Retrospective application of the HEAR score on patients evacuated for chest pain: Assessing the utility of point-of-care troponin.

INTRODUCTION: The HEART scoring system codifies the clinical gestalt used by physicians with 0-2 points assigned to 5 criteria (history, electrocardiography, age, risk factors and troponin). This scoring provides a prognostic tool that assists in disposition planning. The use of a truncated HEART score, minus the troponin data (HEAR score), was used for patients presenting with chest pain at one of four outpost nursing stations served by La Ronge Health Centre in northern Saskatchewan. These nursing stations have no onsite physician and no ability to obtain any troponin data. This study set out to determine if there was any utility in conducting point-of-care (PoC) troponins in these nursing outposts. MATERIALS AND METHODS: A retrospective analysis was conducted using the La Ronge regional electronic medical record by searching for all patients for whom an outpost nurse had called a physician regarding chest pain symptoms between 01 January 2011 and 31 December 2016. The HEAR and HEART score were then calculated for each individual presentation of patients with chest pain that met inclusion and exclusion criteria. RESULTS: By calculating both the patient's HEART score before evacuation from the outposts and after (i.e. with the troponin data), we were able to determine that, in 89.4% of cases (110/123 events), patients would require evacuation regardless of the troponin values due to a HEART score ≥4. In 10.6% (13/124 events) of cases, the patients who were evacuated had a HEART score ≤3, and in only one case did the troponin data increase this score. CONCLUSIONS: The majority of patients would continue to be evacuated regardless of the result of their PoC troponin due to an already elevated HEAR score. PoC troponin is unlikely to reduce the rate of evacuation of patients with chest pain from the nursing stations served by the La Ronge Health Centre.

Résumé Introduction: Le système de pointage HEART codifie la gestalt clinique utilisée par les médecins avec 0­2 points attribués à 5 critères (anamnèse, ECG, âge, facteurs de risque, troponine). Ce pointage est un outil pronostique qui aide à planifier les soins aux patients. Un score HEART tronqué, c'est-à-dire moins les données de troponine (score HEAR), a été utilisé chez les patients qui se présentaient pour douleur thoracique à 1 des 4 avant-postes de soins infirmiers servis par le centre La Ronge Health Centre au nord de la Saskatchewan. Il n'y a pas de médecin sur place à ces postes de soins infirmiers, et il est impossible d'obtenir des données sur la troponine. Cette étude voulait déterminer si le dosage ciblé de troponine est utile dans ces avant-postes de soins infirmiers. Méthodes: Une analyse rétrospective a été réalisée à l'aide du dossier médical électronique de la région de La Ronge après une recherche de tous les patients pour lesquels un avant-poste de soins infirmiers avait appelé un médecin pour des symptômes de douleur thoracique entre le 1er Janvier 2011 et le 31 Décembre 2016. Les scores HEAR et HEART ont alors été calculés pour chaque cas de douleur thoracique qui répondait aux critères d'inclusion et d'exclusion. Résultats: En calculant le score HEART (c.-à-d. avec les données sur la troponine) avant et après l'évacuation du patient de l'avant-poste, nous avons pu déterminer que dans 89,4% des cas (110/123 événements), les patients devraient être évacués sans égard aux valeurs de troponine en raison d'un score HEART ≤3 et la troponine a augmenté ce score dans un seul cas. Conclusions: La majorité des patients continueraient d'être évacués, peu importe les résultats de troponine ciblée en raison d'un score HEAR déjà élevé. La troponine ciblée ne réduirait probablement pas le taux d'évacuation des patients pour douleur thoracique des postes de soins infirmiers servis par le centre La Ronge Health Centre. Mots-clés: Maladie cardiaque, médecine rurale, score HEART, troponine.

Label-free quantitative proteomics reveals molecular correlates of altered biomechanical properties in molar incisor hypomineralization (MIH): an in vitro study.

