Iris Publishers- Open access Journal of Pediatrics & Neonatal Care | Hypertensive Disorders During Pregnancy, Fatal Effects on Mother and Baby-Prevention a Challenge in Low Resource Settings

 

Authored by Chhabra S*

Abstract

Background: Hypertensive disorders during pregnancy (HDsP), unpredictable, multifaceted disorders which can rapidly develop into dangerous eclampsia and /or life-threatening multiorgan dysfunction, are major causes of morbidity, mortality of mothers, babies.

Objective: Objective was to know status of maternal severe morbidity, mortality and perinatal mortality due to HDsP at a rural institute.

Materials and Methods: Present study was conducted in obstetrics gynecology of a rural institute of low resource region.

Results: There were 34089 obstetric cases admitted over 5 years of analysis period. Of them 4201 had HDsP, 12.32% of all cases. Severe morbidity due to HDsP occurred in 348 (8.28%) women who had HDsP. Of 348 cases with SM ,150 (3.57% of all HDsP) and 18% of all SM, had placental abruption, 63 (1.49% of all HDsP), 18.1% of SM had HELLP, 59 (1.40% of all HDsP), 16.95% of cases of SM had Pulmonary edema, 5 (0.11% of HDsP), 1.43% of all SM, had renal failure, and 71 (1.69% of all HDsP), 20.40% of SM had coagulation failure. Fifteen maternal deaths occurred due to HDsP, 0.35% of 4201 cases of HDsP, 4.31% of 348 cases of severe morbidity due to HDsP. Maternal deaths due to HDsP contributed to 24.6% of overall maternal mortality. Overall 153 perinatal deaths occurred in HDsP cases. contributing to 15.69% perinatal deaths in the same period.

Conclusion: In low resource region incidence of HDsP was high, severity and case fatality were also high. They contributed to a lot of maternal mortality and perinatal mortality.

Keywords: Hypertensive disorders; Pregnancy; Severe morbidity; Mortality; Perinatal mortality

Background

Hypertensive disorders during pregnancy (HDsP), unpredictable and multifaceted disorders which can rapidly develop into dangerous eclampsia and other life-threatening multiorgan dysfunction, are the major causes of morbidity and mortality of women and babies. Bhattacharya et al. [1] reported that the case fatality rates for eclampsia ranged between 0 to 1.8% in high-income countries, 17.7% in India and 2.3% in Uganda. In the UK, preeclampsia affected up to 6% of pregnant women and 2% of severe cases progress to eclampsia. Overall HDsP, which included, gestational hypertension (GH), preeclampsia (PE), and eclampsia (EC) have been reported to occur in 5.2-8.2%, 1.8-4.4% and 0.2-9.2% women respectively [2]. Others have also reported HDsP ranging from 1.6 to 10 cases per 10,000 deliveries in developed countries [3-6] and 6 to 157 cases per 10,000 deliveries in developing countries [7,8]. In India, the incidence of preeclampsia was reported to be 8-10% pregnancies. In a community based study in India hypertension during pregnancy was reported in 6% [9]. Another study revealed 7.8% incidence of HDsP [10]. It has been reported that the HDsP occur in 3 to 8% of pregnancies worldwide [11,12].

Objective

Objective was to know status of severe morbidity and mortality of mother and perinatal mortality due to HDsP at a rural institute in a low resource region, with plans for trying preventive research.

Materials and Methods

Present study was conducted in the department of obstetrics gynecology of a rural institute in a low resource region after approval of ethics committee of the institute. Records of cases of HDsP managed over five years were analyzed to get information about major maternal morbidities and mortality and perinatal mortality as base information for planned preventive interventional study.

Results

There were 34089 obstetric cases over 5 years of the analysis period. Of them 4201 women had HDsP, 12.32% of all obstetric cases. There were 2877 (68.48%) cases of GH, [2014 (44.9% of all HDsP) mild GH and 863 (20.5%) severe GH], 734 (17.44%) PE, [534 (12.71%) mild PE and 20 (4.76%) severe PE] and 304 (7.23%) Eclampsia (Table 1). Severe morbidity due to HDsP occurred in 348 (8.28%) women with HDsP. Overall 150 (3.57% of all HDsP) women had placental abruption, 104 (49.7%) of 209 primigravida with severe morbidity, 35 (36.8%) of 95 women with 1 or 2 births, 11 (23.4%) of 44 with more than 2 births. Of the 150 women, who had placental abruption, 50 (33%) were of 15-19 years age, 74 (49.3%) of 20-29 years, 12 (8%) of 30-39 years and 04 (2.6%) of 40-49 years. Total 63 (1.49% of all HDsP) women had Haemolysis, Elevated Liver, Enzyme and Low Platelets. (HELLP), 38 (18.1%) of 209 primigravida with severe morbidity, 15 (15.7%) of 95 with one or two births and 09 (1.9%) of 44with more than 2 births, 10(15.8%) women were of 15-19 years age, 30(44.6%) of 20-29 years, 15(23.8%) of 30-39 years and 08 (12.7%) of 40-49 years. A total of 59 women (1.40% of all HDsP) had pulmonary edema, 33 (15.7%) of 209 primigravida with severe morbidity, 15 (15.7%) of 95 with one or two births, 11 (25%) of 44 with more than 2 births, 37(62.7%) were of 20-29 years, 12(20.3%) of 30-39 years and 04(6.8%) of 40-49 years. Five (0.11% of all HDsP) had renal failure, 02(0.9%) out of 209 primigravida, 02 (2.10%) of 95 with one or two births and one (2.1%) of 44 with more than two births. One (1%) was an adolescent and 04(2.2%) were of 20-29 years. Seventy one (1.69% of all HDsP), women developed coagulation dysfunction , 30 (14.35%) of 209 primigravida, 26(27.3%) of 95 with one or two births and 15(31.9% of 44) with more than 2 births, 17(9.1%) of 35 were of 20-29 years, 10 (4.7%) of 30-39 years and 8 (3.8%) of 40-49 years (Table 2). More women with first pregnancy had complications. Fifteen maternal deaths occurred due to HDsP, 0.35% of all cases of HDsP (4201), and 4.31% of 348 cases of severe morbidity. Maternal deaths due to HDsP contributed to 24.6% of maternal mortality over the analysis period. HDsP cases contributed to 19.63% intrauterine deaths, 21.67% still births and 8.35% of all neonatal deaths, overall contributed to 15.69% Perinatal mortality during the analysis period (Table 3 & 4).

