Genioplasty - A Review.

Genioplasty, a key technique for dentofacial abnormalities, is essential for establishing facial harmony. This surgical procedure entails an osteotomy of the chin, which alters its three-dimensional location to restore overall face equilibrium. Modern genioplasty, which is frequently performed alone or in combination with rhinoplasty, facelifts, and orthognathic surgery, employs a variety of materials for chin augmentation, ranging from autologous to alloplastic. Recent improvements include porous graft materials such as high-density polyethylene. Despite the need for secure osteotomy segments, soft tissues around the mandible have a natural propensity to return to their original anatomical position. In the discipline of genioplasty, face esthetics and facial evaluation have been a prominent emphasis, with historical evidence emphasizing the relevance of the chin in harmony, balance, and character perception. Customized implants provide a single therapy for rare anatomical defects, generally with lower morbidity, making them critical for patients undergoing many procedures or suffering from syndromic disorders. Virtual surgical planning advances will continue to give dependable solutions for small and complex chin position issues. Modern surgeons will continue to combine history, anatomy, rigorous evaluation, excellent execution, and technological breakthroughs to achieve the best possible outcomes for their patients, raising their social standing.

Photoluminescence behavior of Eu3+ doped XAl2O4(X = Mg, Ca, Sr and Ba) phosphors: a comparative study.

In this work, the Eu3+doped stuffed tridymite type structure of alkaline earths aluminate i.e. XAl2O4(X = Mg, Ca, Sr and Ba) phosphor materials have been synthesized by conventional high temperature solid state reaction method at 1623 K. The Samples were structurally and morphologically characterized by x-ray diffraction (XRD) and Scanning electron microscope (SEM) measurements. The vibrational behavior of the phosphor samples were investigated by Fourier transform infrared (FTIR) measurements. The phosphor samples emit intense red emission in 610-615 nm range due to5D0 â†’ 7F2transition of Eu3+ion on excitation with charge transfer band (CTB) wavelength arising due to Eu3+-O2-and also by the discrete bands of Eu3+ions .The decay time of5D0level of Eu3+ion were recorded on excitation with 393 nm and by the CTB wavelength for all the four samples. The optimized 1 mol% Eu3+doped CaAl2O4phosphor exhibits optimum emission intensity and color purity under the excitation with 393 nm than others. The decay time is also found to be larger in the case of Eu3+doped CaAl2O4phosphor sample. Therefore, Eu3+doped CaAl2O4phosphor may be promising material for red color light emitting applications and white light generation.

Conservation agriculture based integrated crop management sustains productivity and economic profitability along with soil properties of the maize-wheat rotation.

Field experiments were conducted to evaluate eight different integrated crop management (ICM) modules for 5 years in a maize-wheat rotation (MWR); wherein, ICM1&2-'business-as-usual' (conventional flatbed maize and wheat, ICM3&4-conventional raised bed (CTRB) maize and wheat without residues, ICM5&6-conservation agriculture (CA)-based zero-till (ZT) flatbed maize and wheat with the residues, and ICM7&8- CA-based ZT raised bed maize and wheat with the residues. Results indicated that the ICM7&8 produced significantly (p < 0.05) the highest maize grain yield (5 years av.) which was 7.8-21.3% greater than the ICM1-6. However, across years, the ICM5-8 gave a statistically similar wheat grain yield and was 8.4-11.5% greater than the ICM1-4. Similarly, the CA-based residue retained ICM5-8 modules had given 9.5-14.3% (5 years av.) greater system yields in terms of maize grain equivalents (MGEY) over the residue removed CT-based ICM1&4. System water productivity (SWP) was the highest with ICM5-8, being 10.3-17.8% higher than the ICM1-4. Nevertheless, the highest water use (TWU) was recorded in the CT flatbed (ICM1&2), ~ 7% more than the raised bed and ZT planted crops with or without the residues (ICM4-8). Furthermore, the ICM1-4 had produced 9.54% greater variable production costs compared to the ICM5-8, whereas, the ICM5-8 gave 24.3-27.4% additional returns than the ICM1-4. Also, different ICM modules caused significant (p < 0.05) impacts on the soil properties, such as organic carbon (SOC), microbial biomass carbon (SMBC), dehydrogenase (SDH), alkaline phosphatase (SAP), and urease (URE) activities. In 0.0-0.15 m soil profile, residue retained CA-based (ICM5-8) modules registered a 7.1-14.3% greater SOC and 10.2-17.3% SMBC than the ICM1-4. The sustainable yield index (SYI) of MWR was 13.4-18.6% greater under the ICM7&8 compared to the ICM1-4. Hence, this study concludes that the adoption of the CA-based residue retained ICMs in the MWR could sustain the crop yields, enhance farm profits, save water and improve soil properties of the north-western plans of India.