PURPOSE: Molar-incisor hypomineralization (MIH) is a qualitative developmental defect of enamel that affects first permanent molars with or without affecting permanent incisors. We aimed to carry out a quantitative proteomics-based study to compare and evaluate proteins in sound and MIH-affected enamel. MATERIALS AND METHODS: Ten blocks each of the MIH-affected enamel and sound enamel were processed and prepared for LC-MS/MS analysis. Label-free quantitation was carried out to evaluate the differentially expressed proteins in the two groups of samples. RESULTS: A significant increase in the number of proteins in MIH-affected enamel (50.3 ± 29.6) was observed compared to the sound enamel (21.4 ± 3.2). While proteins like collagens, α1-anti-trypsin, kallikrein-4 (KLK4), matrix metalloprotease-20 (MMP-20), alpha-2-macroglobulin, and alpha-2-HS-glycoprotein were upregulated in sound enamel, there was over-expression of albumin, calcium-binding proteins, anti-thrombin III, and dentin sialophosphoprotein (DSPP), along with proteins implicated in stress response and inflammatory processes in MIH. CONCLUSION: We propose that altered biomechanical properties of the enamel in MIH samples arise due to (i) down-regulation of proteins contributing to collagen biosynthesis and fibril formation; (ii) an overall imbalance in required levels of proteases (KLK4 and MMP-20) and anti-proteases (anti-thrombin-III which inhibits KLK-4), essential for optimal mineralization; (iii) very low levels of alpha-2-macroglobulin with important consequences in enamel mineralization and amelogenesis; and (iv) increased albumin in MIH, preventing proper growth of hydroxyapatite crystals. Increased inflammatory component was also seen in MIH; however, whether inflammation is a cause or consequence of the poor mineralization process needs to be assessed.

Salivary parameters and their correlation with neutrophil counts in children with acute lymphoblastic leukemia.

BACKGROUND: Chemotherapy for Acute Lymphoblastic Leukemia (ALL) is known to render children immuno-deficient. A concomitant suppression of local defence mechanisms, such as saliva may further aggravate the adverse consequences of chemotherapy. The present study was conducted to evaluate alterations in salivary flow rate, pH and buffering capacity and to correlate these parameters with Absolute Neutrophil Counts (ANC). METHODS: A cohort of 43 patients, aged 3-12 years were evaluated for the aforementioned parameters at baseline, post-induction and post-consolidation phases. Salivary collection was done and ANC was measured from routine haematological reports. RESULTS: A decrease in the salivary parameters was observed at the end of Induction phase as compared to baseline, with a statistically significant decrease in unstimulated salivary flow rates (p < 0.01). Statistically significant positive correlations were found between ANC and salivary flow rate (p = 0.005), pH (p < 0.00) and buffering capacity (p < 0.00). On testing the significance of these correlations, all the values for these parameters were found to be statistically significant. CONCLUSION: Salivary parameters showed derangements over the phases of chemotherapy, with maximum decrease at the end of induction phase. The positive correlations of salivary parameters with ANC of the subjects may be considered indicative of a concomitant immunological compromise in these children.

A case-controlled investigation of risk factors associated with molar incisor hypomineralization (MIH) in 8-12 year-old children living in Chandigarh, India.

PURPOSE: Despite mounting evidence in favour of various perinatal risk factors for occurrence of MIH, verification of these remains doubtful because of lack of documented proof. The present study was aimed at examining the putative risk factors for MIH based on hospital-maintained records assessment. METHODS: A total of 3176, 8-12 year-old children were screened for MIH using EAPD criteria (2003). Of these, risk factor analysis was carried out for 104 MIH affected and 211 non-MIH affected children with complete peri-natal medical records maintained up to 3 year post-birth. Chi-square test was used for risk factor comparison, while significance was assessed using logistic regression. RESULTS: Prevalence of MIH in study population was 11.72% (372/3176). Various pre-natal, natal and post-natal risk factors including intra-uterine growth retardation (6.7 vs. 1.4%); maternal anaemia (10.6 vs. 3.8%) and neonatal jaundice (29.8 vs. 14.2%) were significantly higher in the MIH group. Furthermore, pre-term birth (OR 3.01), low birth weight (OR 2.37), more than three pyrogenic episodes (OR 7.61) and consumption of Amoxicillin Clavulanate (OR 3.01) were significantly associated with higher risk of developing MIH. CONCLUSIONS: Pre and post-natal risk factors showed a moderate to high association for occurrence of MIH although social and nutritional factors had a lesser association.