Discussion

Severe complications associated with HDsP are probably among the most difficult to predict and prevent. Because of high burden of HDsP, delayed recognition, delay in accessing vital services and delay in accessing prompt and appropriate care, many women present with multi organ involvement leading to death. In a study [13], HDsP were responsible for severe obstetric complications during hospitalization for delivery and contributed to a relatively large proportion of hospitalization for severe obstetric complications. Lawn et al. [14] opined that 99% of such problems occurred in less developed countries. Poon et al. [15] reported that pre-eclampsia killed around 76000 women and 500000 babies every year. The only current available preeclampsia cure is delivery of the placenta, because placenta is believed to be responsible for proinflammatory substances which affected the maternal cardiovasculature apparatus responsible for the clinical picture [16]. Further complications in mother and baby also depend on the gestation at which it occurs, becomes obvious and further management. For very preterm pre-eclampsia (24- 34 weeks’ gestation), the current evidence suggested fetal health benefited by prolonging the pregnancy. But this in turn required close clinical surveillance of the woman [17]. A study revealed that early onset HDsP lead to more adverse perinatal outcome than late onset HDsP. However, in a study for pregnancy which could go to around 34 weeks of pregnancy, perinatal survival was similar to term cases [18]. More studies are required to investigate further. A randomized controlled trial revealed a non-significant reduction in maternal adverse outcome if late preterm pre-eclampsia cases were intervened before term [19]. Chappell et al. [20] suggested shared decision making in cases of late preterm pre-eclampsia (34-37 weeks’ gestation), offering initiation of delivery with the aim of reducing maternal morbidity and severe hypertension, balanced against the increased risk of neonatal unit admissions, without increasing newborn respiratory or other morbidities. Researchers reported that at the expense of increased neonatal unit admissions related to premature births, immediate planned delivery reduced maternal morbidity and severe hypertension compared with expectant management among women with late preterm pre-eclampsia but the under estimation of long-term neonatal morbidities remains. There was strong evidence to suggest that planned delivery reduced, severe hypertension and maternal morbidity compared to expectant management but with more neonatal unit admissions. However, others [21] reported that pregnancy prolongation in early-onset preeclampsia was associated with improved offspring outcome and survival. These effects did not appear to be deleterious to short-term maternal cardiovascular and metabolic function but were associated with a modest increase in risk of residual albuminuria, admissions because of prematurity but no greater neonatal morbidity. In a study the case fatality due to eclampsia ranged from 0 to 1.8% in high-income countries to 18% in middle-income countries like India, which reflected the gap in quality of care. No maternal death due to eclampsia occurred in a one-year period in the whole of the Sweden, and one hospital in India reported 11 eclampsia-related deaths [22], Jiang et al. [23] also did a study and reported gap between high-income countries and low-and middle-income countries. HDsP, seem to be systemic inflammatory disease that may lead to multi organ damage, be it liver, kidneys, lungs, and central nervous system with danger of renal failure, thrombocytopenia, disseminated intravascular coagulation, acute pulmonary edema, and future chronic hypertension and cerebro-vascular disorders, 3 to 25 times risk than normotensive women. So, the problems of diagnosis and management in low resource regions. In the present study, it was revealed that HDsP, occurred in 12.32% obstetric cases. Severe morbidity occurred in 348 (8.28%) of 4201 cases of HDsP. Of all the women with SM, 209 (60%) were primigravida, 95(27.2%) with one and two births and 44(12.64%) had more than 2 births. Total 94 (27%) women with SM were of 15-19 age, 179(51.4%) of 20-29 years age, 51(14.7%) of 30-39 years age and 24 (6.9%) of 40-49 years age. Out of total 348 cases with SM, 150 (3.57% of all HDsP) and 18% of all SM had placental abruption, 63 (1.49% of all HDsP) and 18.1% of all SM had HELLP. 59 (1.40% of all HDsP) , 16.95% of cases of SM had pulmonary edema, 5 (0.11% of HDsP) and 1.43% of all SM, had renal failure, 71 (1.69% of HDsP), 20.40% of SM had coagulation dysfunction. The placenta- related complications included placental insufficiency, placental abruption, fetal growth restriction, preterm births and intrauterine fetal deaths. In the present study 13.4% women had preterm births in HDsP cases, 231 (10%) women of GH, 80 (12%) of preeclampsia, and 132 (40%) of eclampsia. HDsP have been reported to be accounting for 12% of all maternal deaths globally [24]. In the present analysis HDsP contributed to 24.6% maternal mortality. Also, women with HDsP have more chances of preterm births, fetal growth restriction (FGR), low birth weight (LBW) and perinatal deaths. In the present analysis HDsP cases contributed to 19.63% intrauterine deaths, 21.67% still births and 8.35% of all neonatal deaths during the analysis period and HDsP cases. contributed to 15.69% perinatal deaths in same period. A previous study showed that the risk of neurodevelopmental delay and neonatal death decreased with increased gestational age, even in late preterm births [25]. Studies in low- and middleincome countries suggested that improving communications is essential. Early identification of pre-eclampsia and its appropriate management before the onset of eclampsia, it is recognized as a way to mitigate the worst outcome for mothers and newborns. Ridder et al. [26] reported that maternal cardiovascular function played a significant role in the pathophysiology of preeclampsia. The predisposition of women with cardiovascular dysfunction for developing preeclampsia, the development of cardiovascular dysfunction prior to disease onset, the predominance of cardiovascular signs/ biology at presentation , and the longterm cardiovascular health risks, all support the assertion that preeclampsia could be a primary cardiovascular disorder. Since HDsP continue to be a leading cause of maternal and Perinatal mortality and morbidity with direct estimated maternal deaths of about 41000 per year (14% of all maternal deaths), of whom 94% occurred in low- income countries [27] attempts continue to find modes of prediction and prevention. Peguero et al. [28] did a prospective cohort study to assess women with early-onset severe preeclampsia whether longitudinal changes in angiogenic factors improved the predictions of adverse outcome and reported that levels of placental growth factor [PIGF], soluble fms-like tyrosine kinase [sFIt-1] and s Fit- 1/PIGF ratio, added prognostic value of longitudinal changes of angiogenic factors in early- onset severe preeclampsia. Others [29] have proposed a new biomarker. Glycosylated fibronectin (GlyFn) for late onset HDsP too. Recently Guy et al. [30] have reported that first trimester combined screening for pre-eclampsia, maternal risk factors, blood pressure, PAPP-A and uterine artery Doppler indices, is both feasible and effective in public healthcare settings. Various attempts continue for prevention. Aspirin is, most often suggested. Rolnik et al. [31] reported that although there was concern that aspirin might disrupt the vasoconstrictor/ vasodilator balance in high –risk women, there was no eclampsia in those women who were given aspirin. Hobmeyl et al. [32] reported the complex pathogenesis of preeclampsia, and the need to take a multi-pronged approach not only for identification of predicated risk but also subsequent prevention. Wide range of incidence of HDsP, their complications and sequela have been reported from Hospitals, Districts, States, Countries and Regions due to differences in occurrence, diagnosis, pregnancy care, and further complications and case fatality. There are differences in morbidity and mortality due to HDsP. The mortality rates are high in low-income countries due to various reasons including low quality maternal care due to various reasons, may be infrastructure, non-availability of services for investigations and management of severely ill women. At present it is unrealistic to assume that HDsP can be completely prevented. Better understanding of the etiology of HDsP is essential for preventing their occurrence and further complications. Some women enter pregnancy with pre-existing risk factors and pre-existing medical diseases, like diabetes, chronic hypertension, chronic kidney disease or autoimmune disease, or HDsP in previous pregnancy, in addition to other known risk factors such as obesity, primiparity, later age, family history of HDsP, or blood pressure higher than the normal range for the age.