Hydrogen sulphide: an emerging regulator of plant defence signalling.

Hydrogen sulphide (H2 S), a gaseous signalling molecule in plants, has gained considerable attention in recent years because of its emerging roles in the regulation of plant growth and development and responses to abiotic stressors. Although the involvement of H2 S in biotic stress is not well documented in the literature, a growing body of evidence indicates its potential role in plant defence, particularly against bacterial and fungal pathogens. Recent reports have suggested that H2 S participates in plant defence signalling potentially by (1) regulating glutathione metabolism, (2) inducing expression of pathogenesis-related (PR) and other defence-related genes, (3) modulating enzyme activity through post-translational modifications, and (4) interacting with phytohormones such as jasmonic acid, ethylene and auxin. In this review, we discuss the biosynthesis, metabolism and interaction of H2 S with phytohormones, and highlight evidence gathered so far to support the emerging roles of H2 S in plant defence against invading pathogens.

Estimation of Fertilization Rate, Implantation Rate, Pregnancy Rate and Live Birth Rate in Intracytoplasmic Sperm Injection in Association with Number of Attempts and Sperm Morphology.

Infertility is a growing health problem. It affects relatively large number of couples both globally as well as in India. Fertility treatment registers suggest that infertility is on increase. With the advancement in the knowledge and technology about the In Vitro fertilization (IVF) process, In Vitro fertilization success rates are improving over the time. In many cases of male-factor infertility, Intracytoplasmic sperm injection (ICSI) is the recommended treatment. The aim of this study was to estimate fertilization, implantation and pregnancy rates in ICSI cycles in association with number of attempts and sperm morphology. A total of 250 IVF-ICSI cycles were performed at a Fertility Center in Jaipur, Rajasthan, India. This cohort study was performed during 2013 to 2015. The differences in the outcomes of ICSI in association with sperm morphology and number of ICSI attempt were evaluated. Significantly higher mean was observed in fertilization rate and live birth rate with ≥5% sperm morphology 79.63% vs. 71.46% and 20% vs. 13.9% respectively). Significantly higher mean implantation rate and clinical pregnancy rate (CPR) and live birth rate were observed with attempt 3 as compared to 1 and 2 attempts. IVF success rates are improving over the time as knowledge and technology are advancing. Sperm morphology and number of attempt affect the ICSI outcomes.

Awareness Regarding Causes of Infertility Among Out-patients at a Tertiary Care Hospital in Karachi, Pakistan.

INTRODUCTION:  Infertility is the inability of a couple to achieve pregnancy within 12 months of sexual intercourse without the use of contraceptives. The Pakistani population, belonging to a low-middle income country, has a high prevalence of infertility due to a low knowledge and awareness regarding its causes, and lack of healthcare-seeking behavior for this medical issue. The prevalence of infertility in Pakistan is reported as 22%, with primary infertility accounting for 4% of the total cases. This leads to psychological trauma among women as societal norms equate infertility with failure on a personal, emotional, and social level. In this study, we aimed to assess among this population the general awareness regarding infertility and its causes; and identify any key knowledge gaps pertaining to the subject. METHODS:  A cross-sectional study was carried out between June 2019 and November 2019, at a public hospital (Civil Hospital Karachi) in Karachi, Pakistan. Convenience sampling technique was used to collect data from adult participants (older than 18 years) via an interview-administered questionnaire. The questionnaire was based on the Cardiff Fertility Knowledge Scale (CFKS) and assessed the knowledge regarding causes of infertility such as smoking, healthy lifestyle, contraceptives, genital tract infections among others. We also determined the association between socio-demographic variables with mean knowledge scores. Data were analyzed using Statistical Package for Social Sciences (SPSS), version 20.0. RESULTS:  The majority of the participants were married (n=342, 68.8%) and more than half were unemployed (n=259, 52.1%). Approximately, two-quarters (n=250, 50.3%) did not believe that equal proportions of males and females contribute to infertility. The mean knowledge score of our study population was 12.95 ± 2.48 points. An overwhelming proportion of the participants (n=326, 65.6%) falsely believed that the usage of the intra-uterine device contributes to infertility. Additionally, more than half of the responders (n=278, 55.9%) incorrectly believed that a male achieving erection is an indication of fertility. Education (p=0.019), vehicle ownership (p=0.018), and marital status (p=0.031) were the only demographic factors that showed significant differences with mean knowledge scores. CONCLUSION:  Awareness regarding the causes of infertility among the general population was found to be inadequate. Emphasis on targeted fertility education, in association with general public awareness programs regarding its causes and risk factors may help mitigate this problem by potentially reducing the prevalence of this condition, and increasing the number of affected individuals who seek medical care in a timely fashion.

