Modified World Health Organization Research Articles

Severity of pulmonary hypertension and pregnancy outcomes: newer insights from the M-PAC registry

Abstract Background Pregnancy outcomes in women with pulmonary hypertension remain suboptimal. Pregnant women with pulmonary hypertension (PH) are placed in the modified WHO category IV, regardless of the severity or etiology of PH. Earlier studies have indicated that pregnancy outcomes may differ based on the etiology, with more favourable outcomes observed with PH related to left to right shunts. However, it is possible that the pregnancy outcomes may vary based on the severity of PH also. Purpose To analyse pregnancy outcomes in women with PH and investigate differences based on disease severity. Methods M-PAC Registry, is a single center prospective study of pregnancies in women with heart diseases, conducted between July 2016 and December 2019 in a low-and middle-income country from South Asia, whose methodology and outcomes have been published(1). The current study analysed pregnancies with PH enrolled in the M-PAC registry. The tricuspid regurgitation velocity obtained during transthoracic echocardiography, was used to estimate right ventricular systolic pressure (RVSP). Based on the estimated RVSP, PH was classified into three groups; mild (36-45 mm of Hg), moderate (46-64 mm of Hg) and severe (≥ 65 mm of Hg). The differences in the maternal and foetal outcomes among the groups were analysed. Results Of the 1029 pregnancies complicated by heart disease enrolled in the M-PAC registry, 352(34.2%)had PH. Among these 352 pregnancies, 186(52.8%) had mild, 73 (20.7%) had moderate and 93 (26.5%) had severe PH. Adverse maternal cardiac events occurred in 77 pregnancies (21.8%), with heart failure in 53(15.1%) and mortality in 10(2.8%). The composite adverse foetal event rate was 38.6%, foetal loss at 9.7%, low birth weight at 28.9%, and preterm labour at 7.1%. The mean (±standard deviation) RVSP was higher in pregnancies with adverse maternal outcome (58.81±16.9 vs 51.16±15.9; P < 0.001) or adverse foetal outcome (58.10±17.3 vs 49.52±14.9; P < 0.001)compared to those without. When comparing the three groups, pregnancies with mild PH exhibited significantly lower rates of adverse maternal and fetal events compared to those with severe and moderate PH (Fig-1 and Table-1). Mild PH was associated with outcomes similar to those without PH in the M-PAC registry. Conclusion The severity of PH significantly correlated with the adverse pregnancy outcomes. Women with mild PH tend to experience pregnancy outcomes comparable to those without PH, suggesting that pregnancy should not be deemed contraindicated in this subgroup. Therefore, re-evaluation of the placement of PH within the modified World Health Organization (mWHO) classification is warranted, considering the severity of PH.Figure 1:Pregnancy Outcomes & PH SeverityTable-1 PH Severity & Pregnacny Outcomes

Pregnancy and inherited cardiomyopathies: insights from specialized care

Abstract Background Pregnancy and postpartum represent periods of increased risk of cardiovascular complications. Management of women with modified World Health Organization (mWHO) class II–III, III, and IV during pregnancy and around delivery should be conducted at an expert centre by a multidisciplinary team. Purpose Our objective was to analyze the impact of pregnancy on cardiomyopathy outcomes in a centre specialized in inherited cardiovascular conditions in the United Kingdom. Methods All women with cardiomyopathy referred due to pregnancy to our centre between 2016 and 2023 were retrospectively analyzed. Demographic, clinical, obstetric, genetic, electrocardiographic, and multimodal imaging variables were collected. Results Between 2016 and 2023, follow-up and delivery planning were initiated for 86 pregnancies in women with cardiomyopathies referred to our centre, resulting in 81 live births and 5 miscarriages, all in the first trimester. Among the full-term pregnancies, 17 (21%) were in patients in mWHO class I or II, 22 (27.2%) in II-III, 34 (42%) in III, and 8 (9.8%) in IV. The distribution of cardiomyopathy types among different mWHO classification is represented in Table 1. Women in mWHO class ≥ II-III had more pregnancy-related events than patients in mWHO I or II [28 (34.6%) vs 1 (1.2%); p = 0.004]. The most common complication in the first group was supraventricular tachycardia in 11 pregnancies (13.6%), followed by gestational diabetes in 9 (11.1%), left ventricular ejection fraction impairment in 4 (4.9%), preeclampsia in 3 (3.7%), and 1 (1.2%) ventricular tachycardia. One patient in the second group developed gestational diabetes. The distribution of the type of delivery among different mWHO classification is represented in Table 2. Only one patient with hypertrophic cardiomyopathy in mWHO II-III who underwent a caesarean section presented a post-delivery complication related to retroperitoneal haematoma, with no statistical significative differences between the groups (p = 0.604). 100% of the patients survived pregnancy and postpartum period. Conclusions Pregnant women with cardiomyopathy face an increased risk of adverse events. Despite the presence of cardiovascular and obstetric complications, careful monitoring at a specialized centre leads to favourable outcomes particularly concerning mortality rates for both the mother and fetus. This highlights the importance of a comprehensive risk assessment and meticulous pregnancy and delivery planning to ensure optimal maternal and fetal health.Table 1.Cardiomyopathy and mWHOTable 2.Type of delivery and mWHO