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Iris Publishers- Open access Journal of Modern Concepts in Material Science | Electromagnetic Processing for Elaboration of Dissimilar Joints. Case Studies with Aluminum

 

Authored by S Marya*

Abstract

Magnetic pulse welding (MPW) has potential applications where fusion welding is problematic, such as in dissimilar joints or where the very part integrity, as in electronic components, is likely to be threatened by hot environments. The paper describes some critical applications such as: joining of similar joints between Al wire to Al plate for electric and hybrid applications, dissimilar joints of Al to Cu for electrical conductors, Al to Steel for vehicles, Manganin to Copper for cryogenic applications and joining flexible printed circuit boards. The inductor design and the part set up for the aforementioned applications are critical for successful implementation of MPW. Generally, an air gap between the driver part and the opposite stationary part is required. This prerequisite becomes penalizing in mass production. To circumvent this, the authors have developed innovative solutions via localized humps in case of sheets. The paper proposes to discuss process highlights and characterization of the joints.

Keywords: Magnetic pulse welding; Applications; Air gap; Similar and dissimilar metal joints; Inductor

Introduction

Welding and joining more conventionally involve atomic scale continuity between parts that is obtained by localized fusion, or diffusion combined with or without plastic deformation. Temperature is thus an important physical parameter that combined with time determines the extent of atomic scale mixing. In homogeneous assemblies, the extent of interpenetration between parts does not have important implications other than grain size, phase transformations and overall deformation. However, in heterogeneous assemblies, particularly when the interpenetration is not immune to the formation of intermetallic compounds, temperature –time must become primordial to limit the extent of intermetallic [1]. In other critical assemblies such as wire to plates in electronic components, temperature must remain localized at the junction point such that surrounding elements do not undergo thermal damage [2]. In short for heterogeneous joints or joints with different thermal capacities, solid state welding turns to be the best option. Frictional processes (Linear, Orbital, Stir...), brazing/soldering, explosive and magnetic pulse welding are then the evident options [3]. The choice that is intended in this paper is oriented towards the exploration of the magnetic pulse welding. After a brief description of the process, some case studies will be presented.