Laurence-Moon-Bardet-Biedl Syndrome with Coexisting Abdominal Distension and Positive Fluid Thrill: A Rare Manifestation Reported in Karachi, Pakistan.

Laurence-Moon-Bardet-Biedl syndrome (LMBBS) is a rare autosomal recessive (AR) disorder. It is characterized predominantly by hypogonadism, polydactyly, retinitis pigmentosa, obesity, and mental retardation. Herein, we present a classic case of LMBBS with generalized body edema, abdominal distension, and positive fluid thrill in a 32-year-old male. LMBBS patients are friendly with a happy predisposition, proper management, and regular examinations should be done in order to maintain healthy organ function and to avoid an early death. Renal failure is the most common cause of mortality in LMBBS patients.

Smokeless tobacco: Risk factor for cardiovascular and breathing in young Indian adolescent.

BACKGROUND: Teenagers are the foremost susceptible population to smokeless tobacco usage and limited studies have surveyed the influence of smokeless tobacco on cardiac and respiratory response. OBJECTIVE: This study aims to measure consequence (cardiovascular and breathing) of smokeless tobacco usage (gutkha and chewing tobacco) among young Indian men. METHOD: On random basis, the applicants were divided into Group I (n=50) - healthy control group, Group II (n=50) - smokeless tobacco users. Anthropometric measurements and recording of blood pressure (BP), pulse wave analysis (PWV), heart rate variability (HRV) and pulmonary function test (PFT) was performed. RESULT: We observed that altogether anthropometric variables were comparable among all individuals. In blood pressure variable, except DBP, other variables for example SBP, PP and MAP were significantly increased in Group II individuals, once compare to Group I. Pulse wave analysis, (such as, AP, AIx, and SEVR), was comparable in individuals of both groups. As compare to Group I, HR was significantly increased in Group II. In HRV investigation, NN, VLF, LF, LF(nu), LF/HF were increased significantly and TSP, HF, HF(nu) were decreased significantly in Group II with compare to Group I. In PFT analysis, FVC was comparable among individuals of both the group and conversely, significant decrease in FEV1, FEV1/FVC, FEF25-75 and PEFR in Group II when compare with Group I. CONCLUSION: This study illustrate that smokeless tobacco practice has increasing adverse effects on cardiovascular as well as breathing system and become an important public health problem.

A Challenging Diagnosis of Systemic Lupus Erythematosus with Status Epilepticus.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder of unknown pathogenesis. In SLE, the body's immune system mistakenly attacks healthy tissues and organs thereby involving multiple body systems including joints, skin, blood, brain, heart, and lungs. SLE has a wide variation in the symptoms, hence making the diagnosis more challenging at the time of initial presentation. Sometimes, the patient presents with Status epilepticus (SE) without prior history of epilepsy, as SE is common at the beginning in the course of SLE. In this report, there is a case showing correlation of seizures with SLE, without prior history of epilepsy. A 43-year-old female presented in the emergency department of the hospital with SE. Her previous medical and family history for epilepsy was unremarkable. The patient had high titers for positive anti-nuclear antibody (ANA), while other autoimmune workup was negative. A complete evaluation of the symptoms and investigations revealed that she met the criteria of American College of Rheumatology (ACR) for the diagnosis of SLE. Hence, physicians should be diligent with regards to the variations in the initial presentation and complications of SLE. With the advancement in treatment modalities of SLE, it can be managed successfully, if diagnosed early.

