Case of pelvic relapse in a child suffering from acute lymphoblastic leukemia

We describe here a case of an eight years old child suffering from acute lymphoblastic leukemia. She developed pelvic infiltration of leukemic cells while in bone marrow remission and receiving maintenance chemotherapy: She also developed leukemic infiltration of Central Nervous System and died of complications resulting from massive pelvic relapse. With greater number of children in bone marrow and CNS remission, the issue ofpossible greater predisposition to extramedullary relapse has been discussed. The need for greater vigilance towards pelvic surveillance has been stressed

Biostimulatory effects of low-intensity pulsed ultrasound on rate of orthodontic tooth movement and associated pain, applied at 3-week intervals: A split-mouth study

Objective: Low-intensity pulsed ultrasound (LIPUS) is a noninvasive modality to stimulate bone remodeling (BR) and the healing of hard and soft tissues. This research evaluates the biostimulatory effect of LIPUS on the rate of orthodontic tooth movement (OTM) and associated pain, when applied at 3-week intervals.Methods: Twenty-two patients (11 males and 11 females; mean age 19.18 ± 2.00 years) having Angle\u27s Class II division 1 malocclusion needing bilateral extractions of maxillary first bicuspids were recruited for this split-mouth randomized clinical trial. After the initial stage of alignment and leveling with contemporary edgewise MBT (McLaughlin-Bennett-Trevisi) prescription brackets (Ortho Organizers, Carlsbad, Calif) of 22 mil, followed by extractions of premolars bilaterally, 6 mm nickel-titanium spring was used to retract the canines separately by applying 150 g force on 0.019 × 0.025-in stainless steel working archwires. LIPUS (1.1 MHz frequency and 30 mW/cm2 intensity output) was applied for 20 minutes extraorally and reapplied after 3 weeks for 2 more successive visits over the root of maxillary canine on the experimental side whereas the other side was placebo. A numerical rating scale- (NRS-) based questionnaire was given to the patients on each visit to record their weekly pain experience. Impressions were also made at each visit before the application of LIPUS (T1, T2, and T3). Models were scanned with a CAD/CAM scanner (Planmeca, Helsinki, Finland). Mann-Whitney U test was applied for comparison of canine movement and pain intensity between both the groups.Results: No significant difference in the rate of canine movement was found among the experimental (0.90 mm ± 0.33 mm) and placebo groups (0.81 mm ± 0.32 mm). There was no difference in pain reduction between experimental and placebo groups (p \u3e 0.05).Conclusion: Single-dose application of LIPUS at 3-week intervals is ineffective in stimulating the OTM and reducing associated treatment pain

Incentives to change: effects of performance-based financing on health workers in Zambia

Background: Performance-based financing (PBF) has been implemented in a number of countries with the aim of transforming health systems and improving maternal and child health. This paper examines the effect of PBF on health workers’ job satisfaction, motivation, and attrition in Zambia. It uses a randomized intervention/control design to evaluate before–after changes for three groups: intervention (PBF) group, control 1 (C1; enhanced financing) group, and control 2 (C2; pure control) group. Methods: Mixed methods are employed. The quantitative portion comprises of a baseline and an endline survey. The survey and sampling scheme were designed to allow for a rigorous impact evaluation of PBF or C1 on several key performance indicators. The qualitative portion seeks to explain the pathways underlying the observed differences through interviews conducted at the beginning and at the three-year mark of the PBF program. Results: Econometric analysis shows that PBF led to increased job satisfaction and decreased attrition on a subset of measures, with little effect on motivation. The C1 group also experienced some positive effects on job satisfaction. The null results of the quantitative assessment of motivation cohere with those of the qualitative assessment, which revealed that workers remain motivated by their dedication to the profession and to provide health care to the community rather than by financial incentives. The qualitative evidence also provides two explanations for higher overall job satisfaction in the C1 than in the PBF group: better working conditions and more effective supervision from the District Medical Office. The PBF group had higher satisfaction with compensation than both control groups because they have higher compensation and financial autonomy, which was intended to be part of the PBF intervention. While PBF could not address all the reasons for attrition, it did lower turnover because those health centers were staffed with qualified personnel and the personnel had role clarity. Conclusions: In Zambia, the implementation of PBF schemes brought about a significant increase in job satisfaction and a decrease in attrition, but had no significant effect on motivation. Enhanced health financing also increased stated job satisfaction

