Complications of exercise and pharmacologic stress echocardiography.

Stress echocardiography is a diagnostic cardiovascular exam that is commonly utilized for multiple indications, including but not limited to the assessment of obstructive coronary artery disease, valvular disease, obstructive hypertrophic cardiomyopathy, and diastolic function. Stress echocardiography can be performed via both exercise and pharmacologic modalities. Exercise stress is performed with either treadmill or bicycle-based exercise. Pharmacologic stress is performed via either dobutamine or vasodilator-mediated (i.e., dipyridamole, adenosine) stress testing. Each of these modalities is associated with a low overall prevalence of major, life-threatening adverse outcomes, though adverse events are most common with dobutamine stress echocardiography. In light of the recent COVID-19 pandemic, the risk of infectious complications to both the patient and stress personnel cannot be negated; however, when certain precautions are taken, the risk of infectious complications appears minimal. In this article, we review each of the stress echocardiographic modalities, examine major potential adverse outcomes and contraindications, assess the risks of stress testing in the setting of a global pandemic, and examine the utilization and safety of stress testing in special patient populations (i.e., language barriers, pediatric patients, pregnancy).

Right atrial structural remodeling predict worse outcomes in transcatheter mitral valve repair.

BACKGROUND: In the current study, we assess the predictive role of right and left atrial volume indices (RAVI and LAVI) as well as the ratio of RAVI/LAVI (RLR) on mortality following transcatheter mitral valve repair (TMVr). METHODS: Transthoracic echocardiograms of 158 patients who underwent TMVr at a single academic medical center from 2011 to 2018 were reviewed retrospectively. RAVI and LAVI were calculated using Simpson's method. Patients were stratified based on etiology of mitral regurgitation (MR). Cox proportional-hazard regression was created utilizing MR type, STS-score, and RLR to assess the independent association of RLR with survival. Kaplan-Meier analysis was used to analyze the association between RAVI and LAVI with all-cause mortality. Hemodynamic values from preprocedural right heart catheterization were also compared between RLR groups. RESULTS: Among 123 patients included (median age 81.3 years; 52.5% female) there were 50 deaths during median follow-up of 3.0 years. Patients with a high RAVI and low LAVI had significantly higher all-cause mortality while patients with high LAVI and low RAVI had significantly improved all-cause mortality compared to other groups (p = 0.0032). RLR was significantly associated with mortality in patients with both functional and degenerative MR (p = 0.0038). Finally, Cox proportion-hazard modeling demonstrated that an elevated RLR above the median value was an independent predictor of all-cause mortality [HR = 2.304; 95% CI = 1.26-4.21, p = 0.006] when MR type and STS score were accounted for. CONCLUSION: Patients with a high RAVI and low LAVI had significantly increased mortality than other groups following TMVr suggesting RA remodeling may predict worse outcomes following the procedure. Concordantly, RLR was predictive of mortality independent of MR type and preprocedural STS-score. These indices may provide additional risk stratification in patients undergoing evaluation for TMVr.

The impact of COVID-19 on clinical outcomes among acute myocardial infarction patients undergoing early invasive treatment strategy.

BACKGROUND: The implications of coronavirus disease 2019 (COVID-19) infection on outcomes after invasive therapeutic strategies among patients presenting with acute myocardial infarction (AMI) are not well studied. HYPOTHESIS: To assess the outcomes of COVID-19 patients presenting with AMI undergoing an early invasive treatment strategy. METHODS: This study was a cross-sectional, retrospective analysis of the National COVID Cohort Collaborative database including all patients presenting with a recorded diagnosis of AMI (ST-elevation myocardial infarction (MI) and non-ST elevation MI). COVID-19 positive patients with AMI were stratified into one of four groups: (1a) patients who had a coronary angiogram with percutaneous coronary intervention (PCI) within 3 days of their AMI; (1b) PCI within 3 days of AMI with coronary artery bypass graft (CABG) within 30 days; (2a) coronary angiogram without PCI and without CABG within 30 days; and (2b) coronary angiogram with CABG within 30 days. The main outcomes were respiratory failure, cardiogenic shock, prolonged length of stay, rehospitalization, and death. RESULTS: There were 10 506 COVID-19 positive patients with a diagnosis of AMI. COVID-19 positive patients with PCI had 8.2 times higher odds of respiratory failure than COVID-19 negative patients (p = .001). The odds of prolonged length of stay were 1.7 times higher in COVID-19 patients who underwent PCI (p = .024) and 1.9 times higher in patients who underwent coronary angiogram followed by CABG (p = .001). CONCLUSION: These data demonstrate that COVID-19 positive patients with AMI undergoing early invasive coronary angiography had worse outcomes than COVID-19 negative patients.