Neuropsychiatric Manifestation of Addison's Disease: A Rare Case Report.

Addison's disease (AD), also known as primary adrenal insufficiency, is a rare autoimmune disorder affecting males and females equally. The most common cause of AD is autoimmune adrenalitis and other causes include metastatic cancers, tuberculosis and acquired immunodeficiency syndrome. AD presents with a wide variety of signs and symptoms and thus, making a diagnosis challenging. The common symptoms of this disease include weakness and fatigability, orthostatic hypotension, nausea, vomiting, diarrhea, anorexia and weight loss. Addison's disease often presented with other autoimmune disorders, such as autoimmune polyglandular syndrome. We herein report a case of a patient who presented in a hospital emergency department, with Addisonian crisis and predominant neuropsychiatric manifestation. On review of the patient's history, combined with biochemical testing, a diagnosis of Addison's disease was established. This type of presentation is relatively uncommon.

Efficacy of cryotherapy as first line therapy in patients with Barrett's neoplasia: a systematic review and pooled analysis.

Cryotherapy has been used as salvage therapy; however, its efficacy as first line treatment in patients with Barrett's esophagus (BE) neoplasia has not been well studied. The aim of this paper was to perform a systematic review to look at the efficacy of cryotherapy as the primary treatment of BE. An electronic database search was performed (PubMed, Embase, Cochrane, and Google Scholar) to search for studies with cryotherapy as the initial primary modality of ablation in patients with BE neoplasia. Studies that included patients with other prior forms of therapy were excluded. The primary outcomes were the pooled rates of complete eradication of intestinal metaplasia (CE-IM) and CE of neoplasia (CE-N). Secondary outcomes were recurrence rates of neoplasia and intestinal metaplasia (IM) and adverse events. The statistical software OpenMetaAnalyst was used for analysis with pooled estimates reported as proportions (%) with 95% confidence intervals (CI) with heterogeneity (I2) among studies. The search revealed 6 eligible studies with a total of 282 patients (91.5% male, average age 65.3 years) with 459 person years of follow-up. 69.35% [95% CI (52.1%-86.5%)] of patients achieved CE-IM and 97.9% (95% CI: 95.5%-100%) had CE-N. 7.3% of patients had persistent dysplasia with 4% progressing to cancer. The recurrence rate of neoplasia was 10.4 and that of IM was 19.1 per 100 patient years of follow-up. The overall rate of stricture formation was 4.9%. There are scarce data on the use of cryotherapy as the primary modality for the treatment of BE dysplasia. The published data demonstrate efficacy rates of 69% and 98% for complete eradication of metaplasia and neoplasia, respectively. These results need to be assessed in prospective, comparative trials with other forms of therapy.

Enhanced upconversion emission of Er3+/Yb3+ and Er3+/Yb3+/Zn2+ doped calcium aluminate for use in optical thermometry and laser induced optical heating.

There are two key factors to design an efficient green upconversion (UC) emission based optical sensor for temperature. The primary need is to develop a thermally stable and economical material, for a stable sensor, and the second essence is to get an efficient green UC emission, for high sensitivity of the sensor. The proof of this concept is demonstrated on a model system CaAl2O4: Er3+, co-doped with Yb3+ and Zn2+. UC emission of Er3+ ion is enhanced, primarily, through co-operative energy transfer from Yb3+ to Er3+ ions. Secondly, we prove that, incorporation of Zn2+ ions alters local crystal field environment around Er3+ ions which causes an enhancement in green UC emission. The variation in intensity ratio of 2H11/2 â†’ 4I15/2 (green) and 4S3/2 â†’ 4I15/2 (green) transitions with temperature is studied to report the sensing property. We show that, sensitivity becomes better with an increase in UC efficiency and the best sensitivity is attained for CaAl(0.793)2Er0.007Yb0.05Zn0.15O4 sample, ∼0.0154 K-1 at 308 K. The obtained result is compared with other works and implies its better suitability. Further, the laser induced optical heating is also observed. The laser induced optical heating has been observed experimentally at 400 K above 1 W laser power. This has been further verified by theoretical justification of heating at various pump powers.

Outcomes of viscocanalostomy and phaco-viscocanalostomy in patients with advanced glaucoma.

