Nationwide Outcome Analysis of Primary Carotid Endarterectomy in Symptomatic Patients Depending on Closure Technique and Patch Type

OBJECTIVE

Current European guidelines recommend both eversion carotid endarterectomy (CEA) and conventional CEA with routine patch closure, rather than routine primary closure. Polyester and polytetrafluoroethylene (PTFE) have been used as patch material for a long time. More recently, bovine pericardium has been used; however, there are few studies comparing long term results between bovine pericardium and other patch types. The aim of this study was to investigate the short and long term results after CEA depending on surgical technique and patch material.

METHODS

A registry based study on all primary CEAs (n = 9 205) performed for symptomatic carotid artery stenosis in Sweden from July 2008 to December 2019, cross linked with data from the Swedish stroke registry, Riksstroke, and chart review for evaluation of any events occurring during follow up. The primary endpoint was ipsilateral stroke < 30 days. Secondary endpoints included re-operations due to neck haematoma and < 30 day ipsilateral stroke, > 30 day ipsilateral stroke, all stroke > 30 days, and all cause mortality.

RESULTS

2 495 patients underwent eversion CEA and 6 710 conventional CEA for symptomatic carotid stenosis. The most commonly used patch material was Dacron (n = 3 921), followed by PTFE (n = 588) and bovine pericardium (n = 413). A total of 1 788 patients underwent conventional CEA with primary closure. Two hundred and seventy-three patients (3.0%) had a stroke < 30 days. Primary closure was associated with an increased risk of ipsilateral stroke and stroke or death <30 days: odds ratio 1.7 (95% confidence interval [CI] 1.2 - 2.4, p = .002); and 1.5 (95% CI 1.2 - 2.0), respectively. During follow up (median 4.2 years), 592 patients had any form of stroke and 1 492 died. There was no significant difference in long term risk of ipsilateral stroke, all stroke, or death depending on surgical technique or patch material.

CONCLUSION

There was an increased risk of ipsilateral stroke < 30 days in patients operated on with primary closure compared with eversion CEA and patch angioplasty. There was no difference between primary closure, different patch types, or eversion after the peri-operative phase.

IL-6 signalling biomarkers in hospitalised patients with moderate to severe SARS-CoV-2 infection in a single centre study in Sweden

Background

Method

Results

Conclusion

Low Incidence of Late Ipsilateral Ischaemic Stroke After Treatment for Symptomatic Carotid Stenosis in Sweden 2008-2017: Increased Risk in the Elderly and After Carotid Stenting

OBJECTIVE

Carotid stenosis is a major risk factor for stroke and surgical treatment is key in preventing recurrent ischaemic events. Previous randomised trials have demonstrated the net benefit of surgery for significant symptomatic carotid stenosis but, with present day medical treatment, there is limited evidence on the risk of late ipsilateral ischaemic stroke (IS) and its main risk factors.

METHOD

Ipsilateral IS after the peri-operative period (≤ 30 days) was investigated in a nationwide, registry based cohort study of patients treated for symptomatic carotid stenosis in Sweden between 2008 - 2017. The Swedish National Registry for Vascular Surgery (Swedvasc) was used to establish the cohort, and the Swedish stroke registry (Riksstroke), combined with hospital records, was used to determine outcome. Stroke of any type and all cause mortality after the peri-operative period were studied as secondary outcomes. Cox regression was used to analyse associations between clinical factors and outcomes.

RESULTS

In total, 7 589 patients (mean age 72 ± 8 years, 68% men) were followed for 4.2 ± 2.6 years. Ipsilateral IS occurred in 232 patients corresponding to a yearly incidence of 0.73%. Age above 80 years compared with 65 - 79 years was associated with an increased risk of ipsilateral IS (adjusted HR 1.94, 95% CI 1.43 - 2.65). Carotid artery stenting (CAS) compared with carotid endarterectomy (CEA) was also associated with increased risk (adjusted HR 3.20, 95% CI 2.03 - 5.03). Stroke of any type occurred in 7.7% of patients, and 19.6% of patients died during the follow up period.

CONCLUSION

The incidence of ipsilateral IS after treatment for symptomatic carotid stenosis in Sweden 2008-2017 was low, demonstrating the effectiveness and durability of surgery in a real world setting. Only age above 80 years and CAS compared with CEA were associated with increased risk of ipsilateral IS.