Safely reopening and operating a primary healthcare facility after closure due to SARS-CoV-2 infection in a healthcare worker – Nairobi, Kenya, 2020

The first COVID-19 case in a healthcare worker in Kenya was reported on March 30, 2020, in Nairobi, leading to a 41-day closure of the health facility where he had worked. We assessed infection prevention and control (IPC) activities and implemented recommendations to re-open and operate the facility. We conducted a risk assessment of the facility in April 2020 using a modified World Health Organization, six-element IPC facility risk assessment tool. IPC recommendations were made, and a follow-up assessment of their implementation was conducted in July 2020. Breaches in IPC measures included poor ventilation in most service delivery areas; lack of physical distancing between patients; inadequate COVID-19 information, education, and communication materials; lack of standard operating procedures on cleaning and disinfecting high-touch areas; insufficient IPC training; inadequate hand hygiene facilities; insufficient personal protective equipment supplies; and an inactive IPC committee. Strengthening IPC measures is critical to prevent healthcare facility closures.

Effectiveness of the modified WHO labour care guide to detect prolonged and obstructed labour among women admitted at publicly funded facilities in rural Mbarara district, Southwestern Uganda: an ambispective cohort study.

Obstructed labour, a sequel of prolonged labour, remains a significant contributor to maternal and perinatal deaths in low- and middle-income countries. We evaluated the modified World Health Organization (WHO) Labour Care Guide (LCG) in detecting prolonged and or obstructed labour, and other delivery outcomes compared with a traditional partograph at publicly-funded maternity centers of rural Mbarara district and City, Southwestern Uganda. Since November 2023, we deployed the LCG for use in monitoring labour by trained healthcare providers across all maternity centers in Mbarara district/City. We systematically randomized a total of six health center IIIs (HCIIIs) out of 11, and all health center IVs (HCIVs), reviewed all their patient labour monitoring records for their first quarter of 2024 (LCG-intervention) and 2023 (partograph-before LCG introduction). Our primary outcome was the proportion of women diagnosed with prolonged and or obstructed labour. Our secondary outcomes included; tool completion, mode of delivery, labour augmentation, stillbirths, maternal deaths, Apgar score, uterine rupture, postpartum haemorrhage (PPH). Data was collected in RedCap and analyzed using STATA version 17. Statistical significance was considered at p<0.05. A total of 2,011 women were registered; 991 (49.3%) monitored using the LCG, and 1,020 (50.7%) using a partograph, 87% (1,741/2011) delivered from HCIVs and 270/2011 (13%) from HCIIIs. Mean maternal age (25.9; SD=5.6) and mean gestation age (39.4; SD=1.8) were similar between the two groups. A total of 120 (12.4%) cases of prolonged/obstructed labour were diagnosed (100 for LCG versus 20 for partograph), with the LCG having six times higher odds to detect/diagnose prolonged/obstructed labour compared to the partograph (aOR=5.94; CI 95% 3.63-9.73, P<0.001). Detection of obstructed labour alone increased to 12-fold with the LCG compared to the partograph (aOR=11.74; CI 95% 3.55-38.74, P<0.001). We also observed increased Caesarean section rates (aOR=6.12; CI 4.32-8.67, P<0.001), augmentation of labour (aOR=3.11; CI 95% 1.81-5.35, P<0.001), and better Apgar Score at 5 minutes (aOR=2.29; CI 95% 1.11-5.77, P=0.025). The tool completion rate was better for LCG compared to (58.5% versus 46.3%), aOR=2.11; CI 95% 1.08-5.44, P<0.001. We observed no differences in stillbirths, maternal deaths, post-partum haemorrhage (PPH) and uterine rupture. Our data shows that LCG diagnosed more cases of prolonged and or obstructed labour compared to the partograph among women delivering at rural publicly funded facilities in Mbarara city/district. We also observed increased C-sections, labour augmentation, and 5-minute Apgar scores. There were no differences in stillbirths, maternal deaths, PPH and uterine rupture. More controlled and powered studies should evaluate the two tools for other delivery outcomes, in different sub-populations.Trial registration number NCT05979194 clinical trials.gov.