PURPOSE: To determine the medium-term outcomes for patients with advanced glaucoma undergoing viscocanalostomy. METHODS: All patients with advanced glaucoma (mean deviation (MD) - 12.00 dB or above) and patients with poor visual acuity secondary to advanced glaucoma which precluded formal visual field assessment undergoing viscocanalostomy (VC) and phaco-viscocanalostomy between 2010 and 2014 under the care of a single surgical team were included. Intraocular pressure (IOP), visual acuity (VA) and visual field outcomes were assessed from data prospectively collected into a surgical outcome database. Success was defined at two IOP cut-off points: IOP ≤ 21 and ≤ 16 mmHg with (qualified) or without (complete) medications. RESULTS: One hundred thirty-five patients were included. Mean IOP changed from 23.6 ± 6.4 mmHg pre-operatively to 15.3, 15.8 and 14.8 mmHg at 1, 2 and 3 years, a change of 35, 33.5 and 39% respectively. Qualified success for an IOP ≤ 21 mmHg was achieved in 95.66, 90.6 and 80% and complete success in 52.5, 48.6 and 30.6% at year 1, 2 and 3. Qualified success for an IOP ≤ 16 mmHg was achieved in 66.6, 66.05 and 60% and complete success in 44.8, 37.6 and 30.6% at year 1, 2 and 3. The cumulative probability for achieving an IOP ≤ 21 mmHg with or without drops was 86.1, 81.4 and 81.4% at 12, 24 and 36 months. Eleven patients (8.1%) failed to achieve adequate IOP control and needed further surgical intervention. Eleven (8.1%) patients needed an intervention (Yag goniopuncture) following VC. Four patients (2.9%) had some post-operative complications, which resolved within 2 weeks following surgery. Nine patients (6.7%) lost more than 2 Snellen lines. There was no significant change in the MD across time points. CONCLUSION: Viscocanalostomy and viscocanalostomy combined with phacoemulsification is a safe and effective method of controlling IOP in the medium term in patients with advanced glaucoma.

Microvesicles in hepatic and peripheral vein can predict nonresponse to corticosteroid therapy in severe alcoholic hepatitis.

BACKGROUND: Severe alcoholic hepatitis patients have high mortality and limited response to corticosteroids. Microvesicles reflect cellular stress and disease conditions. AIMS: To investigate whether microvesicles are associated with severity, response to steroid therapy and inflammation in severe alcoholic hepatitis. METHODS: Microvesicles originating from different cells were studied pre-therapy in 101 patients; (71 responder to corticosteroid therapy and 30 nonresponders) and 20 healthy controls. Microvesicles and cells were determined in peripheral and hepatic vein samples using flow cytometry and correlated with outcomes. Inflammatory signalling pathways and functional alterations of immune cells after stimulation with microvesicles were also investigated. RESULTS: Microvesicles mean levels were higher in nonresponders for T cells (CD3+ CD4+ ; 10.1 MV/µL vs 5.4; P = 0.06), macrophages (CD68+ CD11b+ ; 136.5 vs 121.9 MV/µL; P = 0.01), haematopoietic stem-cells (CD45+ CD34+ ; 116.8 vs 13.4 MV/µL; P = 0.0001) and hepatocytes (ASGPR+ ; 470 vs 361 MV/µL; P = 0.01); the latter two predicting steroid nonresponse in 94% patients at baseline in peripheral plasma. Microvesicle levels correlated with histological and liver disease severity indices. Whereas, in non-responders hepatic vein CD34+ cells were lower (P = 0.02), the CD34+ microvesicles there from were higher (P = 0.04), thus suggesting impaired regeneration. Also, microvesicles of 0.2-0.4 µm size were higher in nonresponders (P < 0.03) at baseline. Microvesicles from patients trigger more (P = 0.04) ROS generation, TNF-α production (P = 0.04) and up-regulate pro-inflammatory cytokine related genes in neutrophils in vitro. CONCLUSIONS: Pre-therapy peripheral plasma levels of CD34+ and ASGPR+ microvesicles are reliable non-invasive markers of steroid nonresponse and mortality in patients with severe alcoholic hepatitis.

Artemisinin: A Promising Adjunct for Cancer Therapy.