Magnetic Pulse Welding

The principle underlying magnetic pulse welding is the impact of one part with another in a way analog to explosive welding, except that the impact energy is imparted by high transient magnetic fields via a rigidly fixed solenoid coil placed close to the flying part as schematically depicted in Figure 1. First, the circuit is charged by accumulating a large amount of electrical energy in a capacitor bank and then rapidly discharged in a solenoid or inductor. The conductive part adjacent to the solenoid is subjected to a changing magnetic field and becomes bestowed with skin currents that in return generate its own magnetic field. The resulting Lorentz forces accelerate the immediate part so as to explosively impact the second stationary part that is rigidly fixed [4-10]. A joint similar to one observed in explosive welding between the two parts is then produced, when two additional conditions are satisfied namely:

1. Impact energy is enough to create short but intense heat at impact point, which implies that an air gap between the flyer and the fixed part is installed for acceleration to take place. The velocity (V) when the flyer part impacts the stationary part depends on the magnetic pressure, the mass of the accelerated part, its material properties and the initial gap between the two parts. For successful welding, roughly the following impact velocity criterions are required [4]:

where HV is the material hardness; ρ the density and dσ/dε is the strain hardening coefficient of the material. This implies that the outer material should be light, its hardness low and should be very good conductor. Subsequently in Al-Cu, Al-Steel, Al-Mg joints, Aluminum reported later on, Aluminum would be the outer part in spite of the fact that copper is a better conductor but heavier than Aluminum.

2. The collision takes at such an angle that the oxides are washed away by the air jet, providing thereby clean surfaces for diffusional contact. The minimum contact angle decreases with increasing velocity and density of the flyer material (Figure 2).

The above-mentioned conditions are met by appropriate part arrangement and induction coils (Figure 2&3) that have been proposed earlier by the authors. In all cases, it’s important to provide a relatively small air gap and conditionally it becomes a handicap in real industrial production. Very recently A.P. Manogaran et al.[5] advanced and implemented the idea of using localized stamped humps such that outside the humps, the parts, mostly sheets, can be rapidly fixed as outside the humps, the sheets are in contact (Figure 3f). Only at humps, the parts are apart so as to provide air gap for acceleration. However, this works for sheets and can be implemented in mass production industry such as automotive sector. This process is designated as magnetic pulse spot welding and described later on in this paper.

Case Studies

Dissimilar joints of Al-Cu tubes

Figure 4 presents some important sequences and observation before and after the pulse welding operations. After welding, it’s easy to peel off aluminum from the copper from the early sections of the joints, i.e. the locations of the first impact on the conical copper tube where acceleration for required impact velocity is still insufficient (Figure 4B). In this part, only traces of aluminum are seen on the peeled copper tube. Progressively towards the mid length of the joint, intermetallics with wavy interfacial pockets are observed by metallographic observations on etched sections (Figure 4D). Peeling from the terminal end is comparatively harder and observation of the peels shows spherical voids that seem to result from local melting subsequent to high impact energy. During impact, aluminum undergoes deformations and its total elongation can be as high as 25 to 30%. There is an effective thinning of the outer tube. Micro-hardness tests on the etched sections with micro constituents show HV of 400 that decreases abruptly section before rising again in aluminum. Hardness reduction in the immediate section of micro constituents suggests that the exothermic reaction during the formation of compound softened the material. Further far off on aluminum, the hardness increases due to strain hardening. This hardness behavior is observed only on sections where microconstituents are observed. For instance, in the first part where impact did not yield only segmented or partial bonding, hardness decreases all the way from the interface to far off locations on aluminum.

Dissimilar Al-Steel spot welds

The stringent requirement of an air gap or standoff distance between parts to be welded remains impractical in production, though not impossible. This constraint can be eliminated by stamping one of the sheets so as to create a natural gap via hump as shown in Figure 3e and 3f. The inductor is designed in such a way that it is placed just above the hump. When the current is discharged, according to the MPW principle, the hump deforms and impacts on to the other material at a very high velocity to realize spot welding. AP Manogaran et al. [5] have successfully tested an optimized stamp shape that generates resistant spot welds. The geometry of the hump determines the size of the spot weld. Tensile shear tests reveal tearing of 0.5 mm thick aluminum sheet around the spot weld made on 1.5 mm plain carbon steel. As suggested and established by metallographic observations of the etched cross sections of spot welds, the central part of the rectangular spot is un-welded (plain interface) and the opposite sides show packets of waves progressing in opposite directions (Figure 5). Since, the process is rapid, only very thin intermetallic layers (2-5μm) are formed and that too only around those wavy regions.

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Iris Publishers- Open access Journal of Dentistry & Oral Health | Oral Pyogenic Granuloma: Case Report of an Atypical Presentation

 

Authored by Iquebal Hasan*

Abstract

“Granulomas seem to be a defensive mechanism that triggers the body to “wall off” foreign invaders such as bacteria or fungi to keep them from spreading” [1]. Pyogenic granuloma is a relatively common benign skin growth that consists of vascular nodules of proliferating capillaries [2]. They grow rapidly and often occur following a minor injury or trauma, most likely as a vascular or fibrous response to injury or irritant [2]. Ultimately, the etiology of pyogenic granuloma is still unknown. Oral pyogenic granuloma is most commonly found on the gingiva, followed by the lips, tongue, buccal mucosa, and hard palate [3]. It often presents as a red, smooth, or lobulated exophytic lesion which can be pedunculated or sessile and often bleeds on provocation [4]. A microscopic evaluation of pyogenic granuloma often reveals that the lesion is fully or partially covered by parakeratotic or non-keratinized stratified squamous epithelium. The majority of the lesion is formed by a lobulated or non-lobulated mass of angiomatous tissue, with limited collagen present in the connective tissue of the lesion. The surface of the lesion may or may not be ulcerated but can be infiltrated by plasma cells, lymphocytes, and neutrophils [5]. Treatment of these lesions most often consists of surgical excision or curettage and electrodesication [2].