Soluble angiotensin-converting enzyme 2 is transiently elevated in COVID-19 and correlates with specific inflammatory and endothelial markers

The main entry receptor of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is angiotensin-converting enzyme 2 (ACE2). SARS-CoV-2 interactions with ACE2 may increase ectodomain shedding but consequences for the renin-angiotensin system and pathology in Coronavirus disease 2019 (COVID-19) remain unclear. We measured soluble ACE2 (sACE2) and sACE levels by enzyme-linked immunosorbent assay in 114 hospital-treated COVID-19 patients compared with 10 healthy controls; follow-up samples after four months were analyzed for 58 patients. Associations between sACE2 respectively sACE and risk factors for severe COVID-19, outcome, and inflammatory markers were investigated. Levels of sACE2 were higher in COVID-19 patients than in healthy controls, median 5.0 (interquartile range 2.8-11.8) ng/ml versus 1.4 (1.1-1.6) ng/ml, p < .0001. sACE2 was higher in men than women but was not affected by other risk factors for severe COVID-19. sACE2 decreased to 2.3 (1.6-3.9) ng/ml at follow-up, p < .0001, but remained higher than in healthy controls, p = .012. sACE was marginally lower during COVID-19 compared with at follow-up, 57 (45-70) ng/ml versus 72 (52-87) ng/ml, p = .008. Levels of sACE2 and sACE did not differ depending on survival or disease severity. sACE2 during COVID-19 correlated with von Willebrand factor, factor VIII and D-dimer, while sACE correlated with interleukin 6, tumor necrosis factor α, and plasminogen activator inhibitor 1. Conclusions: sACE2 was transiently elevated in COVID-19, likely due to increased shedding from infected cells. sACE2 and sACE during COVID-19 differed in correlations with markers of inflammation and endothelial dysfunction, suggesting release from different cell types and/or vascular beds.

Prothrombotic changes in patients with COVID-19 are associated with disease severity and mortality

BACKGROUND AND AIMS

Patients with severe coronavirus disease 2019 (COVID-19) are at significant risk of thrombotic complications. However, their prothrombotic state is incompletely understood. Therefore, we measured in vivo activation markers of hemostasis, plasma levels of hemostatic proteins, and functional assays of coagulation and fibrinolysis in plasma from patients with COVID-19 and determined their association with disease severity and 30-day mortality.

METHODS

We included 102 patients with COVID-19 receiving various levels of respiratory support admitted to general wards, intermediate units, or intensive care units and collected plasma samples shortly after hospital admission.

RESULTS

Patients with COVID-19 with higher respiratory support had increased in vivo activation of coagulation and fibrinolysis, as reflected by higher plasma levels of d-dimer, thrombin-antithrombin, and plasmin-antiplasmin complexes as compared to patients with no to minimal respiratory support and healthy controls. Moreover, the patients with COVID-19 with higher respiratory support exhibited substantial ex vivo thrombin generation and lower ex vivo fibrinolytic capacity, despite higher doses of anticoagulant therapy compared to less severely ill patients. Fibrinogen, factor VIII, and von Willebrand factor levels increased, and ADAMTS13 levels decreased with increasing respiratory support in patients with COVID-19. Low platelet count; low levels of prothrombin, antithrombin, and ADAMTS13; and high levels of von Willebrand factor were associated with short-term mortality.

CONCLUSIONS

Severe COVID-19 is associated with prothrombotic changes with increased in vivo activation of coagulation and fibrinolysis, despite anticoagulant therapy.

High Thrombin Generation after Acute Ischemic Stroke or Transient Ischemic Attack Is Associated with a Reduced Risk of Recurrence: An Observational Cohort Study