An evaluation of remineralised MIH using CPP-ACP and fluoride varnish: An in-situ and in-vitro study.

BACKGROUND: Molar incisor hypomineralization (MIH) affected teeth have enamel with altered mineral content like decreased calcium and phosphorus and increased carbon content leading to porous enamel and subsequent post-eruptive breakdown. AIM: An in situ study was conducted to evaluate and compare the effects of a Casein Phosphopeptide-Amorphous Calcium Phosphate (CPP-ACP)-based cream and fluoride varnish on the remineralization of MIH affected teeth. METHODS: Enamel slabs were prepared from MIH affected teeth that had been extracted for various reasons and inserted in appliances of 30 participants who were undergoing interceptive orthodontic therapy. They were randomly divided into two groups using block randomization technique: Group A-daily single application of CPP-ACP cream (n = 15); Group B-professional application of fluoride varnishes every 3 months (n = 15). After 6 months of regular wear of the appliance, the enamel slabs were placed under Field Emission Scanning Microscope (FESEM) and Energy-Dispersive Spectroscopy (EDS) for evaluation of ultra structure and mineral content, respectively. RESULTS: A significant increase in calcium and phosphorus content, and a decrease in carbon content was observed within the 6 months period, suggesting remineralization in both the groups. On comparing the Ca:P and Ca:C ratios, a significant increase in the Ca:C ratio was evident in the two groups. No significant difference was seen in the Ca:P ratio in the CPP-ACP group at six months. The inter-group comparison did not reveal any significant difference between the two groups either at baseline or at 6 months post-intervention. CONCLUSION: Remineralization can be achieved in MIH affected teeth with the use of remineralizing agents.

Relations among maternal physical activity during pregnancy and child body composition.

OBJECTIVE: Physical activity (PA) during pregnancy is associated with lower neonatal fat mass, but associations with child body composition are mixed. The purpose of this study was to examine associations between trimester-specific pregnancy PA and child body composition at 4 years. METHODS: Participants of the Minnesota Infant Nutrition, Neurodevelopment, and Obesity Study were asked to recall participation in any moderate or vigorous PA in the first (T1), second (T2) and third (T3) trimesters at about 5 years postpartum. Child fat mass and fat-free mass were measured via air displacement plethysmography at 2 weeks, 3 months and 4 years of age. Multivariate linear regression was used for analyses. RESULTS: Of 51 possible participants, 37 recalled pregnancy PA. Any vigorous PA in T3 was associated with lower child fat mass at 4 years (adjß = -1.077, p < 0.05). CONCLUSION: Late pregnancy PA may have lasting benefits for child body composition. Replication of these findings is needed in a larger sample with prospective measures.

A clinical and radiographic investigation comparing the efficacy of cast metal and indirect resin onlays in rehabilitation of permanent first molars affected with severe molar incisor hypomineralisation (MIH): a 36-month randomised controlled clinical trial.

PURPOSE: Definitive restorative management of young permanent molars affected with severe MIH is still elusive with a dearth of conservative restorative options. The present trial compared the 36 months clinical and radiographic performance of minimally invasive cast metal and indirect resin onlays for rehabilitation of permanent first molars affected with severe MIH. METHODS: In this parallel group open label randomised trial, 42 vital molars affected with severe MIH in 30 children, aged 8-13 years were randomly allocated using stratified permuted block randomization to receive either a cast metal onlay or an indirect composite onlay (n = 21 each). Clinical and radiographic evaluations of these onlays were carried out at 9, 18 and 36 months using the USPHS criteria. Cumulative survival rate as well as the calculated clinical success rates of both types of onlays were also determined. The longevity of onlays was assessed using Kaplan-Meier survival analysis. RESULTS: At 36 months, overall retention rate was found to be 95% with complete elimination of any pre-existing sensitivity. Cumulative survival rates were found to be 95% vs. 100%, p = 0.67, while the calculated clinical success rates were 90% and 85.7% for metal and resin onlays, respectively, with no significant differences (p = 0.76). Mean survival rates based on Kaplan-Meier analysis were determined to be 85% vs. 100% for the metal and composite groups, respectively (p = 0.075). CONCLUSIONS: Irrespective of the type of material used, onlays offer a predictable and conservative restorative alternative for molars affected with severe MIH. CLINICAL TRIAL REGISTRY: The trial is registered under Clinical Trial Registry India (CTRI/2016/10/007379).

