Navigating Cirrhosis: A Comprehensive Review of Liver Scoring Systems for Diagnosis and Prognosis.

This comprehensive review navigates the landscape of liver scoring systems for the diagnosis and prognosis of cirrhosis. Cirrhosis, a chronic and progressive liver disease, presents significant challenges in its diagnosis and management. The review begins by defining and providing an overview of cirrhosis, emphasizing its clinical implications. Highlighting the significance of liver scoring systems, including the Child-Pugh score, end-stage liver disease, albumin-bilirubin (ALBI) score, and fibrosis-4 (FIB-4) index, the study explores their role in assessing liver dysfunction severity and predicting outcomes. A meticulous analysis identifies the strengths and limitations of these scoring systems, offering valuable insights for clinicians. The recommendations emphasize incorporating these tools into routine clinical practice for early intervention and personalized treatment plans. Interdisciplinary collaboration is underscored as crucial for a holistic approach to cirrhosis management. The conclusion calls for future research to refine existing scoring systems, explore emerging biomarkers and imaging techniques, and conduct prospective studies to enhance precision. By embracing these recommendations, the medical community can advance the understanding and management of cirrhosis, ultimately improving patient outcomes and revolutionizing liver disease approaches.

An Extremely Rare Case of Isolated Aortic Valve Prolapse Causing Aortic Regurgitation in the Absence of Any Other Pre-existing Cardiovascular or Non-cardiovascular Condition.

In this case report, we present an extremely rare case of isolated aortic valve prolapse causing aortic regurgitation having no association with any comorbid conditions that are commonly seen with aortic valve prolapse. A 27-year-old female patient presented with chief complaints of dyspnea on exertion (New York Heart Association grade III) for 20 days, decreased appetite for 15 days, and a history of significant weight loss for one and a half years. Transthoracic and transesophageal echocardiography revealed a trileaflet floppy aortic valve with prolapsing non-coronary and right coronary cusps, associated with moderate aortic regurgitation. The incidence of aortic valve prolapse is roughly around 1%. Exceptionally, very few cases of isolated aortic valve prolapse with moderate-to-severe aortic regurgitation without any associated pathology have been reported to date.

Effectiveness of Orthopantomograms as a Screening Tool for Osteoporosis: A Case-Control Study.

Introduction Osteoporosis is a disease that is characterised by low bone mineral density (BMD), and loss of structural and biomechanical properties that are essential in maintaining bone homeostasis. Osteoporosis is diagnosed by clinical measurement of BMD and is the best predictor of osteoporosis. The study was conducted with the aim of assessing the effectiveness of orthopantomogram (OPG) as a screening tool for osteoporosis in postmenopausal women and chronic drug users. Objectives The primary objective of the current study was to assess the mandibular cortical width and antegonial index in postmenopausal women and chronic drug users, the secondary objective was to compare the mandibular cortical width and antegonial index of postmenopausal women and chronic drug users with that of the control group (healthy individual). Methods Three groups were taken in this study with a sample size of 300 with 100 OPG in each group. The groups categorised in the study were postmenopausal women, patients under drugs (glucocorticoids, proton pump inhibitor, anti-epileptic drugs, selective serotonin reuptake inhibitor) and the control group and the parameters assessed were antegonial index and mandibular cortical width. Results Results were tabulated and analysed using Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 26.0, Armonk, NY). The normality tests Kolmogorov-Smirnov and Shapiro-Wilks test results reveal that the variables (both indices) follow the normal distribution. The mandibular cortical width was 3.44, 2.66 and 2.96 in the normal, postmenopausal women and women on drugs respectively. The antegonial index was 163.5, 157.2 and 158.8 in the normal, postmenopausal women and women on drugs respectively. Conclusion From the above results, it is evident that there is a statistically significant reduction in antegonial index and mandibular cortical width in postmenopausal women compared to normal individuals. Alterations of this value are suggestive that early pre-clinical changes of osteoporosis can be detected in the high-risk group using OPG.

Oral Health of Women and Children: Progress, Challenges, and Priorities.