A Novel Case of Hyperglycemic Hyperosmolar State After the Use of Teprotumumab in a Patient With Thyroid Eye Disease.

Background/Objective: Teprotumumab, a novel treatment for thyroid eye disease (TED), which blocks the insulin-like growth factor 1 receptor, has been associated with improvement in proptosis and inflammatory ocular symptoms. In the original trials, hyperglycemia was reported in 5% to 12% of patients; however, none required hospitalization. We report a case of hyperglycemic hyperosmolar state after the first infusion of teprotumumab. Case Report: A 56-year-old woman with Graves' disease, severe thyroid eye disease, and prediabetes presented with polyuria, polydipsia, nausea, abdominal pain, headache, dizziness, and a fall to the emergency department 3 weeks after her first teprotumumab infusion. She was noted to have serum glucose levels of 939 mg/dL, serum bicarbonate levels of 28 meq/dL, serum osmolality of 324 mOsm/kg, and trace ketones in urine. She was treated with intravenous fluids and insulin with subsequent improvement in clinical status and biochemical profile. She was then discharged on multiple daily injections of insulin. Discussion: Hyperglycemia is a known adverse effect of insulin-like growth factor 1 receptor inhibitors like teprotumumab. The incidence of hyperglycemia in the original trials was 5% to 12%. Most cases were mild and resolved with titration of current diabetes medications. No cases of hospitalization due to severe hyperglycemia or hyperglycemic hyperosmolar state have been reported until now. Conclusion: We intend to highlight the severity of hyperglycemia that could occur with the use of teprotumumab and the need for research to evaluate the true incidence of this condition.

A systemic congestive index (systemic pulse pressure to central venous pressure ratio) predicts adverse outcomes in patients undergoing valvular heart surgery.

BACKGROUND AND AIMS: Invasive hemodynamics may provide a more nuanced assessment of cardiac function and risk phenotyping in patients undergoing cardiac surgery. The systemic pulse pressure (SPP) to central venous pressure (CVP) ratio represents an integrated index of right and left ventricular function and thus may demonstrate an association with valvular heart surgery outcomes. This study hypothesized that a low SPP/CVP ratio would be associated with mortality in valvular surgery patients. METHODS: This retrospective cohort study examined adult valvular surgery patients with preoperative right heart catheterization from 2007 through 2016 at a single tertiary medical center (n = 215). Associations between the SPP/CVP ratio and mortality were investigated with univariate and multivariate analyses. RESULTS: Among 215 patients (age 69.7 ± 12.4 years; 55.8% male), 61 died (28.4%) over a median follow-up of 5.9 years. A SPP/CVP ratio <7.6 was associated with increased mortality (relative risk 1.70, 95% confidence interval [CI] 1.08-2.67, p = .019) and increased length of stay (11.56 ± 13.73 days vs. 7.93 ± 4.92 days, p = .016). It remained an independent predictor of mortality (adjusted odds ratio 3.99, 95% CI 1.47-11.45, p = .008) after adjusting for CVP, mean pulmonary artery pressure, aortic stenosis, tricuspid regurgitation, smoking status, diabetes mellitus, dialysis, and cross-clamp time. CONCLUSIONS: A low SPP/CVP ratio was associated with worse outcomes in patients undergoing valvular heart surgery. This metric has potential utility in preoperative risk stratification to guide patient selection, prognosis, and surgical outcomes.