Pain Perception and Rate of Canine Retraction Through Self- Ligating Brackets and Conventional Elastomeric Ligation System: A Split Mouth Study

Objective: To evaluate the rate of tooth movement and the pain perception via self-ligating (SL) and conventional elastomeric ligation brackets (CB) system. Material and Methods: This study has been conducted at the Orthodontic Department of Baqai Dental College, Baqai Medical University. The sample size of this study comprised 40 patients, falling between the age of 12-30 years without any sex discrimination. Shapiro-Wilk was used to check the distribution of data. Non-parametric Mann Whitney U test was applied to evaluate the pain associated with SL and CB brackets system. To analysis the canine retraction Wilcoxon test was applied for the comparison of CB and SL brackets system. For all statistical analyses, the p-value of <0.05 was considered significant. Results: Pain level associated with retraction via CB and SL shows significant differences. However, the rate of canine retraction via CB and SL shows no significant differences at stages T0-T1 and T1-T2. However, stage T2-T3 shows a significant difference. Conclusion: As pain during orthodontic treatment is mostly associated with the level of compression of the periodontal ligament, it may be hypothesized that lower frictional forces generate less compression of the periodontal ligament and blood vessels, and so alter the type of pain experienced

Peak myocardial work assessment to detect coronary ischemia during dobutamine stress echocardiography

IntroductionPeak global myocardial work efficiency (GWE), a measure of peak global myocardial constructive to wasted work ratio, has been shown to discriminate coronary ischemia during treadmill stress echocardiography (SE). We wanted to assess additive utility of peak global longitudinal strain (GLS), global work index (GWI), and GWE in improving positive predictive value (PPV) of an abnormal dobutamine stress echocardiography (DSE) and calculate cost-savings by avoiding secondary tests.MethodsWe prospectively enrolled patients with abnormal DSE who underwent secondary confirmatory tests to confirm significant CAD as our primary cohort, and measured baseline and peak GLS, GWI, and GWE. We also included a control group with normal DSE results and similar measurements. The cost of secondary testing was used to calculate potential savings.ResultsAmong the 45 patients (71% females, mean age 60 ± 12 yrs.), 9 had significant CAD, 11 had non-significant CAD, and 25 were controls (N). Patients with significant CAD had significantly lower peak GLS [−15 (−17, −12.5) vs. −20 (−22, −19.5)%, p < 0.001], peak GWI [1,057 (810.5, 1,057) vs. 2,245 (1,928.5, 2,961) mmHg%, p = 0.02], peak GWE [82 (74.5, 86.5) vs. 89 [(86, 93.5)%, p = 0.001], and peak GCW [1,618 (1,153.5, 2,003) vs. 2,585 (2,262.5, 3,262) mmHg%, p = 0.02] compared to control. ROC analysis demonstrated peak GWE [AUC 0.76 (0.55, 0.97) p = 0.01] to discriminate coronary ischemia. Incorporating peak GWE of <87% into abnormal DSE interpretation improved PPV from 45% to 81%, resulting in an estimated cost savings of $8,274.00 per screened patient.ConclusionsIncorporating peak GWE into standard DSE interpretation enhanced diagnostic accuracy and reduced the cost of downstream testing

Prognostic implications of left ventricular hypertrophy

Left ventricular hypertrophy (LVH) was one of the earliest studied echocardiographic characteristics of the left ventricle. As the myriad of measurable metrics has multiplied over recent years, this reliable and relevant variable can often be overlooked. In this paper, we discuss appropriate techniques for accurate analysis, underlying pathophysiology, and the contributions from various risk factors. The prognostic implications of LVH on stroke, serious arrhythmias, and sudden cardiac death are reviewed. Finally, we examine the effect of therapy to reduce LVH and the resultant clinical outcomes. (C) 2018 Elsevier Inc. All rights reserved

Impact of Preinfection Left Ventricular Ejection Fraction on Outcomes in COVID-19 Infection.