Effect of Risk Factors on Blood Pressure Using Multivariate Model amongst Adult Tribal Population in a District of India

Abstract Background: This research study uses multivariate model to analyse the effect of various risk factors on blood pressure (BP) levels amongst adults in the tribal communities. Materials and Methods: A community-based cross-sectional observational study with adult tribal population residing in Lohandiguda, Bastar district, Chhattisgarh, India. A multistage sampling was followed and the modified World Health Organization questionnaire for hypertensive patients was used. Results: Three hundred and thirty adults were included. Positive moderate-weak correlation in all three groups shown by body mass index (BMI) (0.208, 0.214 and 0.287) and waist–hip ratio (WHR) (0.223, 0.240 and 0.359) with systolic BP and (BMI = 0.223, 0.240 and 0.240; WHR = 0.166, 0.198 and 0.288) diastolic BP, respectively, was found. The Pearson correlation coefficient shows that the highest predictor of high BP was BMI (0.226) followed by WHR (0.198), age (0.182), number of bidi/cigarette use per day (0.131) and smokeless tobacco frequency per day (0.114). The multivariate general linear model is moderately distinguishable (0.529) amongst all study subjects and (0.543) amongst addicted study subjects with BP having strong significance (0.000) each for addicted and overall study subjects. Conclusion: These findings call for careful consideration in the development of dietary recommendations, quitting addictions, increased attention on physical activities and public health policies tailored to tribal communities.

A phase II randomized trial of talimogene laherparepvec oncolytic immunotherapy with or without radiotherapy for patients with cutaneous metastases from solid tumors

BackgroundCutaneous metastases (CMs) are a manifestation of advanced cancer and can be treated with oncolytic immunotherapy. Laboratory studies suggest radiotherapy (RT) may facilitate response to immunotherapy. We hypothesized that oncolytic immunotherapy with talimogene lapherparepvec (T-VEC, an oncolytic immunotherapy that expresses granulocyte–macrophage colony stimulating factor) and RT would produce response in non-targeted metastases. MethodsA randomized phase 2 trial of T-VEC+/-RT was conducted. Eligible patients had ≥1 CM from a solid tumor amenable to T-VEC and RT and another measurable metastasis. Tumor and overall response was assessed using modified World Health Organization (mWHO) criteria. Adverse events (AEs) and quality of life (QOL) were characterized using CTCAE v4.0 and Skindex-16, respectively. Correlative analyses of tumor genomics and the immune system were performed. Results19 patients were randomized to receive T-VEC (n = 9) or T-VEC+RT (n = 10). One patient in each arm demonstrated complete response in the largest non-targeted metastasis. The trial was closed after the first stage of enrollment because of no overall mWHO responses, slow accrual and the COVID-19 pandemic. AEs were consistent with prior reports of T-VEC. Skin related QOL was poor before and after treatment. Median progression free survival was 1.2 and 2.5 months in the T-VEC and T-VEC+RT arms; median overall survival was 4.9 and 17.3 months in the T-VEC and T-VEC+RT arms. Analyses of peripheral blood cells and cytokines demonstrated responders exhibited several outlying lymphocyte and cytokine parameters. ConclusionsLow overall response rate, slow accrual, and the COVID-19 pandemic led to closure of this trial. Responses in non-injected and non-irradiated metastases were infrequent.