Systemic arterial pulsatility index (SAPi) predicts adverse outcomes in advanced heart failure patients.

Ventriculo-arterial (VA) coupling has been shown to have physiologic importance in heart failure (HF). We hypothesized that the systemic arterial pulsatility index (SAPi), a measure that integrates pulse pressure and a proxy for left ventricular end-diastolic pressure, would be associated with adverse outcomes in advanced HF. We evaluated the SAPi ([systemic systolic blood pressure-systemic diastolic blood pressure]/pulmonary artery wedge pressure) obtained from the final hemodynamic measurement in patients randomized to therapy guided by a pulmonary arterial catheter (PAC) and with complete data in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial. Cox proportional hazards regression was performed for the outcomes of (a) death, transplant, left ventricular assist device (DTxLVAD) or hospitalization, (DTxLVADHF) and (b) DTxLVAD. Among 142 patients (mean age 56.8 ± 13.3 years, 30.3% female), the median SAPi was 2.57 (IQR 1.63-3.45). Increasing SAPi was associated with significant reductions in DTxLVAD (HR 0.60 per unit increase in SAPi, 95% CI 0.44-0.84) and DTxLVADHF (HR 0.81 per unit increase, 95% CI 0.70-0.95). Patients with a SAPi ≤ 2.57 had a marked increase in both outcomes, including more than twice the risk of DTxLVAD (HR 2.19, 95% CI 1.11-4.30) over 6 months. Among advanced heart failure patients with invasive hemodynamic monitoring in the ESCAPE trial, SAPi was strongly associated with adverse clinical outcomes. These findings support further investigation of the SAPi to guide treatment and prognosis in HF undergoing invasive hemodynamic monitoring.

Fibromuscular dysplasia: A comprehensive review on evaluation and management and role for multidisciplinary comprehensive care and patient input model.

Fibromuscular dysplasia is a nonatherosclerotic, under-recognized disorder primarily seen in middle-aged women. It can lead to several complications, such as hypertension, headaches, dissections, aneurysms, myocardial infarctions, and cerebrovascular accidents, to name a few. This article provides a comprehensive review of current literature on epidemiology, etiology, diagnosis, treatment, and long-term surveillance and fibromuscular dysplasia management. In addition, it renders the role of education and prevention for patients living with this condition and family screening. Lastly, it emphasizes the importance of a comprehensive multidisciplinary care model and patient input, given the complexity of this disease and its systemic presence and protean manifestations.

Spine Myeloid Sarcoma: A Case Series with Review of Literature.

Myeloid sarcoma (MS) is a malignant extramedullary tumor consisting of immature cells of myeloid origin. It may precede, present concurrently or follow acute myeloid leukemia (AML) in de novo case or may also be present and might be the only manifestation of recurrent AML, myelodysplastic syndrome, or chronic myeloid leukemia. It frequently involves skin, orbit, bone, periosteum, lymph nodes, and gastrointestinal tract, soft tissue, central nervous system, and testis. Because of its different localization and symptoms, and the lack of diagnostic algorithm, MS is a real diagnostic challenge particularly in patients without initial bone marrow involvement. The correct diagnosis of MS is important for optimum therapy, which is often delayed because of a high misdiagnosis rate. We reported three cases of MS derived from spine presented with back pain, paraplegia, paraparesis, respectively, and reviewed the relevant literature.

MAGGIC, STS, and EuroSCORE II Risk Score Comparison After Aortic and Mitral Valve Surgery.

