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The quantity contract is a contract that happens after the quotation but before an order Quantity contracts are used mainly to limit the quantity the customer can buy and to offer special pricing Generally, quantity contracts are used when the demand for a material is greater than the available supply, and the business has to implement measures to limit the supplied quantity evenly between its customer base The SAP standard sales document type for quantity contracts is KM or CQ (English)

The diagnostic criteria first described by Jones were updated in 1992 The presence of two major criteria or one major and two minor criteria establishes the diagnosis

Rheumatic fever may be confused with the following: rheumatoid arthritis, osteomyelitis, endocarditis, chronic meningococcemia, systemic lupus erythematosus, Lyme disease, sickle cell anemia, surgical abdomen, and many other diseases

residual valvular disease, it can be stopped at 10 years after the episode If carditis has occurred with residual valvular involvement, it should be continued for 10 years after the last episode or until age 40 years if the patient is in a situation in which reexposure would be expected

The preferred method of prophylaxis is with benzathine penicillin G, 12 million units intramuscularly every 4 weeks Oral penicillin (200,000 250,000 units twice daily) is less reliable

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CHF occurs in severe cases In the longer term, the development of rheumatic heart disease is the major problem Other complications include arrhythmias, pericarditis with effusion, and rheumatic pneumonitis

If the patient is allergic to penicillin, sulfadiazine (or sulfisoxazole), 1 g daily, or erythromycin, 250 mg orally twice daily, may be substituted The macrolide azithromycin is similarly effective against group A streptococcal infection If the patient has not had an immediate hypersensitivity (anaphylactic-type) reaction to penicillin, then cephalosporin may also be used

The patient should be kept at strict bed rest until the temperature returns to normal (without the use of antipyretic medications) and the sedimentation rate, plus the resting pulse rate, and the ECG have all returned to baseline

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1 Salicylates The salicylates markedly reduce fever and relieve joint pain and swelling They have no effect on the natural course of the disease Adults may require large doses of aspirin, 06 09 g every 4 hours; children are treated with lower doses 2 Penicillin Penicillin (benzathine penicillin, 12 million units intramuscularly once, or procaine penicillin, 600,000 units intramuscularly daily for 10 days) is used to eradicate streptococcal infection if present Erythromycin may be substituted (40 mg/kg/d) 3 Corticosteroids There is no proof that cardiac damage is prevented or minimized by corticosteroids A short course of corticosteroids (prednisone, 40 60 mg orally daily, with tapering over 2 weeks) usually causes rapid improvement of the joint symptoms and is indicated when response to salicylates has been inadequate

Initial episodes of rheumatic fever may last months in children and weeks in adults The immediate mortality rate is 1 2% Persistent rheumatic carditis with cardiomegaly, heart failure, and pericarditis implies a poor prognosis; 30% of children thus affected die within 10 years after the initial attack After 10 years, two-thirds of patients will have detectable valvular abnormalities (usually thickened valves with limited mobility), but significant symptomatic valvular heart disease or persistent cardiomyopathy occurs in less than 10% of patients with a single episode In developing countries, acute rheumatic fever occurs earlier in life, recurs more frequently, and the evolution to chronic valvular disease is both accelerated and more severe

Chronic rheumatic heart disease results from single or repeated attacks of rheumatic fever that produce rigidity and deformity of valve cusps, fusion of the commissures, or shortening and fusion of the chordae tendineae Stenosis or insufficiency results, and the two often coexist The mitral valve alone is affected in 50 60% of cases; combined lesions of the aortic and mitral valves occur in 20%; pure aortic lesions are less common Tricuspid involvement occurs in about 10% of cases but only in association with mitral or aortic disease and is thought to be more common when recurrent infections have occurred The pulmonary valve is rarely affected A history of rheumatic fever is obtainable in only 60% of patients with rheumatic heart disease

Carapetis JR et al Acute rheumatic fever Lancet 2005 Jul 9 15;366(9480):155 68 [PMID: 16005340] Lee GM et al Changing epidemiology of acute rheumatic fever in the United States Clin Infect Dis 2006 Feb 15;42(4):448 50 [PMID: 16421786]

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