Peripartum anesthesia management and outcomes of patients with congenital heart disease: a single-center retrospective analysis (2009–2023)

BackgroundAdvances in medicine have enabled more patients with congenital heart disease (CHD) to become pregnant. However, these patients face significant challenges during the peripartum period. Current peripartum anesthesia guidelines for CHD patients mainly rely on case reports and small series. MethodsIn this retrospective study at a high-volume tertiary care center, we analyzed peripartum anesthetic approaches, postpartum hemorrhage (PPH) incidence, and maternal outcomes in CHD patients stratified by the modified World Health Organization (mWHO) classification. ResultsAmong 85 473 deliveries between 2009 and 2023, 409 occurred in 282 patients with CHD. Cesarean deliveries were significantly more frequent in mWHO class III, p=0.005. Labor epidural analgesia was the most common analgesic modality for vaginal deliveries (epidural rate was 71.1% with no differences between mWHO classes). Anesthesia management for cesarean deliveries varied significantly by class p<0.001. While spinal anesthesia was predominant in classes I and II, combined spinal-epidural anesthesia was more common in class III. PPH incidence was 6.4%, with no significant difference across classes, and no association was found between mWHO class severity and PPH risk (OR 0.97; 95% CI; 0.93 to 1.02, p=0.2). Higher mWHO classes correlated with significantly higher intensive care unit (ICU) admission rates, longer hospital stays, and one-year cardiac hospitalizations. ConclusionIn this retrospective study on the peripartum anesthetic management and outcomes of CHD patients stratified by mWHO class, cases with greater mWHO class were more likely to deliver preterm, by cesarean delivery, with a combined spinal-epidural anesthetic and an arterial line placement for that cesarean delivery. They overall had a longer hospital stay and were more likely to be admitted to the ICU. However, the overall risk of PPH did not increase with mWHO class severity.

A randomized single-blind non-inferiority trial of delayed start with drospirenone-only and ethinyl estradiol-gestodene pills for ovulation inhibition

We compared the efficacy of 4 mg drospirenone (DRSP) progestin-only pills (POPs) versus combined oral contraceptive pills (COCs) containing 0.02 mg of ethinyl estradiol (EE) and 0.075 mg of gestodene (GS) in ovulation inhibition and inducing unfavorable cervical mucus changes using a delayed-starting approach. This randomized controlled trial involved 36 participants aged 18–45 years. The major outcomes included ovulation inhibition assessed using the Hoogland and Skouby score, and cervical mucus permeability, assessed using the modified World Health Organization score. The results demonstrated ovulation inhibition rates of 77.8% for the EE/GS group and 88.9% for the DRSP group. The risk ratio and absolute risk reduction were 0.50 (95% confidence interval [CI]: 0.10, 2.40) and − 0.11 (95% CI: − 0.35, 0.13), respectively, satisfying the 20% non-inferiority margin threshold. The median time to achieve unfavorable cervical mucus changes was comparable between the DRSP (3 days, interquartile range [IQR]: 6 days) and EE/GS (3.5 days, IQR: 4 days) groups. However, the DRSP group had a higher incidence of unscheduled vaginal bleeding (55.56% vs. 11.11%; p = 0.005). DRSP-only pills, initiated on days 7–9 of the menstrual cycle, were non-inferior to EE/GS pills in ovulation inhibition. However, they exhibited delayed unfavorable cervical mucus changes compared to the standard two-day backup recommendation.Clinical trial registration: Thai Clinical Trials Registry (TCTR20220819001) https://www.thaiclinicaltrials.org/show/TCTR20220819001.

3D video tracking analysis reveals that mosquitoes pass more likely through holes in permethrin-treated than in untreated nets

In addition to killing, mosquito nets treated with permethrin have been claimed to repel mosquitoes, reducing their success in passing through a holed net. We have tested this hypothesis by tracking mosquitoes in a modified World Health Organization tunnel test. In the original assay, mosquitoes are released at one end of the tunnel and have to pass through a holed piece of net to reach the bait at the other end. The mosquitoes are left in the tunnel overnight, while mortality and feeding rates are scored the following morning. Since the original test does not reveal how mosquitoes move within the tunnel, we combined the tunnel with a 3D video camera system. We tracked susceptible and permethrin-resistant Anopheles gambiae s.s. as they moved in the tunnel and interacted with an untreated or a permethrin-treated net (Olyset Net®). Surprisingly, while permethrin increased the mortality and reduced blood-feeding rates, twice as many mosquitoes passed through the holes of the permethrin-treated net. The flight trajectories reveal that upon exposure to the permethrin-treated net, both mosquito colonies showed increased ‘excitation’, thereby augmenting their chance of getting through the holes in the net. The study underlines the complexity of behavioural modes of action of insecticides.