Case Report

This case report is about a 54-year-old Caucasian woman who presented to the ECU School of Dental Medicine (ECU Sodom) for treatment of a pedunculated palatal lesion on the left side of her hard palate oral candidiasis which was present throughout her mouth. The patient was referred to oral medicine specialist at ECU School of Dentistry for evaluation of a “skin tag” on the left side of the palate and white and red lesions which were in her entire mouth but mainly in the posterior hard palate. Her past medical history was significant for gastroesophageal reflux disorder, chronic obstructive pulmonary disease, anxiety, depression, diabetes, hypertension, myocardial infarction, stroke, and severe peripheral vascular disease. When she presented to the ECU SoDM Faculty Practice clinic, she was taking proventil, amlodipine, carvedilol, lisinopril, nitroglycerin, polyethylene glycol, vitamin D, klonopin, welbutrin, percocet, hydrochlorothiazide, plavix, aspirin, advair, diskus, gabapentin, albuterol, ferrous sulphate, Zanaflex, diazepam, cefdinir, and prednisone. The patient also reported that she smoked one pack of cigarettes a day for the past 38 years and uses recreational marijuana.

The patient was mainly concerned about the white areas throughout her mouth. She had previously been prescribed antibiotics and steroids for the white areas, but she believed they had made the white areas worse. She also reported that she had noticed that her voice had become hoarse sounding. Upon examination, the patient was edentulous and wore maxillary and mandibular dentures. She had severe dry mouth with lack of pooling of saliva in the anterior floor of her mouth. The white lesions were diagnosed as candidiasis and it was present in her entire mouth including the tongue and oropharynx. Her initial diagnosis was dry mouth and oral candidiasis secondary to dry mouth. The lesion on the left anterior palate was thin, smooth, and pedunculated. It measured 4mm at the base, 6mm at the widest area, and 8mm in length. It was flat and wide and hung from its base, shaped similar to a paddle. It was attributed to frictional trauma from her denture.

The patient’s treatment recommendations were over the counter dry mouth products, clotrimazole troches to treat the candidiasis. She was also told to contact her physician regarding stopping the antibiotic. She was also scheduled for biopsy of the “skin tag” after initial treatment with anti-fungal medication.

The patient returned for a follow-up appointment 21 days after her initial appointment. She reported significant improvement in oral dryness and in the white lesions. Examination revealed that there was improvement in lubrication in her mouth and the candidiasis had improved significantly as well but was still present. She was recommended to take an additional course of the antifungal medication and was scheduled for biopsy (Figure 1).

The patient presented for biopsy of the palatal lesion with the oral surgeon. Oral surgeons’ clinical diagnosis was same as oral medicine specialist as traumatic fibroma. Local anesthesia of the area was achieved using one half of a carpule of lidocaine 2% 1:100,000 epinephrine. An excisional biopsy was performed using a 15-blade scalpel and eye loop cautery for hemostasis. The patient was recommended to return in two weeks for a post-surgical followup appointment and biopsy result with oral medicine specialist.

Results

The surgical pathology report obtained from the biopsy revealed that the lesion was pyogenic granuloma, and not a traumatic fibroma as it had initially been diagnosed. The microscopic examination displayed a focally ulcerated nodular fragment of oral mucosa, partially surfaced by hyperparakaratotic stratified squamous epithelium with a normal pattern of maturation, and a fibropurulent membrane. The underlying connective tissue was characterized by lobular aggregates of hyperplastic granulation tissue with numerous vascular channels contained within this stroma. An acute and chronic inflammatory cell infiltrate was observed throughout the histologic specimen, mainly composed of neutrophils, lymphocytes, plasma cells, and extravasated erythrocytes. There was no evidence of malignancy.

Discussion

Pyogenic granuloma is very common but what makes this case unique is its location and appearance. While oral pyogenic granuloma is relatively common, it develops most often on the gingiva. This also made the clinic diagnosis challenging even for two experienced clinicians with combined experience of over forty year. Histological examination was the only way it was possible. Since the patient wore a maxillary complete denture, it was initially assumed that the lesion was a fibroma caused by an ill-fitting denture. The lesion discussed in this case was smooth, fibrous and pedunculated in appearance. While these presentations are within the realm of normal appearance of typical pyogenic granuloma, this lesion was also flat and paddle-shaped, which is atypical of the exophytic nature of pyogenic granuloma. The lesion was also not erythematous and did not bleed upon provocation, a common occurrence in pyogenic granuloma. The uncharacteristic appearance of the lesion supported the initial fibroma diagnosis and not pyogenic granuloma.

The biopsy revealed an ulcerated lesion with hyperparakaratotic stratified squamous epithelium with normal maturation. The normal maturation of cells seen under microscopic evaluation indicated that the lesion was benign, ruling out malignant diagnoses. Similarly, the biopsy showed an abundance of vascular channels with inflammatory cell infiltrate including neutrophils, lymphocytes, plasma cells, and extravasated erythrocytes. This presentation is typical for microscopic appearance of pyogenic granuloma, thus confirming the diagnosis.

Recurrence can happen in pyogenic granuloma and the rate ranges from 0-15.8% of cases [6, 7]. Recurrence is more common in patients who develop pyogenic granuloma while pregnant and less common for patients who present with extragingival pyogenic granuloma [8]. The patient was informed of this possibility and told to monitor the area for recurrence of the lesion.

Conclusion

“Pyogenic granuloma” is a misnomer because the lesion does not contain pus and is not strictly speaking a granuloma [9]. Combination of poor oral hygiene and trauma causes one third of these lesions [9]. The visual presentation appeared similar to a traumatic fibroma, but the histological presentation distinguished the palatal lesion as pyogenic granuloma. This case emphasizes the importance of biopsy and histopathological examination in diagnosis of oral lesion. It also demonstrates the significance of managing oral dryness. Lack of lubrication in the mouth can contribute to poor oral hygiene and also cause trauma from denture. It may also contribute to oral fungal infection. In case of this patient the reduced salivary flow is most likely due to medications. This can be managed with over the counter dry mouth products. While taking care of the fungal infection and pyogenic granuloma was the primary reason for patients visit, it is also important in cases like to take care of the root cause of the problem.