Artemisinin is a herb derived from Artemesia annua (also known as sweet wormwood) and is known for its use as effective antimalarial pharmacotherapy. Recent studies have shown that artemisinin has anti-angiogenic and growth inhibition effects, as well as an apoptotic ability secondary to its inherent endo-peroxidase activity.

Transient Smartphone Blindness: Precaution Needed.

The transient smartphone blindness (TSB) is a relatively new phenomenon that affects vision. However, it warrants immediate attention by the physicians and the smartphone users, lest it leads to long-term consequences such as blindness.

Traumatic stress-induced persistent changes in DNA methylation regulate neuropeptide Y expression in rat jejunum.

BACKGROUND: Stress-induced chronic neuropsychiatric conditions such as anxiety are often co-morbid with gastrointestinal malfunctions. While we find enduring anxiety-like symptoms following minimal traumatic brain injury (MTBI) in rats, gastrointestinal consequences of MTBI remain elusive. METHODS: In this study, we examined the effects of MTBI on a major gut peptide, neuropeptide Y (NPY) and gut motility. DNA methylation was studied as a possible epigenetic mechanism operative in the regulation of NPY expression in the gut. KEY RESULTS: Minimal traumatic brain injury reduced the gut motility 48 hours and 30 days after trauma. The expression of DNA methyltransferase isoforms (DNMT1, DNMT3a, and DNMT3b) was altered in the jejunum 48 hours and 30 days after MTBI. However, the mRNA levels of growth arrest and DNA damage 45 (GADD45) isoforms, GADD45a, and GADD45b, which are believed to be involved in active DNA demethylation, initially decreased at 48 hours but subsequently increased after 30 days of trauma. Similarly, DNA hypomethylation at the NPY promoter region in the jejunum was correlated with the increase in NPY mRNA and protein levels 30 days post-trauma. On the other hand, DNA hypomethylation at 48 hours was associated with a decline in NPY expression. Treatment with 5-azacytidine (5-AzaC), a DNMT inhibitor, retarded DNA methylation and restored the NPY mRNA levels in the jejunum of MTBI-induced rats. CONCLUSIONS & INFERENCES: These results suggest that DNA demethylation could be operative as an epigenetic mechanism in the long-term regulation of NPY gene expression to alter the gut motility during traumatic stress.

A Study to Assess Empowerment of Adolescent Girls in Terms of Knowledge-Based Life Skills Education About Child Survival and Safe Motherhood Practices.

OBJECTIVE: This study has been designed with the intention to bring a substantial change in the mindsets or life skills of adolescent girls at secondary school level regarding their concept of child survival and safe motherhood practices in order to deal effectively with real-life situations. METHODOLOGY: A cross-sectional analytical study was carried out with 538 adolescent girls regarding assessment of their knowledge on variables like correct nutrition, iron-deficiency anemia and its prevention, care during pregnancy, safe birth, skilled birth attendance, breast feeding and complementary feeding practices, child's growth and development issues, immunization, management of common childhood illnesses. etc. CONCLUSION: Analysis was done using Mc Nemar's Chi-square test for paired data. Values obtained were highly significant for nutrition, iron-deficiency anemia and its prevention, care during pregnancy, and management of childhood illnesses variables, whereas study findings were found to be insignificant for rest of the variables. This study based on life skills approach and counseling worked well to promote and motivate adolescent girls for positive decision making. In this context, every adolescent girl should be encouraged to raise her unsolved issues in order to achieve safe motherhood plus growth and development of their children.

Titanium elastic nailing in femoral diaphyseal fractures in children of 6-14 years age.

BACKGROUND: Traditionally conservative methods were used in managing paediatric femoral diaphyseal fractures. There has been a renewed interest for operative treatment with Titanium elastic nail system (TENS) in the age group of 6-14 years. MATERIALS AND METHODS: This prospective study was done on 20 patients. Two titanium nails were used for stabilization. We followed them for maximum of two years. The results were evaluated using Flynn's scoring criteria. RESULTS: In our study we had fifteen males and five females with average age 10.35 years. Average time for fracture union was 9.0 weeks, full weight bearing 9.2 weeks, hospital stay 8.6 days and return to school at 10 weeks. The results were excellent in 14, good in 5 and poor in 1 patient. Most common complication was irritation at nail entry site. No delayed union or nonunion seen. CONCLUSION: Treatment of diaphyseal femoral fracture in selected pediatric patients by TENS is reasonably effective.