OBJECTIVES: To compare the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score with the established Society of Thoracic Surgeons (STS) and EuroSCORE II risk prediction models regarding mortality discrimination after aortic and mitral valve surgery. DESIGN: Retrospective cohort study. SETTING: Single tertiary academic medical center. PARTICIPANTS: A total of 259 patients who underwent open aortic valve replacement or open mitral valve repair/replacement from 2009-2014. INTERVENTIONS: Retrospective chart review. MEASUREMENTS AND MAIN RESULTS: MAGGIC, STS, and EuroSCORE II risk scores for each patient were studied using binary logistic regression and receiver operating characteristic analysis for the primary endpoint of one-year mortality and secondary endpoint of 30-day mortality. One-year mortality C-statistics were similar across risk scores (STS 0.709, 95% confidence interval [CI] 0.578-0.841; MAGGIC 0.673, 95% CI 0.547-0.799; EuroSCORE II 0.642, 95% CI 0.521-0.762; p = 0.56 between STS and MAGGIC; p = 0.20 between STS and EuroSCORE II; and p = 0.69 between MAGGIC and EuroSCORE II). Thirty-day mortality C-statistics also were similar between STS (0.797, 95% CI 0.655-0.939; p < 0.0001 v null hypothesis), MAGGIC (0.721, 95% CI 0.581-0.860; p = 0.33 v STS), and EuroSCORE II (0.688, 95% CI 0.557-0.818; p = 0.06 v STS; p = 0.68 v MAGGIC). CONCLUSIONS: The MAGGIC risk score performs similarly to STS and EuroSCORE II risk models in mortality discrimination after aortic and mitral valve surgery, albeit in a small sample size. This finding has important implications in establishing MAGGIC as a viable prognostic model in this population subset, with fewer variables and ease of use representing key advantages over STS and EuroSCORE II.

Osteosarcoma journey over two decades in India: Small steps, big changes.

BACKGROUND: The management of osteosarcoma is challenging especially in lower-income and middle-income countries, and there is an unmet need to evolve efficient and sustainable chemotherapy regimens. METHODS: We compared the outcomes in nonmetastatic osteosarcoma patients treated with three sequential non-high-dose methotrexate-based combination chemotherapy protocols at a single tertiary care center over two decades. The first protocol, OGS-99, involved dose-intense, alternating dyads of three drugs: doxorubicin (Dox), cisplatin (CDDP), and ifosfamide (Ifo). The second protocol, OGS-99 enhanced, included OGS-99 drugs with etoposide and enhanced supportive care. The OGS-12 protocol involved dose-dense administration of eight sequential dyads of Dox, CDDP and Ifo, universal growth factor prophylaxis and targeted nutritional support. Event-free survival (EFS), overall survival (OS), and toxicity were reported using a retrospective chart review in the OGS-99 and OGS-99 enhanced protocols and prospectively in the OGS-12 protocol. RESULTS: A total of 41, 94, and 385 treatment-naïve, consecutive, nonmetastatic patients with extremity osteosarcoma were treated with the OGS-99 (2000-2005), OGS-99 enhanced (2010), and OGS-12 (2011-2016), respectively. At a median follow-up of 19, 86, and 39 months, the five-year EFS rates were 38%, 50%, and 62% in the OGS-99, OGS-99 enhanced, and OGS-12, respectively. The corresponding rates of five-year OS were nonevaluable, 60% and 77%, respectively, with acceptable rates of grade 3-4 toxicities: febrile neutropenia (40%), thrombocytopenia (36%), anemia (51%), and 1% deaths related to toxicity. CONCLUSIONS: Sequential selection of an intelligent, dose-dense chemotherapy regimen together with enhanced supportive care resulted in marked improvement in outcomes of nonmetastatic osteosarcoma and this "small steps-big changes" model deserves wider recognition and usage.

A Case of Severe Psychosis Due to Cushing's Syndrome Secondary to Primary Bilateral Macronodular Adrenal Hyperplasia.