Autoimmunity and epithelial dysplasia in patients with oral lichenoid diseases.

The primary objective of this study was to explore relationship between autoimmunity and epithelial dysplasia in patients with oral lichenoid diseases. A total of 66 patients with oral lichen planus (OLP), 35 with oral lichenoid lesion (OLL), and 85 with oral lichenoid drug reaction (OLDR) were enrolled. OLP, OLL, and OLDR were diagnosed following the definitions of the modified World Health Organization criteria, except for the absence of epithelial dysplasia. All patients underwent diagnostic incisional biopsy and adjunctive direct immunofluorescence assays. An indirect immunofluorescence assay was conducted to determine the antinuclear antibody (ANA) positivity. OLP and OLDR patients with epithelial dysplasia demonstrated higher prevalence of serum ANA positivity compared to those without epithelial dysplasia. Elevated serum levels of high sensitivity-C reactive proteins were observed in the OLP, OLL, and OLDR patients with epithelial dysplasia. In the DIF analysis, patients with epithelial dysplasia in the OLP exhibited a higher prevalence of C3 deposition in the basement membrane zone. This study proposed that autoimmunity may contribute to elevating levels of focal and chronic systemic inflammation, potentially influencing abnormal wound healing and development of dysplastic changes in the oral epithelium among patients with oral lichenoid disease.

Against all odds: successful pregnancy in an adult patient with unrepaired coarctation of the aorta.

According to the modified World Health Organization classification, pregnant women with unrepaired aortic coarctation are at very high risk for both maternal and fetal complications and should, therefore, be counselled against pregnancy. The most frequent maternal complications include systemic hypertension, renal failure, preeclampsia, and aortic dissection. Herein, we describe a successful pregnancy in an adult patient with unrepaired aortic coarctation.

Cardiovascular Risk Assessment in Pregnancy: Findings From a Large Urban Academic Medical Center [ID 2683572

INTRODUCTION: The goal of this study is to describe patients who screened positive and had true cardiovascular disease (CVD) identified using a risk assessment tool in pregnancy or postpartum. METHODS: This is a prospective validation study of the CVD screening algorithm proposed by the California Maternal Quality Care Collaborative (CMQCC). The CVD risk assessment tool was embedded in the electronic medical record for use by all prenatal care providers with a goal of at least one CVD risk assessment during pregnancy and/or postpartum period. Patients identified with increased risk of CVD received an echocardiogram, electrocardiogram, and cardiology consultation. We describe the assessment tool responses, timing of assessment, cardiac findings, and subsequent interventions. This study was approved by the IRB at Albert Einstein College of Medicine. RESULTS: A total of 1,877 patients were screened as of September 1, 2023, with 148 screening positive for at risk of CVD. Thirty-two patients were found to be true positives including 2 (6.25%) with systolic and/or diastolic dysfunction, 10 (31.3%) with ventricular dilation or hypertrophy, and 23 (71.9%) with a valvular abnormality. CONCLUSION: All 32 true-positive cases were seen by a multidisciplinary cardio-obstetrics team at least once. Ten patients had multiple visits with the cardio-obstetrics team. Three patients were deemed to be of higher risk for decompensation during labor by modified World Health Organization classification and required detailed plans for intrapartum and postpartum management. Seven patients were started on cardiovascular medications. The cardiovascular risk assessment tool proved valuable for identifying and providing individualized care for cardio-obstetric patients.

The Prevalence of Violence Against Healthcare Workers in Trinidad and Tobago.