INTRODUCTION: Tooth decay remains the most prevalent chronic disease in children and adults, even though it is largely preventable. Studies show that mothers' oral and overall health is linked to children's oral health and pregnancy outcomes. This paper examines achievements during the last 20 years, assesses current challenges, and discusses future priorities. ORAL HEALTH STATUS: Data show a modest improvement in children's oral health during the last 20 years; however, tooth decay still affects more than half of adolescents. According to national survey data, about 26% of working-age adults had untreated tooth decay. Overall, significant oral health disparities by race/ethnicity and income persist. DENTAL SERVICE UTILIZATION: The annual dental visit rate for children in the 2015 Medical Expenditure Panel Survey was 48%. Among children enrolled in Medicaid, dental visit rates increased from 18% in 1993 to nearly 50% in 2018. About 46% of women are estimated to receive teeth cleaning during pregnancy. Over the years, race or ethnicity and income-level differences in dental visits observed in the early 2000s have narrowed substantially in children but not among pregnant women. DISCUSSION: Many effective interventions are available at the community and individual levels but are underutilized. Lack of integration of oral health into the overall health care system and programs, community conditions, poverty, and limited health literacy make it difficult for families to engage in healthy habits, use preventive interventions, and access treatment promptly. CONCLUSION: To further improve oral health, policy and system reforms are needed to address the factors mentioned above. Therefore, we urge the federal Maternal and Child Health Bureau to take steps to convene a workshop to develop a framework for future actions.

Association between low fluoride exposure and children's intelligence: a meta-analysis relevant to community water fluoridation.

OBJECTIVES: Previous meta-analyses have mainly focused on studies conducted in endemic fluorosis areas with relatively high fluoride concentrations. These are impoverished rural communities in China, India, and Iran, and the findings cannot be generalised to developed countries. Therefore, we investigated the association between fluoride concentrations relevant to community water fluoridation and children's cognition measured with IQ scores by synthesising effect sizes reported in observational studies. METHODS: A previous meta-analysis and the National Toxicology Program database that included a search of multiple databases and the authors' search of PubMed, Google Scholar, and Mendeley provided the data. Cross-sectional and cohort studies examining the association between fluoride and children's cognition and intelligence scores were selected. Two reviewers abstracted data using standard procedures. We performed three meta-analyses to synthesise the effects using the random effects models. RESULTS: Eight studies of standardized mean difference in IQ scores from non-endemic fluorosis areas found no statistically significant difference between recommended and lower levels of fluoride (standardized mean difference = 0.07; 95% confidence interval: -0.02, 0.17; I2 = 0%), and no significant fluctuation in IQ scores across the differences in fluoride concentrations by non-linear modeling with restricted cubic spline (P = 0.21). Meta-analyses of children's and maternal spot urinary fluoride associated pooled regression coefficients (Betachildren = 0.16; 95% confidence interval: -0.40, 0.73; P = 0.57; I2 = 0%, Betamaternal = -0.92; 95% CI: -3.29, 1.46; P = 0.45; I2 = 72%) were not statistically significant. Further regression analysis by standardizing absolute mean IQ scores from lower fluoride areas did not show a relationship between F concentration and IQ scores (Model Likelihood-ratio test: P-value = 0.34.) CONCLUSIONS: These meta-analyses show that fluoride exposure relevant to community water fluoridation is not associated with lower IQ scores in children. However, the reported association observed at higher fluoride levels in endemic areas requires further investigation.

Effect of Papaverine on Left Internal Mammary Artery Flow: Topical Spraying versus Perivascular Injection Method.

