestation

Major manifestations:

  1. ARTHRITIS:
    - very responsive to NSAIDs
    - large joints usually affected (esp knees and ankles)
    - usually asymmetrical and migratory but can be additive
  2. Sydenham Chorea:
    - predominantly affects female teenagers
    - jerky, uncoordinated movements of hands, feet, tongue and face
    - disappear during sleep
    - can occur after a prolonged latent period following GAS, therefore diagnosis does not require other manifestations or strep titres
    - high association with carditis
  3. CARDITIS
    - predominantly endocardial involvement -> valvulitis
    - may not appear until 6 weeks after presentation
    - most common findings: significant murmur (MR or AS), cardiac enlargement (apex beat, echo or CXR), cardiac decompensation (<10% in initial episode but more common in recurrence), pericardial friction rub or effusion
  4. SUBCUTANEOUS NODULES
    - very rare (<2% of cases) but highly specific
    - 0.5-2cm round, firm, freely mobile, painless
    - occur in crops of up to 12 over elbows, wrists, knees, ankles, achilles, occiput and posterior spinous processes
    - appear 1-2 weeks after onset of other symtpoms and only last 1-2 weeks
    - strongly associated with carditis
  5. ERYTHEMA MARGINATUM
    - very rare (<2%) but highly specific
    - bright pink macules or papules
    - blanching
    - wax and wane rapidly during the day
    - not itchy or painful
    - on trunk and proximal extremities
    - more apparent after a shower
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15
Q

Diagnostic criteria for definite initial episode of acute rheumatic fever

A

2 major manifestations + evidence of preceding GAS infection
OR
1 major + 2 minor manifestations + evidence of preceding GAS infection

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16
Q

Diagnostic criteria for recurrent episode of ARF in a patient with documented history of ARF or RHD

A 
Evidence of preceding GAS infection 
PLUS
1. 2 major manifestations
OR
2. 1 major + 2 minor manifestations
OR
3. 3 minor manifestations
17
Q

Definition of probable or possible episode of acute rheumatic fever

A

Clinical presentation where ARF is considered likely but falls short in meeting diagnostic criteria by either:
- 1 major or 1 minor manifestation
OR
- No evidence of preceding GAS infection

18
Q

Major manifestations of acute rheumatic fever

A 
Subcutaneous nodules
Pancarditis
Poly ARTHRITIS (or in high risk groups aseptic monoarthritis or polyarthralgia)
Chorea (Sydenham's)
Erythema marginatum
19
Q

Minor manifestations of acute rheumatic fever

A

CAFE:

CRP>30 or ESR>30 (or ESR>60 in low risk groups)
Arthralgia (monoarthralgia in high risk group, polyarthralgia or aseptic monoarthritis in low risk groups)
Fever >38 (of >38.5 in low risk groups)
ECG changes (prolonged PR interval)

20
Q

Evidence of Group A Stretococcus required for diagnosis of ARF

A

EITHER

  1. Throat swab (poorly sensitive)
  2. Streptococcal antibody titres
    - ASO titre (rises within 1-2 weeks, peaks 3-6 weeks, returns to pre-infection after 6-12 months)
    - Anti-DNase B (takes 6-8 weeks to peak, can remain elevated indefinitely during childhood)

**take titre values in acute stage and repeat in convalescent phase 14-28 days later (positive = 2 fold increase or more)

21
Q

Work up recommended for suspected acute rheumatic fever

A

Admission to hospital is recommended

  • strep serology
  • inflammatory markers (CRP and ESR>30)
  • ECG
  • Echocardiography - all patients with suspected ARF require within a maximum of 4 weeks
  • blood cultures if documented fever
  • joint aspirate if monoarthritis (and treat as per septic arthritis while awaiting results)
22
Q

Short term management of suspected ARF

A
  • notify public health unit (all suspected and confirmed new or recurrent)
  • Eradication antibiotics: Give first dose of benzathine penicillin IM ASAP (1.2million units unless <20kg)
  • Symptom management
  • Pain: paracetamol +/- tramadol while awaiting diagnostic confirmation, NSAIDs following diagnosis
  • Chorea: no txif mild, if mod-severe: CBZ or valproate, if very severe consider oral prednisolone 1-2mg/kg/day
  • Carditis: if CCF, seek specialist advice. Bed rest, frusemide, fluid restriction, spironolactone, enalapril
23
Q

Long term management following episode of ARF

A

Education: primordial and “primary” prevention strategies, education of disease and importance of adherence etc.

Immunisations up to date including annual fluvax

Antibiotic prophylaxis: Benzathine benzylpenicillin 1.2 million units (or 0.6million if<20kg) every 28 days OR every 21 days if breakthrough on 28 day regime or mod-severe carditis. (Oral BD erythromycin if penicillin allergy)

24
Q

Duration to continue prophylactic antibiotics following acute rheumatic fever

A
  • POSSIBLE ARF: 12 months if no signs or symptoms and normal echo at 12 months
  • PROBABLE ARF: 5 years OR until 21yo (whichever is longer)
  • Definite ARF without RHD: 10 years(min 5y) after most recent episode or until 21yo (whichever longer)
  • ARF with mild RHD: minimum 10y or 21yo
  • moderate RHD: until 35yo
  • Severe RHD or post cardiac valve surgery for RHD: until 40y OR lifelong if very severe
25
Q

Recurrent episodes of acute rheumatic fever - statistics

A

Most likely to occur in the first year after ARF diagnosis- then risk continues to decrease over next 5-10 years

Many cases will mimic the initial episode (but can also be non-mimetic, hence why prophylaxis is important even if no carditis in initial episode)

GP ACRRM (14 decks)

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