Abuse of healthcare workers (HCWs) and lack of public trust threaten the foundation of the physician-patient relationship. This growing global problem creates an even more difficult professional environment and hinders the delivery of high-quality clinical care. The primary aim was to determine the prevalence of violence against Trinbagonian HCWs in the public sector. Secondary objectives included determining risk factors for violence and mistrust between the public and providers. A cross-sectional analysis of 434 HCWs in the public sector of Trinidad and Tobago was conducted using a modified World Health Organization (WHO) data collection tool, distributed via social media and administrative emails, and snowballed for two months. Fifteen semi-structured interviews were conducted regarding trust in the healthcare system with patients selected from communities. Of the 434 respondents, 45.2% experienced violence and 75.8% witnessed violence against HCWs in the past two years. Verbal abuse (41.5%) was most common. Perpetrators were patients (42.2%) and patients' relatives (35.5%). Chi-square analysis highlighted that HCWs with the highest probability of being abused were aged 25-39 (63.8%), had two to five years of work experience (24.9%), specialized in emergency and internal medicine (48.6%), and cared for psychiatric and physically disabled patients (p-value < 0.001). HCWs believed the threat of violence negatively impacted performance (64.5%), and further action was necessary for mitigation (86.4%). Patients interviewed doubted physicians' altruism and competence (80%) and honesty (53.3%), expressed mistrust in their physician (46.7%), and cited poor infrastructure/management (66.7%) and dissatisfaction with care (60.0%) as factors that contributed to violence. Analysis revealed that violence against Trinbagonian HCWs in the public sector deteriorated patient experience and adversely affected psychological well-being, efficiency, and job satisfaction. Results suggested mistrust of HCWs by the population. Interventions should be instituted to support at-risk HCWs and educate the public to avoid recurrence.

Use of polygenic and clinical risk scores in wide spectrum congenital heart malformations: a diagnostic and therapeutic perspective

Worldwide, congenital heart defects (CHDs) are a leading cause of mortality and morbidity. Globally, the annual prevalence rate of CHDs is about 1.5 million. It is one of the most common life-threatening congenital malformations, with a visible difference between high-income countries (HICs) and developing countries. This difference may be attributed to the diagnostic facilities and interventions.1 Moreover, the use of genetic and clinical risk scores is less studied in this field compared to other diagnostic and therapeutic approaches. Thus, we comprehensively review the available literature on adult and pediatric syndromic or non-syndromic CHDs and propose limitations and future directions in this field. Risk factors for this fatal disease include genetic and environmental factors.2,3 Risk stratification based on prenatal diagnosis with genetic counseling has shown better clinical outcomes. The modified World Health Organization (mWHO) guidelines are among the first proposed for risk stratification based on clinical scores.4 The combination of polygenic risk scores (PRS) and clinical risk evaluation has been adopted in various populations as better diagnostic and therapeutic approaches for various diseases, including coronary artery disease,5 diabetes,6 obesity,7 and cancers.8,9 However, unlike these diseases, polygenic risk scores are rarely used for the genetic diagnosis of CHD patients. The clinical utility of polygenic risk scores for CHDs is still in the early stages and requires validation studies in different cohorts. Incorporating PRS into the clinical setting may improve CHD diagnosis and therapeutic strategies.10 Recently, an initial attempt was made to determine the clinical utility of polygenic risk scores in a large dataset of the European cohort. Data from this study suggested a high potential for PRS in distinguishing between clinical phenotypes (mild, moderate, and severe) of congenital heart malformations.11 Furthermore, this hypothesis was tested in patients with transposition of the great arteries (TGA) to assess the utility of risk stratification after arterial switch operation. The cumulative risk score was computed for single nucleotide polymorphisms (SNPs) that reached the threshold statistical significance of p&lt;1×10−5 in the initial analysis. Combined clinical and polygenic risk scores showed improved risk stratification in mild, moderate, and severe TGA phenotypes.12 Similarly, in another European cohort, the risk allele frequency was higher in the diseased group compared to the control group. However, statistical analysis suggested a non-significant association with p&gt;0.05. Interestingly, combined risk scores constructed for selected SNPs showed a significant association with the disease with a p-value of 0.002. This evidence further supports the hypothesis that the cumulative effect of polymorphisms has better diagnostic and therapeutic efficacy than individual SNPs.13 There are certain limitations to its clinical use. Firstly, social stigma and lack of awareness regarding this disease are major hurdles. Secondly, there is a need to recruit a large number of samples from different populations to validate the clinical utility of PRS. Additionally, a lack of resources in developing countries also contributes to fatal outcomes. We recommend conducting large cohort studies in different ethnic groups to predict better risk associations, develop better therapeutic strategies, and formulate management guidelines.