Hypercortisolism is a multisystem disorder that results from inappropriate and excessive glucocorticoid secretion and loss of normal feedback mechanisms of the hypothalamic-pituitary axis. It is broadly divided into adrenocorticotropic hormone (ACTH) dependent and ACTH-independent categories. Primary bilateral macronodular adrenal hyperplasia (PBMAH) is a rare cause of ACTH-independent hypercortisolism, accounting for less than 2% of cases. It usually presents as hypertension, metabolic abnormalities, thromboembolic, cardiovascular, or endocrine disorders but rarely as a neuropsychiatric illness. Therefore, a delay in the diagnosis and management of cognitive illnesses substantially increases morbidity in these patients. Herein, we report a case of severe psychosis due to Cushing's syndrome with PBMAH.  A 49-year-old male with a past medical history of diabetes and hypertension presented with acute onset of confusion. The patient's uncontrolled hypertension, hypokalemia, metabolic alkalosis, and resistant psychosis to various psychotropic medications raised the suspicion of an underlying metabolic disorder. Further workup revealed an inappropriate suppression of morning (AM) cortisol after administration of dexamethasone and elevated values of serum AM cortisol and 24-hour urinary cortisol, in addition to low ACTH. Computed tomography (CT) of the abdomen and pelvis with intravenous (IV) contrast was performed to evaluate the adrenal gland which showed multiple nonspecific adrenal nodules bilaterally measuring between 3.5 cm - 4.5 cm. The patient was hence diagnosed with hypercortisolism secondary to PBMAH. The patient was treated with ketoconazole after he refused surgery as a treatment option and was noted to have significant improvement in his psychosis within a week, along with improvement of his hypertension, electrolyte abnormalities, and a significant decrease in the 24-hour urine cortisol level. Neuropsychiatric illness is a rare manifestation and an unusual initial presenting symptom of Cushing's syndrome secondary to primary bilateral macronodular adrenal hyperplasia. A delay in diagnosis often subjects these patients to unnecessary psychotropic medications and prolonged psychiatric hospitalizations. Hence, clinicians must be cognizant of this rare entity when making a diagnostic evaluation to prevent subsequent morbidity and mortality.

Predictors of Clinicopathologic Stage Discrepancy in Oropharyngeal Squamous Cell Carcinoma: A National Cancer Database Study.

Objective To determine the frequency, associated factors, and prognosis of clinicopathologic stage discrepancy in oropharyngeal squamous cell carcinoma (OPSCC). Study Design Retrospective study using a national database. Setting National Cancer Database. Subjects and Methods Cases of OPSCC diagnosed between January 1, 2004, and December 31, 2013, with full clinical and pathologic staging information available were identified. Demographic, clinicopathologic, and treatment variables associated with overall stage discrepancy were identified by multivariate logistic regression analysis. Results In total, 7731 cases of OPSCC were identified. Overall stage discrepancy was present in 30.2% of cases (21.9% upstaging, 8.2% downstaging). A total of 13.1% of cases were T-upstaged, and 10.5% of cases were T-downstaged; 22.9% of cases were N-upstaged, and 8.6% of cases were N-downstaged. Upstaging by overall stage was associated with a high Charlson-Deyo score, high tumor grade, number of lymph nodes examined, and increasing tumor size. No factors were positively associated with downstaging. High tumor grade was negatively associated with downstaging. For stage II, III, and IVA tumors, upstaging was associated with poorer OS. Conclusion Clinicopathologic stage discrepancy is common in OPSCC and is likely attributable to insensitive clinical staging techniques as well as to intrinsic tumor biologic properties. Upstaging is associated with poorer prognosis, which is likely due to advancement of disease.

