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1 Carditis Carditis is most likely to be evident in children and adolescents Any of the following suggests the presence of carditis: (1) pericarditis; (2) cardiomegaly, detected by physical signs, radiography, or echocardiography; (3) CHF, right- or left-sided the former perhaps more prominent in children, with painful liver engorgement due to tricuspid regurgitation; and (4) mitral or aortic regurgitation murmurs, indicative of dilation of a valve ring with or without associated valvulitis The Carey Coombs short mid-diastolic mitral murmur may be present In the absence of any of the above definitive signs, the diagnosis of carditis depends on the following less specific abnormalities: (1) ECG changes, including changing contour of P waves or inversion of T waves; (2) changing quality of heart sounds; and (3) sinus tachycardia, arrhythmia, or ectopic beats 2 Erythema marginatum and subcutaneous nodules Erythema marginatum begins as rapidly enlarging macules that assume the shape of rings or crescents with clear centers They may be raised, confluent, and either transient or persistent Subcutaneous nodules are uncommon except in children They are small ( 2 cm in diameter), firm, and nontender and are attached to fascia or tendon sheaths over bony prominences They persist for days or weeks, are recurrent, and are indistinguishable from rheumatoid nodules 3 Sydenham s chorea Sydenham s chorea involuntary choreoathetoid movements primarily of the face, tongue, and upper extremities may be the sole manifestation; only 50% of cases have other overt signs of rheumatic fever Girls are more frequently affected, and occurrence in adults is rare This is the least common (3% of cases) but most diagnostic of the manifestations of rheumatic fever 4 Polyarthritis This is a migratory polyarthritis that involves the large joints sequentially In adults, only a single joint may be affected The arthritis lasts 1 5 weeks and subsides without residual deformity Prompt response of arthritis to therapeutic doses of salicylates or nonsteroidal agents is characteristic.

(Okay, you caught me I did tell you under rule 1 that external rewards are not important Well, they are not as important as internal motivation, but they still count) So, for special occasions you ve achieved the humongous overarching goal (HOG), come in under budget, or had your best year ever hire a motivational speaker to thank the troops for a job well done (I happen to know a real good one, wink wink) If you can t afford that, start building an audio library Rotate the audio programs to your team members so that they can listen on their way to work Meet in brief weekly meetings, and have team members share one powerful principle they learned from each audio program In this way, everyone can learn from everyone else and energize each other at the same time Or show a motivational videotape during your next training session Your team members will be positively surprised and at the same time master strategies that will enable them and your company to succeed faster And oh yes, if you are the skeptic who says, Well, that stuff doesn t last, then let me remind you that neither does taking a shower, so why do you bother taking one every day Follow these 13 rules, and you and your employees will have more fun and get more done, and you ll save money too

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amyloid protein and extent of disease and may include chemotherapy, stem cell transplantation, and liver transplantation Cardiac transplantation is a potential option in patients with primary cardiac amyloidosis

Ammash NM et al Clinical profile and outcome of idiopathic restrictive cardiomyopathy Circulation 2000 May 30;101 (21):2490 6 [PMID: 10831523] Goldstein JA Cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy Curr Probl Cardiol 2004 Sep;29 (9):503 67 [PMID: 15365561] Shah KB et al Amyloidosis and the heart: a comprehensive review Arch Intern Med 2006 Sep 25;166(17):1805 13 [PMID: 17000935] Yazdani K et al Differentiating constrictive pericarditis from restrictive cardiomyopathy Rev Cardiovasc Med 2005 Spring;6(2):61 71 [PMID: 15976729]

Uncommon in the United States (approximately 2 cases/100,000 population); more common (100 cases/100,000 population) in developing countries Peak incidence ages 5 15 years Diagnosis based on Jones criteria and confirmation of streptococcal infection May involve mitral and other valves acutely, rarely leading to heart failure

Rheumatic fever is a systemic immune process that is a sequela to -hemolytic streptococcal infection of the pharynx Pyodermic infections are not associated with rheumatic fever Signs of rheumatic fever usually commence 2 3 weeks after infection but may appear as early as 1 week or as late as 5 weeks In recent years, the disease has become quite uncommon in the United States, except in immigrants; however, there have been reports of new outbreaks in several regions of the United States The peak incidence is between ages 5 and 15 years; rheumatic fever is rare before age 4 years or after age 40 years Rheumatic carditis and valvulitis may be self-limited or may lead to slowly progressive valvular deformity The characteristic lesion is a perivascular granulomatous reaction with vasculitis The mitral valve is attacked in 75 80% of cases, the aortic valve in 30% (but rarely as the sole valve), and the tricuspid and pulmonary valves in under 5% of cases

These include fever, polyarthralgias, reversible prolongation of the PR interval, and an elevated erythrocyte sedimentation rate or CRP Supporting evidence includes positive throat culture or rapid streptococcal antigen test and elevated or rising streptococcal antibody titer

There is nonspecific evidence of inflammatory disease, as shown by a rapid sedimentation rate High or increasing titers of antistreptococcal antibodies (antistreptolysin O and anti-DNase B) are used to confirm recent infection; 10% of cases lack this serologic evidence

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