In vitro characterization of a synthetic calcium phosphate bone graft on periodontal ligament cell and osteoblast behavior and its combination with an enamel matrix derivative.

OBJECTIVES Recent studies suggest that a combination of enamel matrix derivative (EMD) with grafting material may improve periodontal wound healing/regeneration. Newly developed calcium phosphate (CaP) ceramics have been demonstrated a viable synthetic replacement option for bone grafting filler materials. AIMS This study aims to test the ability for EMD to adsorb to the surface of CaP particles and to determine the effect of EMD on downstream cellular pathways such as adhesion, proliferation, and differentiation of primary human osteoblasts and periodontal ligament (PDL) cells. MATERIALS AND METHODS EMD was adsorbed onto CaP particles and analyzed for protein adsorption patterns via scanning electron microscopy and high-resolution immunocytochemistry with an anti-EMD antibody. Cell attachment and cell proliferation were quantified using CellTiter 96 One Solution Cell Assay (MTS). Cell differentiation was analyzed using real-time PCR for genes encoding Runx2, alkaline phosphatase, osteocalcin, and collagen1α1, and mineralization was assessed using alizarin red staining. RESULTS Analysis of cell attachment revealed significantly higher number of cells attached to EMD-adsorbed CaP particles when compared to control and blood-adsorbed samples. EMD also significantly increased cell proliferation at 3 and 5 days post-seeding. Moreover, there were significantly higher mRNA levels of osteoblast differentiation markers including collagen1α1, alkaline phosphatase, and osteocalcin in osteoblasts and PDL cells cultured on EMD-adsorbed CaP particles at various time points. CONCLUSION The present study suggests that the addition of EMD to CaP grafting particles may influence periodontal regeneration by stimulating PDL cell and osteoblast attachment, proliferation, and differentiation. Future in vivo and clinical studies are required to confirm these findings. CLINICAL RELEVANCE The combination of EMD and CaP may represent an option for regenerative periodontal therapy in advanced intrabony defects.

Patient-reported outcomes of maxillary implant-supported overdentures compared with conventional dentures

OBJECTIVE The aim of the present prospective clinical study was to compare patient-reported outcomes for maxillary conventional dentures and maxillary implant-supported dentures. MATERIAL AND METHODS Twenty-one patients (6 women and 15 men) being edentulous in the maxilla and encountering problems with their existing dentures were included. Twelve patients (4 women and 8 men) received a new set of conventional dentures, due to insufficient dentures. In nine patients (2 women and 7 men), the existing dentures were adjusted by means of relining or rebasing. All patients received implant-supported dentures on two retentive anchors. In total, 42 implants were inserted in the anterior maxilla. The participants rated their satisfaction on their existing conventional dentures, 2 months after insertion of new conventional dentures and 2 months after insertion of implant-supported dentures. Thereby, patients responded to questionnaires capturing the oral health impact profile (OHIP) using visual analog scales. Seven domains (functional limitation, physical pain, psychological discomfort, physical, psychological and social disability and handicap) were assessed. Higher scores implied poorer patient satisfaction. In addition, the questionnaire involved the evaluation of cleaning ability, general satisfaction, speech, comfort, esthetics, stability, and chewing ability. Higher scores implied higher patient satisfaction. RESULTS Patient satisfaction significantly increased for implant-supported dentures compared with old dentures in all seven OHIP subgroups, as well as for cleaning ability, general satisfaction, ability to speak, comfort, esthetics, and stability (P < 0.05). The comparison of new conventional dentures and implant-supported dentures revealed a statistically significantly increased satisfaction for functional limitation (difference of 33.2 mm), psychological discomfort (difference of 36.7 mm), physical disability (difference of 36.3 mm), and social disability (difference of 23.5 mm), (P < 0.05). Additionally, general satisfaction, chewing ability, speech, and stability significantly improved in implant-supported dentures (P < 0.05). CONCLUSIONS Within the limits of this study, maxillary dentures retained by two implants provided some significant short-term improvements over conventional dentures in oral- and health-related quality of life.