OBJECTIVE: To analyze two techniques of papaverine application, topical spray on the harvested left internal mammary artery (LIMA) and perivascular injection, to find out their ability to improve LIMA flow. METHODS: Forty patients were randomized into two groups. In Group 1, papaverine was sprayed on the harvested pedunculated LIMA. In Group 2, papaverine was delivered into the perivascular plane. Drug dosage was the same for both groups. LIMA flow was measured 20 minutes after applying papaverine. Blood flow was recorded for 20 seconds and flow per minute was calculated. The systemic mean pressures were maintained at 70 mmHg during blood collection. The data collected was statistically evaluated and interpreted. RESULTS: The LIMA blood flow before papaverine application in the Group 1 was 51.9±13.40 ml/min and in Group 2 it was 55.1±15.70 ml/min. Statistically, LIMA flows were identical in both groups before papaverine application. The LIMA blood flow, post papaverine application, in Group 1 was 87.20±13.46 ml/min and in Group 2 it was 104.7±20.19 ml/min. The Group 2 flows were statistically higher than Group 1 flows. CONCLUSION: Papaverine delivery to LIMA by the perivascular injection method provided statistically significant higher flows when compared to the topical spray method. Hence, the perivascular delivery of papaverine is more efficient than the spray method in improving LIMA blood flow.

Initial Experience With a Bioresorbable Polymer Anchor.

Background Anchors are frequently used in reconstructive orthopedic surgery to achieve fixation of soft tissue to bone. Anchors vary with respect to material composition, configuration, and methods of fixation at the site of attachment. The fixation component of anchoring devices has generally evolved from metal-fabricated implants to various types of bioresorbable anchors. The SonicAnchorTM (Stryker, Kalamazoo, MI USA) polymer implant provides a unique form of anchor fixation using SonicFusionTM technology to achieve interdigitation within cancellous bone while being radiolucent and providing a small footprint. Methods During a four-year period, 116 patients underwent a reconstructive orthopedic foot and ankle surgical procedure with the use of at least one bioresorbable polymer anchor (SonicAnchor implant). There were 59 males and 57 females, with an average age of 42 years (range: 12-83 years). Results A total of 233 bioresorbable anchor (SonicAnchor) implants were used in 116 patients. Of the 116 patients, 108 (93.1%) achieved successful clinical healing of their surgery at their most recent follow-up. The average follow-up duration was 309 days (range: 14-1,429 days). Eight (6.9%) patients were lost to follow-up prior to clinical healing. Two (1.7%) patients underwent reoperation. Also, 65 (56%) patients had at least six months of follow-up and 36 (31%) had at least one year of follow-up. Conclusions This preliminary clinical trial of patients undergoing soft tissue repair or reconstruction with a bioresorbable polymer appears to perform comparably to other commercially available devices. The lack of adverse events, mechanical failures, or infections further supports the safety of this device.

Barriers and Facilitators to Promoting Oral Health Literacy and Patient Communication among Dental Providers in California.

Studies demonstrate that dental providers value effective provider-patient communication but use few recommended communication techniques. This study explored perspectives of California dental providers and oral health literacy experts in the United States on use of communication techniques. We conducted a qualitative key informant interview study with 50 participants between November 2019 and March 2020, including 44 dental providers (dentists, hygienists, and assistants) in public or private practice in California and 6 oral health literacy (OHL) experts. We undertook thematic analysis of interview transcripts and descriptive statistics about interviewees from pre-surveys. Dental providers reported frequently speaking slowly, and using simple language and models/radiographs to communicate with patients, while infrequently using interpretation/translation, illustrations, teach-back, or motivational interviewing. Providers reported using only 6 of the 18 American Medical Association's (AMA) recommended communication techniques and only 3 of the 7 AMA's basic communication techniques. A majority of providers indicated using one of five oral health assessment and educational strategies. Key barriers to effective communication included limited time, financial incentives promoting treatment over prevention, lack of OHL training, limited plain-language patient education materials, and patients with low OHL knowledge. Dental organizations should prioritize supporting dental providers in effective patient communication practices. Standardizing OHL continuing education, creating an evidence-based OHL toolkit for dental teams, ensuring accessible interpretation/translation services, and incentivizing dental providers to deliver education could improve oral health literacy and outcomes.

A Comparison of Ferric Subsulfate Solution, Silver Nitrate, and Aluminum Chloride for Pain Assessment, Time to Hemostasis, and Cosmesis in Acrochordon Snip Excision.