Evaluations of refraction competencies of ophthalmic technicians in Mozambique / Evaluaciones de las competencias sobre refracción de los técnicos oftálmicos en Mozambique

Purpose: Ophthalmic technicians (OT) work at health facilities in Mozambique and are trained to provide primary and secondary eye care services including basic refraction. This study was designed to assess OT competence and confidence in refraction, and investigate whether an upskilling programme is effective in developing their competence and confidence at refraction. Methods: Thirty-one trainee OTs and 16 qualified OTs were recruited to the study. A background questionnaire was administered to determine the demographic profile of the OTs. A confidence levels questionnaire explored their self-reported skills. Clinical competencies were assessed in relation to knowledge (theory exam) and clinical skills (patient exams). 11 OTs were upskilled and the clinical evaluations carried out post training. Results: Initial evaluations demonstrated that confidence and competence levels varied depending on the OTs training (location and duration), and their location of work (clinical load, availability of equipment and other eye care personnel). The qualified OTs were more competent than trainee OTs in most of the evaluations. Post upskilling results demonstrated significant positive impact on confidence and competence levels. Conclusion: These evaluations identified factors affecting the refraction competencies of the OTs and demonstrated that upskilling is effective in improving confidence and competence levels for refraction. They demonstrate the need for a refraction competency framework. The overarching aim of this research was to inform the development of a nationwide programme of OT mentoring, upskilling and leading to the establishment of clinical competency standards for the new OT curricula, relevant to the professional demands (AU)

Objetivo: Los Técnicos Oftálmicos (TO) trabajan en los centros sanitarios de Mozambique, y están formados para aportar servicios de cuidados oculares primarios y secundarios que incluyen la refracción básica. Este estudio fue diseñado para evaluar la competencia y seguridad de los TO en cuanto a refracción, así como investigar la eficacia de un programa para incrementar sus conocimientos para desarrollar la competencia y seguridad en la refracción. Métodos: Para el estudio se reclutó a treinta y un TO en formación y a dieciséis TO cualificados. Se les proporcionó un cuestionario de antecedentes, para determinar el perfil demográfico de los TO. Un cuestionario sobre los niveles de seguridad exploró sus técnicas auto-reportadas. Las competencias clínicas se evaluaron en relación al conocimiento (examen teórico) y las habilidades clínicas (evaluación de los pacientes). Se incrementaron los conocimientos de 11 TO, realizándose la evaluación clínica tras su formación. Resultados: Las evaluaciones iniciales demostraron que los niveles de seguridad y competencia variaban dependiendo de la formación del TO (emplazamiento y duración), y de su emplazamiento de trabajo (carga clínica, disponibilidad de equipos y de personal adicional de cuidados oculares). Los TO cualificados fueron más competentes que los TO en formación en la mayoría de las evaluaciones. Los resultados tras el incremento de conocimientos demostró un impacto considerablemente positivo sobre los niveles de seguridad y competencia. Conclusión: Estas evaluaciones identificaron aquellos factores que afectan a las competencias sobre refracción de los TO, y demostraron que el incremento de conocimientos es eficaz para mejorar los niveles de seguridad y competencia en cuanto a refracción. Demostraron la necesidad de un marco de competencias en refracción. El objetivo más importante de esta investigación fue el de informar sobre el desarrollo de un programa nacional de tutelaje e incremento de conocimientos de los TO, encaminado a establecer los estándares de competencia clínica para los currículum de los nuevos TO, que sean relevantes para las demandas profesionales (AU)

Development of socially responsive competency frameworks for ophthalmic technicians and optometrists in Mozambique.

BACKGROUND: There is an extreme paucity of eye-care personnel and training facilities in developing countries. This study was designed to develop a comprehensive framework of competency standards for ophthalmic technicians and optometrists, in Mozambique. This could then inform the evolution of socially responsive curricula for both cadres. METHODS: A modified Delphi technique was used with a ten member expert panel consisting of optometrists, ophthalmic technicians and ophthalmologists, all with experience of working in a developing country context. The competencies were derived from literature, primary research data and observations from a competency development workshop. The first round involved scoring the relevance of two frameworks, one for each cadre, using a nine-point Likert scale with a free-text option to modify any competency or suggest additional competencies. The revised frameworks were subjected to a second round of scoring and free-text comment. The final versions of the agreed frameworks were sent out to the relevant stakeholders. RESULTS: There was a 100 per cent response to round 1 and an 89 per cent response to round 2. The final versions of the competency frameworks contained six competencies, 20 elements and 88 performance criteria for optometry and six competencies, 17 elements and 61 performance criteria for ophthalmic technicians. CONCLUSIONS: Application of a consensus methodology consisting of a modified Delphi technique with primary research data allowed the development of competency frameworks for ophthalmic technicians and optometrists. This will help to shape the development of curricula for both cadres and potentially could be replicated in other regions that wish to develop socially responsive education for eye-care professionals.