The value of susceptibility-weighted imaging (SWI) in patients with non-neonatal hypoxic-ischemic encephalopathy

OBJECTIVE In susceptibility-weighted imaging (SWI) in the normal brain, cortical veins appear hypointense due to paramagnetic properties of deoxy-hemoglobin. Global cerebral anoxia decreases cerebral oxygen metabolism, thereby increasing oxy-hemoglobin levels in cerebral veins. We hypothesized that a lower cerebral oxygen extraction fraction in comatose patients with non-neonatal hypoxic ischemic encephalopathy (IHE) produce a pattern of global rarefied or pseudo-diminished cortical veins due to higher oxy-hemoglobin. PURPOSE 1. To investigate the topographic relationship between susceptibility effects in cortical veins and related diffusion restrictions on diffusion-weighted imaging (DWI) in patients with IHE. 2. To relate imaging findings to patterns of altered resting activity on surface EEG. METHODS Twenty-three IHE patients underwent MRI. EEG patterns were used to classify the depth of coma. Regional vs. global susceptibility changes on SWI and patterns of DWI restrictions were compared with the depth of coma. RESULTS All patients exhibited areas of restricted cortical diffusion and SWI abnormalities. The dominant DWI restrictions encompassed widespread areas along the precuneus, frontal and parietal association cortices and basal ganglia. For SWI, nineteen patients had generalized bi-hemispherical patterns, the EEG patterns correlated with coma grades III to V. Four patients had focal decreases of deoxy-hemoglobin following DWI restrictions; associated with normal EEGs. CONCLUSION Focal patterns of diamagnetic effects on SWI according to relative decreases in deoxy-hemoglobin due to reduced metabolic demand are associated with normal EEG in IHE patients. Global patterns indicated increased depth of coma and widespread cortical damage. CLINICAL RELEVANCE The results indicate a potential diagnostic value of SWI in patients with IHE.

BID-dependent release of mitochondrial SMAC dampens XIAP-mediated immunity against Shigella

The X‐linked inhibitor of apoptosis protein (XIAP) is a potent caspase inhibitor, best known for its anti‐apoptotic function in cancer. During apoptosis, XIAP is antagonized by SMAC, which is released from the mitochondria upon caspase‐mediated activation of BID. Recent studies suggest that XIAP is involved in immune signaling. Here, we explore XIAP as an important mediator of an immune response against the enteroinvasive bacterium Shigella flexneri, both in vitro and in vivo. Our data demonstrate for the first time that Shigella evades the XIAP‐mediated immune response by inducing the BID‐dependent release of SMAC from the mitochondria. Unlike apoptotic stimuli, Shigella activates the calpain‐dependent cleavage of BID to trigger the release of SMAC, which antagonizes the inflammatory action of XIAP without inducing apoptosis. Our results demonstrate how the cellular death machinery can be subverted by an invasive pathogen to ensure bacterial colonization.

The mini-clinical evaluation exercise during medical clerkships: are learning needs and learning goals aligned?

OBJECTIVES The generation of learning goals (LGs) that are aligned with learning needs (LNs) is one of the main purposes of formative workplace-based assessment. In this study, we aimed to analyse how often trainer–student pairs identified corresponding LNs in mini-clinical evaluation exercise (mini-CEX) encounters and to what degree these LNs aligned with recorded LGs, taking into account the social environment (e.g. clinic size) in which the mini-CEX was conducted. METHODS Retrospective analyses of adapted mini-CEX forms (trainers’ and students’ assessments) completed by all Year 4 medical students during clerkships were performed. Learning needs were defined by the lowest score(s) assigned to one or more of the mini-CEX domains. Learning goals were categorised qualitatively according to their correspondence with the six mini-CEX domains (e.g. history taking, professionalism). Following descriptive analyses of LNs and LGs, multi-level logistic regression models were used to predict LGs by identified LNs and social context variables. RESULTS A total of 512 trainers and 165 students conducted 1783 mini-CEXs (98% completion rate). Concordantly, trainer–student pairs most often identified LNs in the domains of ‘clinical reasoning’ (23% of 1167 complete forms), ‘organisation/efficiency’ (20%) and ‘physical examination’ (20%). At least one ‘defined’ LG was noted on 313 student forms (18% of 1710). Of the 446 LGs noted in total, the most frequently noted were ‘physical examination’ (49%) and ‘history taking’ (21%). Corresponding LNs as well as social context factors (e.g. clinic size) were found to be predictors of these LGs. CONCLUSIONS Although trainer–student pairs often agreed in the LNs they identified, many assessments did not result in aligned LGs. The sparseness of LGs, their dependency on social context and their partial non-alignment with students’ LNs raise questions about how the full potential of the mini-CEX as not only a ‘diagnostic’ but also an ‘educational’ tool can be exploited.