Dental health status of children with diabetes in Riyadh, Saudi Arabia

ObjectiveThe impact of diabetes on oral diseases remains debatable. We aimed to determine the prevalence of dental caries, gingival health status and knowledge, and oral hygiene level and practice in children with type 1 diabetes mellitus in Riyadh, Saudi Arabia. MethodsThe teeth of Sixty children with diabetes (33 males and 27 females; age 11.3 ± 2.2 [7–14] years) were examined for dental caries following the modified World Health Organization criteria. Data on age, sex, medical history, gingival health status and knowledge, and oral hygiene level and practice were collected from parents. ResultsIn this study, 53 % of the children had dental caries with decayed, missing, and filled primary and permanent teeth scores of 5.6 ± 3.8 and 3.6 ± 3.2, respectively, with similar scores for male and female children. Children with and without caries had similar oral hygiene practices and oral health knowledge but differed in the rates of good or fair oral hygiene status (89.2 vs. 56.6 %; P = 0.024) and normal gingival health status or mild gingivitis (96.5 vs. 81.3 %; P = 0.010). ConclusionsWe found that the oral hygiene status and rate of gingivitis differed in children with type 1 diabetes mellitus with or without dental caries.

Electrocardiographic proarrhythmic changes in pregnancy of women with CHD.

Pregnancy-related physiological adaptations result in increased heart rate as well as electrocardiographic changes such as a mean QTc prolongation of 27 ms. Pregnant women with CHD are at increased risk for cardiovascular complications. The aim of this study was to identify risk factors for abnormally prolonged QTc interval-a risk factor for ventricular arrhythmias-in pregnant women with CHD. Retrospective longitudinal single-centre study. Pre-pregnancy demographic and electrocardiographic risk factors for abnormal QTc duration during pregnancy of (a) > 460 ms and (b) >27 ms increase were analyzed. Eighty-three pregnancies in 63 women were included, of which three had documented arrhythmias. All five Modified World Health Organization Classification of Maternal Cardiovascular Risk (mWHO) classeswere represented, with 15 pregnancies (18.1%) in mWHO class I, 26 (31.3%) in mWHO II, 28 (33.7%) in mWHO II-III, 11 (13.3%) in mWHO III, and three pregnancies (3.6%) in mWHO class IV. Heart rate and QTc interval increased, while QRS duration and PR interval shortened during pregnancy. QTc duration of > 460 ms was associated with increased pre-pregnancy QTc interval, QRS duration, and weight, as well as body mass index. QTc increase of > 27 ms was associated with increased heart rate prior to pregnancy. No significant associations of electrocardiographic changes with mWHO class or CHD type were identified. Increased QTc in pregnant women with CHD was associated with being overweight or having higher heart rate, QRS, or QTc duration prior to pregnancy. These patients should be monitored closely for arrhythmias during pregnancy.

Immediate Postpartum Breastfeeding following Pregnancy with Cardiac Disease.

This study aimed to identify predictors of immediate postpartum breastfeeding among women with maternal cardiac disease (MCD). This study included all gravidas with MCD who delivered at a single institution from 2012 to 2018. Charts were abstracted for maternal demographics, obstetrical outcome, cardiac diagnoses, cardiac risk stratification scores, and prepregnancy echocardiogram findings. Kruskal-Wallis and Fisher's exact tests were used to compare the breastfeeding (BF) group versus the nonbreastfeeding (NBF) group. Logistic regression was used to obtain odds ratios (ORs) with 95% confidence intervals (CIs). Among 211 gravidas with MCD, 12% were not breastfeeding at the time of postpartum hospital discharge. Compared with the BF group, the NBF group had a significantly higher proportion of women with cardiomyopathy (21% NBF vs. 7% BF, OR = 3.44, 95% CI: 1.12-10.71), with modified World Health Organization (WHO) classification ≥III (33 vs. 14%, OR = 3.16, 95% CI: 1.22-8.15), and with prepregnancy ejection fraction (EF) < 50% (55 vs. 14%, OR = 7.20, 95% CI: 1.92-27.06). There were otherwise no differences between the two groups with regards to other cardiac diagnoses or cardiac risk scores. In women with MCD, cardiomyopathy, modified WHO class ≥III, and a prepregnancy EF < 50% were associated with NBF in the immediate postpartum period. These findings may guide providers in identifying a subset of women with MCD who can benefit from increased breastfeeding counseling and support. · Eighty-two percent of patients with cardiac disease are breastfeeding at the time of postpartum discharge.. · Cardiomyopathy is associated with an increased odds of not breastfeeding at postpartum discharge.. · Rationale for not breastfeeding is infrequently documented in the medical record..

Cardiogenic Shock and Utilization of Mechanical Circulatory Support in Pregnancy.