Evaluations of refraction competencies of ophthalmic technicians in Mozambique.

PURPOSE: Ophthalmic technicians (OT) work at health facilities in Mozambique and are trained to provide primary and secondary eye care services including basic refraction. This study was designed to assess OT competence and confidence in refraction, and investigate whether an upskilling programme is effective in developing their competence and confidence at refraction. METHODS: Thirty-one trainee OTs and 16 qualified OTs were recruited to the study. A background questionnaire was administered to determine the demographic profile of the OTs. A confidence levels questionnaire explored their self-reported skills. Clinical competencies were assessed in relation to knowledge (theory exam) and clinical skills (patient exams). 11 OTs were upskilled and the clinical evaluations carried out post training. RESULTS: Initial evaluations demonstrated that confidence and competence levels varied depending on the OTs training (location and duration), and their location of work (clinical load, availability of equipment and other eye care personnel). The qualified OTs were more competent than trainee OTs in most of the evaluations. Post upskilling results demonstrated significant positive impact on confidence and competence levels. CONCLUSION: These evaluations identified factors affecting the refraction competencies of the OTs and demonstrated that upskilling is effective in improving confidence and competence levels for refraction. They demonstrate the need for a refraction competency framework. The overarching aim of this research was to inform the development of a nationwide programme of OT mentoring, upskilling and leading to the establishment of clinical competency standards for the new OT curricula, relevant to the professional demands.

Factors affecting the academic performance of optometry students in Mozambique.

PURPOSE: The Mozambique Eyecare Project is a higher education partnership for the development, implementation, and evaluation of a model of optometry training at UniLúrio in Mozambique. There are many composite elements to the development of sustainable eye health structures, and appropriate education for eye health workers remains a key determinant of successful eye care development. However, from the first intake of 16 students, only 9 students graduated from the program, whereas only 6 graduated from the second intake of 24 students. This low graduation rate is attributable to a combination of substandard academic performance and student dropout. The aim of this article was to identify factors affecting the academic performance of optometry students in Mozambique. METHODS: Nine lecturers (the entire faculty) and 15 students (9 from the first intake and 6 from the second) were recruited to the study. Clinical competency assessments were carried out on the students, semistructured individual interviews were conducted with the course lecturers, and a course evaluation questionnaire was completed by students. The results were combined to understand the complexities surrounding the optometry student training and performance. RESULTS: One student out of nine from the first intake and three students out of six from the second were graded as competent in all the elements of the refraction clinical competency examination. Analysis of data from the interviews and questionnaire yielded four dominant themes that were viewed as important determinants of student refraction competencies: student learning context, teaching context, clinic conditions and assessment, and the existing operating health care context. CONCLUSIONS: The evaluations have helped the university and course partners to better structure the teaching and adapt the learning environments by recommending a preparatory year and a review of the curriculum and clinic structure, implementing more transparent entry requirements, increasing awareness of the program, and improving Internet infrastructure.

A diagnostic dilemma in a patient with lymphoma.

We report the case of a 49-year-old man with a diagnosis of gastric diffuse large B cell non-Hodgkin's lymphoma, treated with two lines of chemotherapy followed by radiotherapy, and presented about 3 months after completing therapy with recurrent episodes of epigastric pain, gastrointestinal (GI) bleeding. Computed tomography scan, positron emission tomography scan, and upper GI endoscopy revealed gastric wall thickening and lymphadenopathy. Biopsy and histopathology ultimately revealed Strongyloides stercoralis infection that was mimicking disease recurrence. Opportunistic parasitic infections represent one of the major challenges in the management of cancer patients.