Feasibility of automated slope III and Scond analysis in children.

BACKGROUND Multiple breath washout (MBW) derived Scond is an established index of ventilation inhomogeneity. Time-consuming post hoc calculations of the expirogram's slope of alveolar phase III (SIII) and the lack of available software hampered widespread application of Scond. METHODS Seventy-two school-aged children (45 with cystic fibrosis; CF) performed 3 nitrogen MBW. We tested a new automated algorithm for Scond analysis (Scondauto ) which comprised breath selection for SIII detection, calculation and reporting of test quality. We compared Scondauto to (i) standard Scond analysis (Scondmanual ) with manual breath selection and to (ii) pragmatic Scond analysis including all breaths (Scondall ). Primary outcomes were success rate and agreement between different Scond protocols, and Scond fitting quality (linear regression R(2) ). RESULTS Average Scondauto (0.06 for CF and 0.01 for controls) was not different from Scondmanual (0.06 for CF and 0.01 for controls) and showed comparable fitting quality (R(2) 0.53 for CF and 0.13 for controls vs. R(2) 0.54 for CF and 0.13 for controls). Scondall was similar in CF and controls but with inferior fitting quality compared to Scondauto and Scondmanual . CONCLUSIONS Automated Scond calculation is feasible and produces robust results comparable to the standard manual way of Scond calculation. This algorithm provides a valid, fast and objective tool for regular use, even in children. Pediatr Pulmonol. © 2014 Wiley Periodicals, Inc.

The brain’s default state interacts with working memory processes in a complex and load-dependent manner

Recently, many studies about a network active during rest and deactivated during tasks emerged in the literature: the default mode network (DMN). Spatial and temporal DMN features are important markers for psychiatric diseases. Another prominent indicator of cognitive functioning, yielding information about the mental condition in health and disease, is working memory (WM) processing. In EEG studies, frontal-midline theta power has been shown to increase with load during WM retention in healthy subjects. From these findings, the conclusion can be drawn that an increase in resting state DMN activity may go along with an increase in theta power in high-load WM conditions. We followed this hypothesis in a study on 17 healthy subjects performing a visual Sternberg WM task. The DMN was obtained by a BOLD-ICA approach and its dynamics represented by the percent-strength during pre-stimulus periods. DMN dynamics were temporally correlated with EEG theta spectral power from retention intervals. This so-called covariance mapping yielded the spatial distribution of the theta EEG fluctuations associated with the dynamics of the DMN. In line with previous findings, theta power was increased at frontal-midline electrodes in high- versus low-load conditions during early WM retention. However, load-dependent correlations of DMN with theta power resulted in primarily positive correlations in low-load conditions, while during high-load conditions negative correlations of DMN activity and theta power were observed at frontal-midline electrodes. This DMN-dependent load effect reached significance during later retention. Our results show a complex and load-dependent interaction of pre-stimulus DMN activity and theta power during retention, varying over the course of the retention period. Since both, WM performance and DMN activity, are markers of mental health, our results could be important for further investigations of psychiatric populations.

The brain’s pre-stimulus default state interacts with working memory in a load-dependent manner