A randomised controlled trial of excision versus invagination in the management of indirect inguinal hernial sac.

INTRODUCTION: Lichtenstein tension-free mesh hernioplasty of primary inguinal hernia is currently considered as the preferred method for the plastic reconstruction of inguinal hernia by the majority of surgeons. Several studies have examined the best way to manage the hernial sac in this surgery, but no consensus has been reached. This study was designed to compare the effects of excision of sac and invagination of sac on post-operative outcomes. METHODS AND METHODS: This prospective randomised study included a total of 70 patients with primary unilateral uncomplicated indirect inguinal hernia. Group A (35 patients) underwent high dissection and invagination of the hernial sac and group B (35 patients) underwent high ligation and excision of the hernial sac. The repair of the posterior wall of the inguinal canal was done according to Lichtenstein tension-free technique. The primary outcome of this study was postoperative pain and secondary outcomes were wound infection, chronic sepsis, sinus formation, persistent pain, testicular atrophy and recurrence during the one-year follow-up period. RESULTS: There was a significant difference (P < 0.01) in pain experienced by the patients in the immediate post-operative period between the two groups; group A experienced less postoperative pain than group B. There was no significant difference in incidence of infection between the groups. CONCLUSIONS: Invagination of the sac results in less postoperative pain compared with excision, with no significant difference in other postoperative outcomes.

Guiding the Child's Teeth with Class III Dental Malocclusion into Correct Occlusion: A Clinician's Parenting.

Pediatric dentists are often the first ones to be consulted for the presence of an anterior cross bite in the primary dentition. The condition requires an early interception to avoid progressive dentoalveolar and skeletal changes. The management, however, poses unique challenges in terms of young age of the child, correct choice of appliance and unpredictability of the response to treatment due to inability to ascertain the inherent growth potential. It is very important therefore for the specialist, to be able to recognize the early signs of a developing class III malocclusion tendency and also know the basic details of successful management of such cases. The following article describes the appropriateness of appliance choice for a case of incisor cross bite in primary dentition using different appliances based on their varied clinical presentations.

Diabetes mellitus and tuberculosis: programmatic management issues.

In August 2011, the World Health Organization and the International Union Against Tuberculosis and Lung Disease launched the Collaborative Framework for Care and Control of Tuberculosis (TB) and diabetes mellitus (DM) to guide policy makers and implementers in combatting the epidemics of both diseases. Progress has been made, and includes identifying how best to undertake bidirectional screening for both diseases, how to provide optimal treatment and care for patients with dual disease and the most suitable framework for monitoring and evaluation. Key programmatic challenges include the following: whether screening should be directed at all patients or targeted at those with high-risk characteristics; the most suitable technologies for diagnosing TB and diabetes in routine settings; the best time to screen TB patients for DM; how to provide an integrated, coordinated approach to case management; and finally, how to persuade non-communicable disease programmes to adopt a cohort analysis approach, preferably using electronic medical records, for monitoring and evaluation. The link between DM and TB and the implementation of the collaborative framework for care and control have the potential to stimulate and strengthen the scale-up of non-communicable disease care and prevention programmes, which may help in reducing not only the global burden of DM but also the global burden of TB.

Lessons learnt from school-based health promotion projects in low- and middle-income countries.