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Iris Publishers- Open access Journal of Otolaryngology and Rhinology | Adult Ear Tubes

 

Authored by Dennis C Fitzgerald*

Short Communication

Ear tubes, a.k.a. PE tubes are one of the most common operative procedures performed in the USA. Most tubes are placed in children for recurrent ear infections and serous otitis media (middle ear fluid). It is estimated that over 500,000 tubes are placed each year. Most of the patient information available relates to the placement of these tubes in children. Little is available for tubes paced in adults.

Myringotomy or ear tubes in adults

When medical therapy is ineffective for the treatment of chronic ear fluid, recurrent ear infections, and hearing loss, myringotomy or ear tubes (PE tubes) may be recommended. These treatments may also be recommended for problems with pressure or fullness of the ears, This fullness usually occurs from allergies or exposure to altitude changes. Less common causes of ear fullness include temporomandibular disorder (TMD), migraine, and endolymphatic hydrops. These causes of fullness would not be appropriate reasons for myringotomy or ear tubes. When a surgical intervention is indicated, the physician may recommend only a myringotomy. This means that an opening is made in the eardrum, but a tube is NOT placed into the eardrum. The eardrum usually heals up on its own after a few days. The procedure is usually done in the office, by using a local anesthetic to numb the eardrum.

To insert an ear tube, a same small incision is made in the eardrum, similar to a myringotomy, which allows the drainage of ear fluid and for air to enter the middle ear and re-establish an aerated middle ear. Hearing is almost immediately restored. Local anesthesia is the same as for a myringotomy. Most adults are able to have this done in the office. Sometimes, due to anxiety or anatomic abnormalities, it will be done in the operating room. Tympanostomy tubes usually stay in place from 9-18 months and fall out of the eardrum.

The tubes are tiny and are not visible. Initially, there may be a sensation of hearing your own voice and/or pressure, but this usually goes away with time. Ear tubes reduce the severity and frequency of infections, development of middle ear fluid, and conductive hearing loss. However, they cannot reverse the underlying reasons for the ear disease (allergies, eustachian tube dysfunction etc.).

The ear tubes work by allowing air to enter into the middle ear space and drainage of the fluid behind the eardrum. This improves the function of the middle ear (the cavity behind the eardrum). The tubes replace the function of the Eustachian tube whose function is to allow air to intermittently but regularly enter the middle ear space. Placement of ear tubes has few risks. When the tubes are in place, it is not unusual for patients to have drainage when they get “colds” or allergy symptoms. When the tubes fall out, patients rarely will have a small hole in the eardrum (perforation) that could require additional surgical repair.

Instructions after the procedure

It is not unusual to have ear drainage for a couple of days after surgery. Sometimes this drainage can be bloody, which can be a sign of inflammation. If you are prescribed ear drops, or sometimes eye drops, use them as directed. Mild ear pain on the night of insertion may require treatment with Tylenol. Normal activity can usually be resumed the same day of the procedure. Most people are able to drive home from the office. Water should be kept out of the ears for as long as the tubes are in place. This can be done by placing a cotton ball covered with Vaseline Petroleum jelly in the ear canal. Usually earplugs are needed during swimming and other water exposure while the tubes are in place. Avoid the use of Q-tips. Please keep your appointment as scheduled or be sure to call back to make follow-up appointments as directed by physician.

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Iris Publishers- Open access Journal of Otolaryngology and Rhinology | Nerves Paralysises Associated to Nasal Obstruction: What is Your Diagnosis??

 

Authored by Ilham Rkain*

Case Report

A 60-year-old man presented with complaints of nasal obstruction (left side), smell disorder, headache and neuralgia on the left side of his face for 2 years, ptosis and diplopia followed by reduction vision of the left side. The patient was treated in another institution with antibiothiques and antituberculous drugs. After two weeks, the treatment was stopped because of the deterioration of the neurologic status, and the appearance of new symptoms such as mouth opening limitation, dyspnea, difficulty of swallowing (dysphagia) and cerebellar syndrome. So, all cranial nerves at the left side were dysfonctionnal. At the onset of these symptoms, tomography computed of the head was done, what is your diagnosis??

(Figure 1,2) Presence of a large heterogeneous 9cm tumor of the nasopharynx and the left nasal fossa, extended to the maxillary sinus, oropharynx, skull base, brainstem and to the left cerebellar hemisphere. Nasal endoscopy biopsy shows a UCNT of the cavum.

Discussion

Guillain Alajouanine Garcin syndrome or garcin syndrome is rare disorder with progressive unilateral involvement of all or at least 7 cranial nerves, first reported in 1926 [1]. This syndrome is frequently seen in the tumors of nasopharynx [2,3] and the base of the skull, which does not affect the brain itself. The syndrome is progressive and, in its complete form, is seen only very rarely. Some reported cases have other symptoms such as headache such as our case. Prognosis as a rule is unfavorable. The findings on the CT scan and MRI scan are important in early diagnosis [4]. Many cases of Garcin’s syndrome have been reported. These include cases that are caused by tonsillar carcinoma, carcinomatous leukemic meningitis, and para-nasal and parotid tumors. Nasopharyngeal carcinoma frequently involves cranial nerves because of its proximity to the skull base [4,5].

Conclusion

This case illustrates the need to consider nasopharyngeal carcinoma as the most common cause of garcin syndrome in the presence of unilateral cranial pair involvement associated with olfactory disorders.