Recently, multiple studies showed that spatial and temporal features of a task-negative default mode network (DMN) (Greicius et al., 2003) are important markers for psychiatric diseases (Balsters et al., 2013). Another prominent indicator of cognitive functioning, yielding information about the mental condition in health and disease, is working memory (WM) processing. In EEG and MEG studies, frontal-midline theta power has been shown to increase with load during WM retention in healthy subjects (Brookes et al., 2011). Negative correlations between DMN activity and theta amplitude have been found during resting state (Jann et al., 2010) as well as during WM (Michels et al., 2010). Likewise, WM training resulted in higher resting state theta power as well as increased small-worldness of the resting brain (Langer et al., 2013). Further, increased fMRI connectivity between nodes of the DMN correlated with better WM performance (Hampson et al., 2006). Hence, the brain’s default state might influence it’s functioning during task. We therefore hypothesized correlations between pre-stimulus DMN activity and EEG-theta power during WM maintenance, depending on the WM load. 17 healthy subjects performed a Sternberg WM task while being measured simultaneously with EEG and fMRI. Data was recorded within a multicenter-study: 12 subjects were measured in Zurich with a 64-channels MR-compatible system (Brain Products) in a 3T Philips scanner, 5 subjects with a 96-channel MR-compatible system (Brain Products) in a 3T Siemens Scanner in Bern. The DMN components was obtained by a group BOLD-ICA approach over the full task duration (figure 1). The subject-wise dynamics were obtained by back-reconstructed onto each subject’s fMRI data and normalized to percent signal change values. The single trial pre-stimulus-DMN activation was then temporally correlated with the single trial EEG-theta (3-8 Hz) spectral power during retention intervals. This so-called covariance mapping (Jann et al., 2010) yielded the spatial distribution of the theta EEG fluctuations during retention associated with the dynamics of the pre-stimulus DMN. In line with previous findings, theta power was increased at frontal-midline electrodes in high- versus low-load conditions during early WM retention (figure 2). However, correlations of DMN with theta power resulted in primarily positive correlations in low-load conditions, while during high-load conditions negative correlations of DMN activity and theta power were observed at frontal-midline electrodes. This DMN-dependent load effect reached significance in the middle of the retention period (TANOVA, p<0.05) (figure 3). Our results show a complex and load-dependent interaction of pre-stimulus DMN activity and theta power during retention, varying over time. While at a more global, load-independent view pre-stimulus DMN activity correlated positively with theta power during retention, the correlation was inversed during certain time windows in high-load trials, meaning that in trials with enhanced pre-stimulus DMN activity theta power decreases during retention. Since both WM performance and DMN activity are markers of mental health our results could be important for further investigations of psychiatric populations.

Alignment between learning needs and learning goals of Mini-CEX in clerkships

Background: Defining learning goals (LG) in alignment with learning needs (LN) is one of the key purposes of formative workplace-based assessment, but studies about this topic are scarce. Summary of Work: We analysed quantitatively and qualitatively how often trainer-student pairs identified the same LN during Mini Clinical Evaluation Exercises (Mini-CEX) in clerkships and to what degree those LNs were in line with the recorded LGs. Multilevel logistic regression models were used to predict LGs by identified LNs, controlling for context variables. Summary of Results: 512 trainers and 165 students conducted 1783 Mini-CEX (98% completion rate). Concordantly, trainer-student pairs most often identified LNs in the domains ‘clinical reasoning’ (23% of 1167 complete forms), ‘organisation / efficiency’ (20%) and ‘physical examination’ (20%). At least one ‘defined’ LG was noted on 313 student forms (18% of 1710), with a total of 446 LGs. Of these, the most frequent LGs were ‘physical examination’ (49% of 446 LGs) and ‘history taking’ (21%); corresponding LNs as well as context variables (e.g. clinic size) were found to be predictors of these LGs. Discussion and Conclusions: Although trainer-student pairs often agreed in their identified LNs, many assessments did not result in an aligned LG or a LG at all. Interventions are needed to enhance the proportion of (aligned) LGs in Mini-CEX in order to tap into its full potential not only as a ‘diagnostic’ but also as an ‘educational tool’. Take-home messages: The sparseness of LGs, their dependency on context variables and their partial non-alignment with students’ LNs raise the question of how the effectiveness of Mini-CEX can be further enhanced.

Prognostic and predictive roles of MGMT protein expression and promoter methylation in sporadic pancreatic neuroendocrine neoplasms.

BACKGROUND/AIMS O(6)-methylguanine-methyltransferase (MGMT) is an important enzyme of DNA repair. MGMT promoter methylation is detectable in a subset of pancreatic neuroendocrine neoplasms (pNEN). A subset of pNEN responds to the alkylating agent temozolomide (TMZ). We wanted to correlate MGMT promoter methylation with MGMT protein loss in pNEN, correlate the findings with clinico-pathological data and determine the role of MGMT to predict response to TMZ chemotherapy. METHODS We analysed a well-characterized collective of 141 resected pNEN with median follow-up of 83 months for MGMT protein expression and promoter methylation using methylation-specific PCR (MSP). A second collective of 10 metastasized, pretreated and progressive patients receiving TMZ was used to examine the predictive role of MGMT by determining protein expression and promoter methylation using primer extension-based quantitative PCR. RESULTS In both collectives there was no correlation between MGMT protein expression and promoter methylation. Loss of MGMT protein was associated with an adverse outcome, this prognostic value, however, was not independent from grade and stage in multivariate analysis. Promoter hypermethylation was significantly associated with response to TMZ. CONCLUSION Loss of MGMT protein expression is associated with adverse outcome in a surgical series of pNET. MGMT promoter methylation could be a predictive marker for TMZ chemotherapy in pNEN, but further, favourably prospective studies will be needed to confirm this result and before this observation can influence clinical routine.