BACKGROUND: Non-communicable diseases (NCD) are now the leading cause of death worldwide. As habits and lifestyle are established in childhood and adolescence, targeting school children before they develop unhealthy habits offers a window of opportunity to halt and reverse the emerging NCD epidemic. However, few experiences from school interventions in low- and middle-income countries have been collected. Therefore, the aim of this study was to review experiences of implementing school-based health promotion interventions to identify barriers and recommendations for future interventions. METHODS: A qualitative investigation of 17 school-based health promotion interventions in low- and middle-income countries was conducted. Data were collected through questionnaires (15 project leaders) and in-depth interviews with nine project leaders. The data from the questionnaires and interviews was triangulated and analysed using content analysis, where themes and categories emerging from the material were explored. RESULTS: Three key themes emerged from the data: 1) policy environment and stakeholder engagement, 2) health education sessions, and 3) practical health promotion activities. The themes explored the experiences and lessons learned from 17 school-based health promotion projects in low- and middle-income countries. Stakeholders at different administrative levels were important for the projects; however, stakeholders close to implementation were seen to be more engaged. Most projects conducted traditional health education lectures, which formed the basis of their intervention. Promotion of physical activity and healthy eating through participatory approaches were identified; however, barriers such as lack of areas suitable for physical activity and lack of healthy food alternatives in schools can obstruct the successful implementation of interventions. CONCLUSIONS: This study has documented experiences with school-based health promotion in low- and middle-income countries, and has shown that schools can play an important role in facilitating NCD-related behavioural change in children. The study recommends increased emphasis on a whole-school approach where activities focusing on individual behavioural change are supported by interventions improving the structural environment.

Role of decompressive hemicraniectomy in extensive middle cerebral artery strokes: a meta-analysis of randomised trials.

BACKGROUND: Prognosis for patients with 'malignant' or space-occupying oedema post middle cerebral artery infarct remains poor despite maximal medical therapy delivered in the intensive care setting. AIM: We performed a meta-analysis to evaluate the value of surgical decompression versus medical management alone in patients suffering from malignant middle cerebral artery infarct. METHODS: A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct and Web of Science. Original data was abstracted from each study and used to calculate a pooled odds ratio (OR) and 95% confidence interval (95% CI). RESULTS: The overall OR for mRS 6 (death) at 6 months for decompressive surgery as compared with standard medical management revealed a statistically significant reduction with OR of 0.19 (95% CI: 0.10-0.37). The frequency of patients with mRS 2, 3 and 5 outcomes was higher in the decompressive surgery cohort; however, these outcomes did not reach statistical significance. On the other hand, the number of patients with a mRS score of 4 was significantly higher in the decompressive surgery cohort with an OR of 3.29 (95% CI: 1.76-6.13). The overall OR for mRS 6 (death) at 12 months for decompressive surgery as compared with standard medical management revealed a statistically significant reduction with OR of 0.17 (95% CI: 0.10-0.29). The frequency of patients with mRS 3 and 5 outcomes was higher in the decompressive surgery cohort; however, these outcomes did not reach statistical significance. On the other hand, the number of patients with a mRS score of 4 was significantly higher in the decompressive surgery cohort with an OR of 4.43 (95% CI: 2.27-8.66). In the long run it was also observed that the number of patients with a mRS score of 2 was significantly higher in the decompressive surgery cohort an OR of 4.51 (95% CI: 1.06-19.24). CONCLUSIONS: Our results imply that surgical intervention decreased mortality of patients with fatal middle cerebral artery infarct at the expense of increasing the proportion suffering from substantial disability at the conclusion of follow up.

Association between vitamin B12 deficiency and long-term use of acid-lowering agents: a systematic review and meta-analysis.

BACKGROUND: Vitamin B12 (cobalamin) deficiency can result in irreversible structural brain changes if not treated appropriately. Long-term use of acid-lowering agents (ALA) has been linked to vitamin B12 deficiency, but results are inconsistent. AIM: To evaluate the association between prolonged ALA use and vitamin B12 deficiency by performing a meta-analysis. METHODS: A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents, Cochrane Library, Google Scholar, Science Direct and Web of Science. Original data were abstracted from each study and used to calculate a pooled odds ratio and 95% confidence interval (95% CI). RESULTS: Of the articles reviewed, four case-control studies (4254 cases and 19,228 controls) and one observational study met full criteria for analysis. The long-term ALA use was significantly associated with development of vitamin B12 deficiency (hazard ratio 1.83, 95% CI: 1.36-2.46, P-value 0.00). CONCLUSION: Chronic use of ALA is a risk factor for developing vitamin B12 deficiency. Judicious prescribing of ALA and regular monitoring of vitamin B12 in patients who are inevitably on long-term ALA therapy are recommended.