Coronavirus disease 2019 (COVID-19) has high infectivity and causes extensive morbidity and mortality. Cardiovascular disease is a risk factor for adverse outcomes in COVID-19, but baseline left ventricular ejection fraction (LVEF) in particular has not been evaluated thoroughly in this context. We analyzed patients in our states largest health system who were diagnosed with COVID-19 between March 20 and May 15, 2020. Inclusion required an available echocardiogram within 1 year prior to diagnosis. The primary outcome was all-cause mortality. LVEF was analyzed both as a continuous variable and using a cutoff of 40%. Among 396 patients (67 ± 16 years, 191 [48%] male, 235 [59%] Black, 59 [15%] LVEF ≤40%), 289 (73%) required hospital admission, and 116 (29%) died during 85 ± 63 days of follow-up. Echocardiograms, performed a median of 57 (IQR 11-122) days prior to COVID-19 diagnosis, showed a similar distribution of LVEF between survivors and decedents (P = 0.84). Receiver operator characteristic analysis revealed no predictive ability of LVEF for mortality, and there was no difference in survival among those with LVEF ≤40% versus >40% (P = 0.49). Multivariable analysis did not change these relationships. Similarly, there was no difference in LVEF based on whether the patient required hospital admission (56 ± 13 vs 55 ± 13, P = 0.38), and patients with a depressed LVEF did not require admission more frequently than their preserved-LVEF peers (P = 0.87). A premorbid history of dyspnea consistent with symptomatic heart failure was not associated with mortality (P = 0.74). Among patients diagnosed with COVID-19, pre-COVID-19 LVEF was not a risk factor for death or hospitalization

Atrial Fibrillation, Heart Failure and Left Atrial Function

Background Our aim was to assess how atrial fibrillation (AF) induction, chronicity, and RR interval irregularity affect left atrial (LA) function and size in the setting of underlying heart failure (HF), and to determine whether AF effects can be mitigated by vagal nerve stimulation (VNS). Methods HF was induced by 4-weeks of rapid ventricular pacing in 24 dogs. Subsequently, AF was induced and maintained by atrial pacing at 600 bpm. Dogs were randomized into control (n = 9) and VNS (n = 15) groups. In the VNS group, atrioventricular node fat pad stimulation (310 μs, 20 Hz, 3–7 mA) was delivered continuously for 6 months. LA volume and LA strain data were calculated from bi-weekly echocardiograms. Results RR intervals decreased with HF in both groups (p = 0.001), and decreased further during AF in control group (p = 0.014), with a non-significant increase in the VNS group during AF. LA size increased with HF (p<0.0001), with no additional increase during AF. LA strain decreased with HF (p = 0.025) and further decreased after induction of AF (p = 0.0001). LA strain decreased less (p = 0.001) in the VNS than in the control group. Beat-by-beat analysis showed a curvilinear increase of LA strain with longer preceding RR interval, (r = 0.45, p <0.0001) with LA strain 1.1% higher (p = 0.02) in the VNS-treated animals, independent of preceding RR interval duration. The curvilinear relationship between ratio of preceding and pre-preceding RR intervals, and subsequent LA strain was weaker, (r = 0.28, p = 0.001). However, VNS-treated animals again had higher LA strain (by 2.2%, p = 0.002) independently of the ratio of preceding and pre-preceding RR intervals. Conclusions In the underlying presence of pacing-induced HF, AF decreased LA strain, with little impact on LA size. LA strain depends on the preceding RR interval duration

Echocardiographic assessment of degenerative mitral stenosis: a diagnostic challenge of an Eemerging cardiac disease

Degenerative mitral stenosis (DMS) is characterized by decreased mitral valve (MV) orifice area and increased transmitral pressure gradient due to chronic noninflammatory degeneration and subsequent calcification of the fibrous mitral annulus and the MV leaflets. The “true” prevalence of DMS in the general population is unknown. DMS predominantly affects elderly individuals, many of whom have multiple other comorbidities. Transcatheter MV replacement techniques, although their long-term outcomes are yet to be tested, have been gaining popularity and may emerge as more effective and relatively safer treatment option for patients with DMS. Echocardiography is the primary imaging modality for evaluation of DMS and related hemodynamic abnormalities such as increased transmitral pressure gradient and pulmonary arterial pressure. Classic echocardiographic techniques used for evaluation of mitral stenosis (pressure half time, proximal isovelocity surface area, continuity equation, and MV area planimetry) lack validation for DMS. Direct planimetry with 3-dimensional echocardiography and color flow Doppler is a reasonable technique for determining MV area in DMS. Cardiac computed tomography is an essential tool for planning potential interventions or surgeries for DMS. This article reviews the current concepts on mitral annular calcification and its role in DMS. We then discuss the epidemiology, natural history, differential diagnosis, mechanisms, and echocardiographic assessment of DMS