Paediatric thyroid surgery is safe - experiences at a tertiary surgical centre.

PRINCIPLES Thyroidectomy in children is rare and mostly performed because of thyroid neoplasms. The aim of this study based on prospective data acquisition was to evaluate whether thyroid surgery in children can be performed as safely as in adults when undertaken by a team of adult endocrine surgeons and paediatric surgeons. METHODS Between 2002 and 2012, 36 patients younger than 18 years underwent surgery for thyroid gland pathologies. All surgical procedures were performed by an experienced endocrine surgeon and a paediatric surgeon. Baseline demographic data, surgical procedure, duration of operation, length of hospital stay, and postoperative morbidity and mortality were analysed. RESULTS The median age of all patients was 13 years (range 2-17 years), with predominantly female gender (n = 30, 83%). The majority of operations were performed because of benign thyroid disease (n = 27, 75%) and only a minority because of malignancy or genetic abnormality with predisposition for malignant transformation (MEN) (n = 9, 25%). Total thyroidectomy was performed in the majority of the patients (n = 24, 67%). The median duration of the surgical procedure was 153 minutes (range 90-310 minutes). The median hospital stay was 5 days (3-1 days). One patient developed persistent hypoparathyroidism after neck dissection due to cancer. One persistent and two temporary recurrent nerve palsies occurred. CONCLUSION This study demonstrated that paediatric thyroidectomy is safe as performed by this team of endocrine and paediatric surgeons, with acceptable morbidity even when total thyroidectomy was performed in the case of benign disease.

Speech Understanding with a New Implant Technology: A Comparative Study with a New Nonskin Penetrating Baha System

Objective. To compare hearing and speech understanding between a new, nonskin penetrating Baha system (Baha Attract) to the current Baha system using a skin-penetrating abutment. Methods. Hearing and speech understanding were measured in 16 experienced Baha users. The transmission path via the abutment was compared to a simulated Baha Attract transmission path by attaching the implantable magnet to the abutment and then by adding a sample of artificial skin and the external parts of the Baha Attract system. Four different measurements were performed: bone conduction thresholds directly through the sound processor (BC Direct), aided sound field thresholds, aided speech understanding in quiet, and aided speech understanding in noise. Results. The simulated Baha Attract transmission path introduced an attenuation starting from approximately 5 dB at 1000 Hz, increasing to 20–25 dB above 6000 Hz. However, aided sound field threshold shows smaller differences and aided speech understanding in quiet and in noise does not differ significantly between the two transmission paths. Conclusion. The Baha Attract system transmission path introduces predominately high frequency attenuation. This attenuation can be partially compensated by adequate fitting of the speech processor. No significant decrease in speech understanding in either quiet or in noise was found.

Should the standard dimethyl sulfoxide concentration be reduced? Results of a European Group for Blood and Marrow Transplantation prospective noninterventional study on usage and side effects of dimethyl sulfoxide.

BACKGROUND Dimethyl sulfoxide (DMSO) is essential for the preservation of liquid nitrogen-frozen stem cells, but is associated with toxicity in the transplant recipient. STUDY DESIGN AND METHODS In this prospective noninterventional study, we describe the use of DMSO in 64 European Blood and Marrow Transplant Group centers undertaking autologous transplantation on patients with myeloma and lymphoma and analyze side effects after return of DMSO-preserved stem cells. RESULTS While the majority of centers continue to use 10% DMSO, a significant proportion either use lower concentrations, mostly 5 or 7.5%, or wash cells before infusion (some for selected patients only). In contrast, the median dose of DMSO given (20 mL) was much less than the upper limit set by the same institutions (70 mL). In an accompanying statistical analysis of side effects noted after return of DMSO-preserved stem cells, we show that patients in the highest quartile receiving DMSO (mL and mL/kg body weight) had significantly more side effects attributed to DMSO, although this effect was not observed if DMSO was calculated as mL/min. Dividing the myeloma and lymphoma patients each into two equal groups by age we were able to confirm this result in all but young myeloma patients in whom an inversion of the odds ratio was seen, possibly related to the higher dose of melphalan received by young myeloma patients. CONCLUSION We suggest better standardization of preservation method with reduced DMSO concentration and attention to the dose of DMSO received by patients could help reduce the toxicity and morbidity of the transplant procedure.