BACKGROUND: Acrochordon (skin tag) removal by snip excision is a routine dermatologic procedure. Bleeding is a common sequelae of snip excision that requires hemostatic control. Chemical cautery is a common means of achieving hemostasis in this procedure. OBJECTIVE: The aim of this study was to evaluate three different chemical cautery solutions for their time to hemostasis, pain upon application, and associated pigmentary changes. METHODS: Twelve patients with six or more skin tags on the bilateral neck and/or axilla were enrolled. Two skin tags were cauterized with ferric subsulfate solution, two with silver nitrate, and two with aluminum chloride hexahydrate solution. Time to hemostasis and pain with application of each cautery solution to the skin tag was recorded. At a two-week follow-up appointment, patient satisfaction was assessed with a survey, and pigmentary changes were documented with digital photography. RESULTS: There was no significant variability in the time to hemostasis among the three chemical cautery solutions (p=0.57). Pain response was significantly different among the three solutions (p=0.003). Compared to silver nitrate (median=6.00, interquartile range [IQR]: 4.50-6.50), aluminum chloride hexahydrate (median=1.00, IQR: 0.50 to 6.00; Sidak p=0.02) and ferric subsulfate (median=1.50, IQR: 0.00-3.50; Sidak p=0.01) had a significantly lower pain response. Among participants, three (25%) experienced a pigmentary change with ferric subsulfate, two (17%) with aluminum chloride, and six (50%) with silver nitrate (overall p= 0.14). CONCLUSION: These results indicate that the three standard chemical cautery solutions for skin tag snip excision have significant differences in pain upon application and pigmentary changes. This might be a relevant consideration when selecting a chemical cautery solution.

Propranolol exhibits activity against hemangiomas independent of beta blockade.

Propranolol is a widely used beta blocker that consists of a racemic mixture of R and S stereoisomers. Only the S stereoisomer has significant activity against the beta-adrenergic receptor. A fortuitous clinical observation was made in an infant who received propranolol for cardiac disease, and regression of a hemangioma of infancy was noted. This has led to the widespread use of propranolol for the treatment of large and life-threatening hemangiomas of infancy. Infants receiving propranolol require monitoring to ensure that they do not suffer from side effects related to beta blockade. The exact mechanism of activity of propranolol in hemangioma of infancy is unknown. In this study, we treated hemangioma stem cells with both beta blockade active S- and inactive R-propranolol and looked for genes that were coordinately regulated by this treatment. Among the genes commonly downregulated, Angiopoietin-like 4 (ANGPTL4) was among the most regulated. We confirmed that propranolol isomers downregulated ANGPTL4 in endothelial cells, with greater downregulation of ANGPTL4 using the beta blockade inactive R-propranolol. ANGPTL4 is present in human hemangiomas of infancy. Finally, R-propranolol inhibited the growth of bEnd.3 hemangioma cells in vivo. The implication of this is that hemangioma growth can be blocked without the side effects of beta blockade. Given that humans have been exposed to racemic propranolol for decades and thus to R-propranolol, clinical development of R-propranolol for hemangiomas of infancy and other angiogenic diseases is warranted.

Does water fluoridation affect the prevalence of enamel fluorosis differently among racial and ethnic groups?

OBJECTIVES: There are reports showing higher prevalence of enamel fluorosis among African-American children. This study was conducted to assess whether the effect of water fluoride level on enamel fluorosis is different among different race/ethnicity groups among US school children. METHODS: Data from the National Survey of Oral Health of US School Children 1986-1987 were analyzed to determine the prevalence of enamel fluorosis among 7-17 year-old children. The association between race/ethnicity and enamel fluorosis was examined using logistic regression modeling after controlling for potential confounders age, gender, water fluoridation, other sources of fluoride, and region of residence. RESULTS: The prevalence of very mild to severe enamel fluorosis was 20.8 (95% CI, 15.4, 26.3) and 25.7 (95% CI, 15.0, 36.5) percent among non-Hispanic White and non-Hispanic Black children, respectively. Neither the adjusted odds ratio of 1.3 (0.8, 2.0) for the non-Hispanic Black group nor the interaction effect between non-Hispanic Black and water fluoridation were statistically significant. CONCLUSIONS: Enamel fluorosis was not associated with race/ethnicity. Our analysis suggests that exposure to similar levels of fluoride in the water does not appear to place certain race/ethnic groups at a higher risk for developing enamel fluorosis, and lowering the optimal range of drinking water fluoride to a single value of 0.7 ppm will provide a level of protection against enamel fluorosis that will benefit all race/ethnicity groups.