Hypertension and treatment outcomes in Palestine refugees in United Nations Relief and Works Agency primary health care clinics in Jordan.

OBJECTIVE: In six United Nations Relief and Works Agency (UNRWA) primary health care clinics in Jordan serving Palestine refugees diagnosed with hypertension, to determine the number, characteristics, programme outcomes and measures of disease control for those registered up to 30 June, 2013, and in those who attended clinic in the second quarter of 2013, the prevalence of disease-related complications between those with hypertension only and hypertension combined with diabetes mellitus. METHOD: Retrospective cohort study with programme and outcome data collected and analysed using E-Health. RESULTS: There were 18 881 patients registered with hypertension with females (64%) and persons aged ≥ 40 years (87%) predominating. At baseline, cigarette smoking was recorded in 17%, physical inactivity in 48% and obesity in 71% of patients. 77% of all registered patients attended clinic in the second quarter of 2013; of these, 50% had hypertension and diabetes and 50% had hypertension alone; 9% did not attend the clinics and 10% were lost to follow-up. Amongst those attending clinic, 92% had their blood pressure measured, of whom 83% had blood pressure <140/90 mm Hg. There were significantly more patients with hypertension and diabetes (N = 966, 13%) who had disease-related complications than patients who had hypertension alone (N = 472, 6%) [OR 2.2, 95% CI 2.0-2.5], and these differences were found for both males [18% vs. 10%, OR 1.9, 95% CI 1.6-2.2] and females [11% vs. 5%, OR 2.4, 95% CI 2.1-2.9]. CONCLUSION: Large numbers of Palestine refugees are being registered and treated for hypertension in UNRWA primary health care clinics in Jordan. Cohort analysis and E-Health can be used to regularly assess caseload, programme outcomes, clinic performance, blood pressure control and cumulative prevalence of disease-related complications. Current challenges include the need to increase clinic attendance and attain better control of blood pressure.

Operational research leading to rapid national policy change: tuberculosis-diabetes collaboration in India.

In 2011, bi-directional screening for tuberculosis (TB) and diabetes mellitus (DM) was recommended by the World Health Organization (WHO), although how best to implement the activity was not clear. In India, with early engagement of national programme managers and all important stakeholders, a countrywide, multicentre operational research (OR) project was designed in October 2011 and completed in 2012. The results led to a rapid national policy decision to routinely screen all TB patients for DM in September 2012. The process, experience and enablers of implementing this unique and successful collaborative model of operational research are presented.

En 2011, un double dépistage de la tuberculose (TB) et du diabète (DM) a été recommandé par l'Organisation Mondiale de la Santé (OMS), mais il n'a pas été précisé clairement comment mettre en œuvre au mieux cette activité. En Inde, grâce à l'engagement précoce des directeurs de programmes nationaux et de tous les partenaires importants, un projet national de recherche opérationnelle (OR) multicentrique a été conçu en octobre 2011 et achevé en 2012. Les résultats ont rapidement amené à une décision politique nationale de dépister en routine tous les patients TB à la recherche de DM en septembre 2012. Cet article présente la procedure et l'expérience de ceux qui ont mis en œuvre ce modèle collaboratif de recherche opérationnelle assez unique et fructueux.

En el 2011, la Organización Mundial de la Salud recomendó la detección bidireccional de la tuberculosis (TB) y la diabetes sacarina (DM), aunque no fue claro cuál sería el mejor mecanismo de ejecución de la iniciativa. En la India, con la participación temprana de los gestores del programa nacional y todos los principales interesados directos, se formuló un proyecto multicéntrico de investigación operativa de ámbito nacional en octubre del 2011 y se completó en el 2012. Los resultados llevaron a una rápida decisión política de alcance nacional en septiembre del 2012, de practicar la detección sistemática de la DM en todos los pacientes con diagnóstico de TB. En el presente artículo se describe el proceso, las experiencias y los factores facilitadores de la ejecución de este excepcional y eficaz modelo colaborativo de investigación operativa.