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Iris Publishers- Open access Journal of Cardiology Research & Reports | Fetal Speckle Tracking Echocardiography: A Comparison Between Fetuses with Normal Heart and Those With Heart Disease

 

Authored by A Balducci*

Abstract

Objective: The aim of our study was to compare left ventricular function in normal fetal hearts and those with cardiac abnormalities using 2D and 4D e-STIC approach.

Methods: We recruited 63 fetuses between 20- and 40- weeks, including twenty-nine affected by heart disease. All measurements were performed by two sonographers experienced in fetal echocardiography. We compared different parameters obtained by 2-dimensional and 4D e-STIC method in normal fetal hearts and those with cardiac defects. We focused on left ventricular global strain, left ventricular ejection fraction, left ventricular length and area in end-systole and end-diastole, and left ventricular fractional area change. Differences between categorical variables were analyzed by using Chi-Quadro Test, while continuous variables by one-way ANOVA Test.

Results: Firstly, no differences were proved between healthy and affected fetuses, regardless of the applied technique. Similarly, fetal strain values did not differ between the affected fetuses distinguished according to the kind of pathology.

Conclusion: In our cohort, 2D and 4D e-STIC imaging techniques have shown similar results for each parameter. We did not find differences between healthy fetuses and those with heart disease because congenital heart disease included did not affect left ventricular systolic function.

Keywords: Echocardiography; Fetal echocardiography; Speckle tracking; Strain; STIC

Introduction

Echocardiography is the most common tool used to diagnose congenital heart disease. Recently, 2-dimensional speckle tracking echocardiography (STE) has been introduced to investigate cardiac function, identifying the movement of endocardium during the cardiac cycle [1]. STE has been used to study segmental and global cardiac function, calculating velocities and deformation parameters such as longitudinal, radial and circumferential strain and strain rate, which are used to evaluate the myocardial function from an objective and quantitative point of view [2-4]. Moreover, 2D speckle tracking is independent from the heart orientation to the ultrasound beam [5-7]. In addition, thanks to the semiautomated software, it has better intra-observer and inter-observer reproducibility than the other techniques commonly used to evaluate cardiac function [3]. STE is currently applied both in adult and pediatric patients to evaluate ischemic heart disease, left ventricular diastolic dysfunction, myocardial mechanics, cardiomyopathy, vascular disease, and myocardial dysfunction in patients undergoing chemotherapy. Even if it has not yet been validated in the evaluation of fetal cardiac dysfunction, it has already been used to measure myocardial deformation in twin-twin transfusion syndrome, fetal cardiomyopathies and structural heart diseases, gestational diabetes, and intrauterine growth restriction [9].

Although there have been differences in findings, STE is considered as an important tool for fetal specialists. However, several issues currently limit its use [8], especially regarding framerate and spatial resolution [9-14]. Recently, three-dimensional (3D) STE has been introduced to overwhelm B-mode imaging limitations. Previous studies proved that four-dimensional (4D) ultrasound technologies, such as spatio-temporal image correlation (STIC), facilitate examination of fetal cardiac images. However, obtaining diagnostic volumes could be limited by fetal movements. Standard mechanical probes allow acquisition of a STIC volume of good quality in 7.5-15 s [15-17]. 4D electronic probes improved image resolution and decreased image artifacts. Electronic STIC acquisition stitches together subvolumes resulting in a higher resolution real time image and in a faster technique [18,19]. The aim of our study was to compare left ventricular function in normal fetal hearts and those with cardiac abnormalities, using 2D STE and 4D e-STIC approach.

Methods and Materials

Population

This prospective study included fetuses between 20- and 40-weeks’ gestation. Thirty-four control fetuses with accurate first or second trimester dating US exams were included. These fetuses were free of malformations or growth disturbances at the time of the inclusion and were referred to our clinic for second and third trimester ultrasound exams. Twenty-nine fetuses with congenital heart disease have been selected among fetuses evaluated in the fetal echocardiography clinic. The malformations were as follows: tetralogy of Fallot, ventricular septal defects, transposition of great arteries, dysplasia of tricuspid associated with pulmonary insufficiency, cardiomegaly with biventricular hypertrophy, aortic valve stenosis, aneurysm right atrium and cardiomyopathy of left ventricular with no-compacted myocardium.

Our study consisted of two phases: in the first one, fetuses have been divided in two groups (group 0: normal heart, group 1:congenital heart disease), while in the second phase fetuses affected by congenital heart disease have been split into 4 subgroups (group 1a: left heart disease, group 1b: right heart disease, group 1c: transposition of the great arteries and group 1d: others) (Table 1a).

All measurements on healthy and affected fetuses were performed by two sonographers experienced in fetal echocardiography (A.P., A.B.).

Image acquisition and analysis

Two-dimensional images of the 4-chambers were acquired using a RM6C or EM6C transducer of the Voluson E10 US system (GE Healthcare, Milwaukee, WI). Three second cine clips of the 4-chambers view were obtained and stored as Digital Imaging and Communications in Medicine files and exported to an offline database. E-STIC volumes were acquired using an electronic 4D probe, EM6C, using the option maximal quality. Once the 2D images and 4D volumes of the 4-chamber view were obtained and stored, they were examined using fetalHQ software (GE Healthcare; Zipf, Austria) using criteria that have been previously described [5,15,18, 20-22]. Using the equation of Hadlock et al, estimated fetal weight (computing the measurements of the biparietal diameter, head circumference, abdominal circumference, and femur length) was expressed using z-score for each fetus [23,24]. At the end of the analysis, raw data were exported to an ASCII text file, later imported into an excel spreadsheet. In this study we focused on left ventricular global strain (GS), left ventricular ejection fraction (EF), left ventricular length and area in end-systole (ESL and ESA) and end-diastole (EDL and EDA), and left ventricular fractional area change (FAC).