Science, Politics, and Communication: The Case of Community Water Fluoridation in the US.

Community water fluoridation (CWF) and its effect in reducing the burden of dental caries (tooth decay) is considered one of the 10 public health achievements in the 20th century. In the U.S., three-quarters (74.4%) of people on community water supplies have optimally fluoridated water, and each year approximately 90 communities actively consider starting or discontinuing CWF. CWF exists within the policy environment and includes actions taken by local community councils, health and water boards, and groups; state legislatures and health departments; national regulatory and science agencies; independent science entities; and professional and nonprofit organizations. Epidemiologists have been in the forefront of CWF. Experience with the past 70 years reveals that the coming decades will bring additional questions, recommendations, and challenges for CWF. The continued involvement of epidemiologists as part of multidisciplinary teams is needed in research, surveillance, peer review of studies, assessment of systematic review findings, and in the translation and communication of science findings to audiences with limited science/health literacy. This chapter's purpose is to 1) examine how epidemiologic evidence regarding CWF has been translated into practice and policy, 2) examine how recommendations for and challenges to CWF have affected epidemiologic research and community decision-making, and 3) identify lessons learned for epidemiologists.

Changes in Caries Experience, Untreated Caries, Sealant Prevalence, and Preventive Behavior Among Third-Graders in New York State, 2002-2004 and 2009-2012.

OBJECTIVE: This study assessed changes in caries experience, untreated caries, sealant prevalence, and preventive behavior among third-grade children in New York State to monitor progress toward state health objectives. METHODS: We analyzed children's data from the 2002-2004 (n=10,865) and 2009-2012 (n=6,758) New York State Oral Health Survey. We calculated differences in weighted percentages and 95% confidence intervals for caries experience, untreated caries, sealant prevalence, and preventive behavior. We used logistic regression procedures to assess the independent effects and interaction terms on dental caries experience. RESULTS: The percentage of children with dental caries and untreated caries decreased from 54.1% and 33.0% in 2002-2004 to 45.2% and 23.6% in 2009-2012, respectively. While this decrease was not uniform across income subgroups, the prevalence of sealants, a key measure of the use of preventive services, increased significantly from 16.7% to 36.0% among lower-income children. CONCLUSIONS: Measurable improvement in reducing dental caries prevalence among third-grade children has been made in New York State, but this improvement was not uniform across subgroups. Specifically, disease prevalence among lower-income children remained high, underscoring the need to strengthen existing programs and identify additional policy and programmatic interventions.

Reducing early childhood caries in a Medicaid population: a systems model analysis.

BACKGROUND: Despite early childhood caries (ECC) being largely preventable, its repair accounts for a disproportionate share of Medicaid expenditures. In this study, the authors model disease reductions and cost savings from ECC management alternatives. METHODS: The authors apply system dynamics modeling to the New York State Medicaid population of young children to compare potential outcomes of 9 preventive interventions (water fluoridation, fluoride varnish, fluoride toothpaste, medical screening and fluoride varnish application, bacterial transmission reduction, motivational interviewing, dental prevention visits, secondary prevention, and combinations) and the effect of defluoridating New York City. RESULTS: Model simulations help project 10-year disease reductions and net savings from water fluoridation, motivational interviewing, and fluoride toothpaste. Interventions requiring health professionals cost more than they save. Interventions that target children at high risk, begin early, and combine multiple strategies hold greatest potential. Defluoridating New York City would increase disease and costs dramatically. CONCLUSIONS: The variety of population-level and individual-level interventions available to control ECC differ substantially in their capacity to improve children's oral health and reduce state Medicaid expenditures. PRACTICAL IMPLICATIONS: Using Medicaid and health department dollars to deliver ECC preventive and management interventions holds strong promise to improve children's oral health while reducing state dental expenditures in Medicaid.

Does fluoride in drinking water delay tooth eruption?