Maternal mortality rates are rising in the United States, a trend which is in contrast to that seen in other high-income nations. Cardiovascular disease and hypertensive disorders of pregnancy are consistently the leading causes of maternal mortality both in the United States and globally, accounting for about one-quarter to one-third of maternal and peripartum deaths. A large proportion of cardiovascular morbidity and mortality stems from acquired disease in the context of cardiovascular risk factors, which include obesity, pre-existing diabetes and hypertension, and inequities in care from maternal care deserts and structural racism. Patients may also become pregnant with preexisting structural heart disease, or acquire disease throughout pregnancy (ex: spontaneous coronary artery dissection, peripartum cardiomyopathy), and be at higher risk of pregnancy-related cardiovascular complications. While risk-stratification tools including the modified World Health Organization (mWHO) classification, Cardiac Disease in Pregnancy (CARPREG II) and Zwangerschap bij Aangeboren HARtAfwijking/Pregnancy in Women with Congenital Heart Disease (ZAHARA) have been designed to help physicians identify patients at increased risk for adverse pregnancy outcomes and who may therefore benefit from referral to a tertiary care center, the limitation of these scores is their predominant focus on patients with known preexisting heart disease. As such, identifying patients at risk for pregnancy complications presents a significant challenge, and it is often patients with high-risk cardiovascular substrates prior to or during pregnancy who are at a highest risk for adverse pregnancy outcomes including cardiogenic shock.

Reach and effectiveness of a non-university cardio-obstetrics program

Background Current guidelines recommend multidisciplinary cardiovascular obstetric programs (CVOB) to manage complex pregnant patients with cardiovascular disease. Minimal evaluation of these programs exists, with most of these programs offered at university-based centers. Methods A cohort of 113 patients managed by a CVOB team at a non-university health system (2018–2019) were compared to 338 patients seen by cardiology prior to the program (2016–2017). CVOB patients were matched with comparison patients (controls) on modified World Health Organization (mWHO) category classification, yielding a cohort of 102 CVOB and 102 controls. Results CVOB patients were more ethnically diverse and cardiovascular risk was higher compared to controls based on mWHO ≥ II-III (57% vs 17%) and. After matching, CVOB patients had more cardiology tests during pregnancy (median of 8 tests vs 5, p < .001) and were more likely to receive telemetry care (32% vs 19%, p = .025). The median number of perinatology visits was significantly higher in the CVOB group (8 vs 2, p < .001). Length of stay was a half day longer for vaginal delivery patients in the CVOB group (median 2.66 vs 2.13, p = .006). Conclusion Implementation of a CVOB program resulted in a more diverse patient population than previously referred to cardiology. The CVOB program participants also experienced a higher level of care in terms of increased cardiovascular testing, monitoring, care from specialists, and appropriate use of medications during pregnancy.

Prevalence of Risk Factors for Hypertension Among Faculty at an Urban University in Uganda.

Hypertension is a major contributor to morbidity and mortality worldwide. Many people however are not aware of their possession of risk factors for hypertension. There is a paucity of literature in Uganda describing the risk profile of faculty at public universities. The purpose of this study was to determine the prevalence of hypertension risk factors among university teaching staff. This study was conducted among faculty at Makerere University in Uganda. The modified World Health Organization STEP-wise approach for non-communicable disease surveillance was used in data collection. Hypertension was defined as having a systolic blood pressure of ≥140mmHg and/or a diastolic blood pressure of ≥90mmHg, or being on antihypertensive medications. Participants were enrolled from the faculty lists by proportionate to size systematic sampling until the sample size for each college was obtained. Data was collected from January to March 2018. Multivariate logistic regression was used to determine factors associated with hypertension. A total of 141 participants were recruited into the study. The prevalent risk factors for hypertension include physical inactivity (78.7%), overweight (46.8%), obesity (20.6%), addition of extra salt to food (46.8%), current alcohol consumption (33.3%), history of smoking (10.6%), inadequate fruit and vegetable servings per day (100%), family history of hypertension (40.4%) and a family history of diabetes (22.7%). Hypertension was prevalent at 26.2% (95% CI 18.94-33.46%). The risk factors significantly associated with hypertension included a family history of hypertension (p=0.009), obesity (p=0.008) and male gender (p = 0.029). The prevalence of known hypertension risk factors among university teaching staff in urban Uganda is high. Majority of these risk factors are modifiable highlighting the need for continuous screening as well as introduction of prevention and health promotion strategies to reduce the risk burden.