Chemotherapy compliance in patients with osteosarcoma.

PURPOSE: Histological response (HR) to neoadjuvant-chemotherapy (NACT) is considered as a robust prognostic marker in treated osteosarcomas. Chemotherapy compliance can affect both, dose intensity and density and may affect the final outcome in these cases. This vital aspect has been inadequately addressed and therefore merits further investigation. METHOD: A retrospective study of NACT-treated osteosarcoma patients, during the year 2010 was conducted. Compliance was defined as receipt of planned cycles of chemotherapy in the planned doses, within the planned duration or up to 25% additional time. HR was assessed by grading for histological necrosis (HN). Good responders (GR) included those with tumors showing ≥90% HN. RESULTS: Of 124 patients, 115 were analyzed for post-NACT HR. Of the 73 (64%) compliant patients, 47 were GR and of the 42 (36%) non-compliant patients, 18 were GR. There was significant association between GR and compliance (P = 0.031). However, at a median follow-up of 7.9 months, there was no significant difference in survival between the noncompliant versus compliant group. Non-compliance was justifiable in 26 patients and not justifiable in 16 patients. Using univariate analysis, T-size, pain, performance status, albumin, LDH, and education were identified as significant factors, while in multivariate analysis, only poor performance status was identified as an independent variable for non-compliance. CONCLUSIONS: Two-thirds patients were found to be compliant with NACT. There was a significant association between GR and compliant patients. Significant correlation between compliance and survival may be established with a longer follow-up particularly since "good necrosis" is generally predictive of good survival.

Acute non-ST elevation myocardial infarction following paclitaxel administration for ovarian carcinoma: a case report and review of literature.

We report a case of an acute non-ST elevation myocardial infarction (AMI) induced by paclitaxel in a patient with ovarian cancer. A 45-year-old premenopausal lady without any co-morbidity was started on the first cycle of neoadjuvant chemotherapy with paclitaxel-based regimen for advanced stage ovarian cancer. The patient developed chest pain 3 h after paclitaxel infusion with characteristic electrocardiographic changes of antero-apical myocardial infarction. The patient recovered on conservative medical management with reversion of electrocardiogram (ECG) changes. Cardiac ischemia and myocardial infarction, possibly due to coronary vasospasm, are rare adverse effects of paclitaxel with reported incidence of 0.26%. We have reported a case of paclitaxel-induced myocardial infarction with reversible cardiac dysfunction. The possibility of myocardial infarction should be considered in patients who develop chest pain or other symptoms after paclitaxel infusion.

Benzofuran- and furan-2-yl-(phenyl)-3-pyridylmethanols: synthesis and inhibition of P450 aromatase.

A series of benzofuran-2-yl-(phenyl)-3-pyridylmethanol derivatives were prepared using an efficient 1-step procedure in good yields. In addition furan-2-yl-(phenyl)-3-pyridylmethanol derivatives were also prepared to determine the effect of the benzene ring in benzofuran with respect to inhibitory activity. The pyridylmethanol derivatives were all evaluated in vitro for inhibitory activity against aromatase (P450(AROM), CYP19), using human placental microsomes. The benzofuran-2-yl-(phenyl)-3-pyridylmethanol derivatives showed good to moderate activity (IC50 = 1.3-25.1 microM), which was either better than or comparable with aminoglutethimide (IC50 = 18.5 microM) but lower than arimidex (IC50 = 0.6 microM), with the 4-methoxyphenyl substituted derivative displaying optimum activity. Molecular modelling of the benzofuran-2-yl-(4-fluorophenyl)-3-pyridylmethanol derivative suggested activity to reside with the (S)-enantiomer. The furan-2-yl-(phenyl)-3-pyridylmethanol derivatives were devoid of activity indicating the essential role of the benzene ring of the benzofuran component for enzyme binding.