Ethics

Each patient of the study signed a consent form at recruitment. The study protocol was approved by the local Ethics Committee of Sant’ Orsola-Malpighi Hospital and a consent form signed at recruitment was obtained from each eligible patient (575/2018/ Oss/AOUBo). The study protocol conforms to the ethical guidelines of the “World Medical Association (WMA) Declaration of Helsinki- Ethical Principles for Medical Research Involving Human Subjects” adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964 and amended by the 59th WMA General Assembly, Seoul, South Korea, October 2008.

Statistics

Categorical variables were expressed as percentage, while continuous variables were expressed as mean ± standard deviation if they are normally distributed. Differences between categorical variables were analyzed by using Chi-Quadro Test, while continuous variables by one-way ANOVA Test. A p-value lesser than 0,05 was considered statistically significative. All the analyses were done through STATA/IC 15.1

Result

The study included 62 fetuses recruited between October 2018 and May 2019, 34 with normal heart and 29 affected by congenital heart disease. Mean gestational age was 29,68 weeks±4,99 days and mean z-score estimated fetal weight was 0,24±1,26. 2D-images have been obtained in 62 fetuses, while the 4D images by STIC in 59 cases.

First phase

The population was homogeneously distributed in the mentioned groups. No differences were found between the groups in regard to gestational age (GA 29,34 ± 4,63 vs 30,09 ± 5,44) and estimated fetal weight (EFW 0,25 ± 0,22 vs 0,22 ± 0,31) at the time of examination (Table 1b). In Table 2 are summarized the measured values obtained with 2D and 4D e-STIC techniques. Compared to normal fetuses using 2D imaging, there was no statistically difference of EF, ESL, ESA, EDL, EDA, FAC, GS. There were not found any significantly different between the two groups of EF, ESL, ESA, EDL, EDA, FAC and GS obtained with 4D e-STIC.

Second phase

We divided the group 1 in 4 subgroups: group 1a, left heart disease (11 patients), group 1b, right heart disease (5 patients), group 1c, transposition of the great arteries (7 patients) and group 1d, others (6 patients with other cardiac diseases). Group 0 included 34 fetuses with normal heart. According to the value of gestational age (GA) and estimated fetal weight (EFW), the population was equally distributed in the mentioned groups (Table 3).

Discussion

This is the first study evaluating fetal left ventricular function by means of 2D and 4D e-STIC speckle-tracking echocardiography. We analyzed and compared several cardiac function parameters in normal fetal hearts and those with cardiac abnormalities. Speckle tracking is a semiautomated process, based on the tracking of ‘speckles’, conceptualized as small myocardial fingerprints, generated by ultrasound-myocardial tissue interactions during cardiac cycle. Specific algorithms allow to evaluate ventricular function [15]. Although 2D-speckle tracking is now considered equal or superior to Doppler techniques [12], thanks to its angle independency, it has several limitations [6,25,26]. The small size of the fetal heart, fetal movements and maternal breathing may affect the image resolution and the quality of the small tracking region. Trying to overcome its limits, recently, some authors experimented 3D approach to fetal speckle tracking echocardiography [27,28]. Our group had already outlined that 4D e-STIC technique can obtain optimal fetal heart volume in more than 90% of cases within the time frame of a standard examination of fetal anatomy [18,19,29].

Aiming to test these techniques to fetal heart abnormalities, we compared different parameters obtained by 2D and 4D e-STIC method in normal fetal hearts and those with cardiac defects. As we expected thanks to recent literature results, we did not find differences between the analyzed groups [5,30] because congenital heart diseases included did not affect left ventricular systolic function. However, post-natal test on a fetus affected by severe left ventricular noncompaction showed a significative low longitudinal strain (-13,9%) similarly to the value obtained during the fetal scan (-15,05%). Different pathophysiology lie under different cardiac abnormalities. The heterogeneity and complexity of cardiac abnormalities can complicate speckle tracking analysis and its interpretation, because the size of ventricular chambers can differ between a cardiac heart defect and another. This technical problem can be added to the uncertainty about angle independency of STE. Furthermore, regarding the acquisition rate, the frame rate is dependent on the angle and depth used for the acquisition [15], but no standards have been established yet to ensure the speckles can be tracked throughout the cardiac cycle. In our study we used high frame rates in order to optimize the resolution.

STE is a well-known modality in pediatric and adult echocardiography to follow changes in ejection fraction in patients with cardiomyopathy and to understand the kind of ventricular disfunction [8]. Even if it is not a routine clinical test in fetal cardiology, STE has the potential to improve our understanding on fetal cardiac function. Firstly, it could lead to the early detection of cardiac disfunction in several clinical conditions, such as structural defects, cardiomyopathies and risky diseases like Parvovirus B19 infection [31]. Moreover, we believe that STE will be a useful tool to compute the prognosis of affected and supposedly affected fetuses, such as DeVore et al had recently proved in a cohort of 108 fetuses with suspected prenatal diagnosis of aortic coarctation [32]. Nevertheless, published studies make comparison between healthy and affected fetus difficult and the results are not homogeneous [8]. There is still a lack of normal values for fetal systolic and diastolic function through gestation [33]. Moreover, the heterogeneity and complexity of cardiac abnormalities can complicate speckle tracking analysis and its interpretation [8]. We believe that this study provides an interesting approach to fetal speckle tracking echocardiography introducing the innovative 4D e-STIC method for cardiac abnormalities research. In our cohort, 2D and 4D e-STIC imaging techniques have shown similar results for each parameter. We believe that this approach will make STE more feasible in the future.

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