OBJECTIVES: The objectives of this study are to determine the effect of fluoride exposure on permanent tooth eruption patterns as well as to understand its effect on caries attack rate by accounting for the number of erupted tooth surfaces. METHODS: We analyzed data from the 1986-1987 National Survey of Oral Health of US Schoolchildren to determine the mean number of erupted permanent teeth and permanent first molars according to fluoride level in drinking water. The analysis included 13,348 children aged 5-17 years with a history of single residence. We also estimated the attack rate (decayed, missing, and filled surfaces/surfaces at risk) for fluoride deficient, suboptimal, and optimally fluoridated areas adjusting for covariates. Multivariable statistical analyses were performed to control for potential confounders. RESULTS: By age 7, almost all permanent first molars had erupted. The adjusted mean number of erupted permanent first molars per child were 3.81, 3.67, and 3.92 in areas with <0.3, 0.3-<0.7, and 0.7-1.2 ppm of fluoride, respectively. The adjusted caries attack rate in the first permanent molars among 5- to 17-year-old children was 93, 81, and 78 per 1,000 surfaces in fluoride deficient, suboptimal, and optimally fluoridated areas, respectively (P < 0.0001). This pattern of higher first molar attack rate among children in the fluoride-deficient communities was also observed in all erupted teeth. CONCLUSION: Exposure to fluoride in drinking water did not delay the eruption of permanent teeth. The observed difference in dental caries experience among children exposed to different fluoride levels could not be explained by the timing of eruption of permanent teeth.

Do community-based rehabilitation programmes promote the participation of persons with disabilities? A case control study from Mandya District, in India.

PURPOSE: In this paper, we measure the effectiveness of Community-Based Rehabilitation (CBR) programmes in promoting the well-being of people with disabilities and removing the barriers to their participation in family and community decision-making processes. METHOD: To evaluate the impact of the CBR programme, we use data from a large-scale control study in Karnataka, India. Propensity score matching is used to evaluate the impacts on disabled persons after 2, 4 and 7 years of entering the CBR. The theoretical framework for the analysis is based on the CBR guidelines, which are combined with the International Classification of Functionings (ICF), the United Nations Convention on the Rights of People with Disabilities (UN CRPD) and Amartya Sen's capability approach. RESULTS: CBR has a positive impact on the well-being of persons with disabilities participating in the programme and particularly on their participation within the family and the society at large. CONCLUSIONS: CBR programmes have a multidimensional and positive impact on individual and collective capabilities; on individual, agency and social empowerment. Implications for Rehabilitation Community-Based Rehabilitation (CBR) can make a lasting difference in the life of persons with disabilities. CBR improves participation and inclusion of persons with disabilities in the family and in the community.

An emancipatory research on CBR and the barriers faced by persons with disabilities.

UNLABELLED: Abstract Purpose: The aim of this research was to understand the barriers faced by persons with disabilities in their daily lives and the role of CBR projects in overcoming them. METHOD: A group of persons with disabilities involved in CBR activities was identified and trained in participatory research methodologies. Research was carried out, with support from a scientific advisory group, through sharing of life stories in residential meetings focusing on specific themes. These meetings were attended by 368 persons with disabilities. RESULTS: The barriers identified ranged from isolation, neglect, abuse and violence to lack of access to social, health, education and livelihood opportunities. People faced their first barriers in their own families. Families also played an important role in overcoming some barriers at the individual level. CBR projects assisted people in overcoming barriers mainly by providing information, by facilitating access to existing support and by helping persons in communities to take collective action against the barriers. The research also stimulated DPOs and CBR projects to identify some gaps in tackling the barriers and to start action to overcome them. CONCLUSIONS: CBR projects can play a role in overcoming some barriers faced by persons with disabilities. Emancipatory research yields rich data, facilitates ownership and possibly future sustainability. Implications for Rehabilitation Community-based rehabilitation (CBR) programmes can promote mainstreaming and helping in overcoming some barriers faced by persons with disabilities in the communities. CBR programmes can facilitate collective action by persons with disabilities in overcoming barriers to inclusion and participation. Participatory research approaches such as emancipatory research can play a role in understanding disability issues and at the same time, help CBR programmes to identify gaps and strengthen activities.