Thrombin is increasingly recognized to be of importance for cardiovascular disease. The aim of this study was to investigate the prognostic value of thrombin generation variables in a cohort of patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA). Thrombin generation potential measured by calibrated automated thrombogram (CAT) and prothrombin fragment F1 + 2 was determined in the acute and convalescent phases for a cohort of 190 patients with AIS/TIA. Microvesicle (MV)-induced thrombin generation potential was determined for a subset of patients using modified CAT. Primary outcome was a composite of fatal and nonfatal AIS or myocardial infarction as documented in Swedish registers during a total follow-up of 986 patient-years. Hazard ratios (HRs) were calculated using Cox regression based on variable median split. Peak thrombin and endogenous thrombin potential (ETP) above median in the acute phase were associated with a reduced risk of primary outcome after adjustment for cardiovascular risk factors, HR: 0.50 (0.27-0.92), p = 0.026 and HR: 0.53 (0.28-0.99), p = 0.048, respectively. F1 + 2 was lower in patients than in healthy controls but not associated with outcome. MV-induced peak thrombin above median in the acute phase was associated with recurrent AIS, unadjusted HR: 2.65 (1.03-6.44), p = 0.044. Contrary to expectation, high thrombin generation potential is associated with a reduced risk of recurrent ischemic event in patients with AIS/TIA. Low ETP/peak thrombin combined with high MV-induced peak thrombin can potentially identify patients at high risk of recurrence.

[ACE2 and coronavirus - a question of balance and dynamics?]

The new SARS-CoV-2 virus enters cells via angiotensin-converting enzyme 2 (ACE2). ACE2 counteracts ACE and angiotensin II in the renin-angiotensin-aldosterone system (RAAS) and has critical functions in the lung and cardiovascular system. SARS-CoV was found to down-regulate ACE2, leaving angiotensin II unbalanced in affected organs.  A similar effect of SARS-CoV-2 could partly explain risk factors and symptoms, and could potentially be treatable.

Prognostic Value of Circulating Microvesicle Subpopulations in Ischemic Stroke and TIA

Platelet microvesicles (PMV) have previously been found elevated in acute ischemic stroke (IS) and could be biomarkers for risk of recurrence. PMV surface antigens such as P-selectin and phosphatidylserine (PS) reflect platelet activation and procoagulance. Tissue factor-positive microvesicles (TF⁺MV) are considered procoagulant, in particular if co-expressing PS. We enumerated MV subpopulations with these surface antigens in a cohort of 211 patients with primarily non-cardioembolic IS or transient ischemic attack (TIA) and investigated their association with long-term outcome. MV concentrations were determined by flow cytometry in the acute and convalescent phase. Primary outcome was a composite of fatal and non-fatal recurrent IS or myocardial infarction. Secondary outcomes were recurrent IS and all-cause mortality. Outcome events were obtained from Swedish registers during a follow-up of 1100 patient years. Concentrations of PS-positive and PS-negative MV populations were elevated in patients compared with healthy controls in both the acute and convalescent phase. PS⁺TF⁺PMV displayed pronounced elevations, median fold change 77 in the acute phase (p < 0.0001) but were not associated with outcome, neither were PS⁺P-selectin⁺PMV. The only subpopulation positively associated with primary outcome was PS^-TF⁺PMV, with adjusted hazard ratio of 1.86 (1.04-3.31, p = 0.036) by Cox regression. Unexpectedly, several MV subpopulations tended to be associated with reduced risk of poor long-term outcome. Our results suggest that PS⁺TF⁺PMV may be a promising marker for cerebral ischemia, and that the in vivo generation of PS^-MV after IS/TIA warrants further study. Future MV studies should ideally enumerate PS⁺ and PS^-MV subpopulations separately.

Clopidogrel Resistance after Minor Ischemic Stroke or Transient Ischemic Attack is Associated with Radiological Cerebral Small-Vessel Disease

BACKGROUND

The objective of this study was to compare nonresponders (NR) and responders (R) to clopidogrel with respect to presence of microvascular and macrovascular pathology in a cohort of patients with recent minor ischemic stroke (IS) or transient ischemic attack (TIA).

METHODS

Seventy-two patients treated with clopidogrel after IS or TIA were evaluated 1 month after onset. Platelet aggregation was measured by multiple electrode aggregometry (Multiplate). Nonresponse was defined according to recent consensus. The degree of cerebral small-vessel disease (cSVD) was evaluated on computed tomography scans of the brain using Fazekas scale for white matter changes. Carotid atherosclerosis was evaluated by ultrasound or computed tomography/magnetic resonance angiography.

RESULTS

Twenty-two percent of patients were NR. Moderate to extensive cSVD was more common for NR than R, 56% versus 25%, odds ratio 3.9 (1.2-12), P = .03. Correspondingly, 39% of patients with cSVD were NR versus 14% of patients with no or mild cSVD. No differences were found between NR and R in prevalence or severity of carotid atherosclerosis. NR had higher platelet aggregation response than R after stimulation with arachidonic acid or thrombin receptor-activating peptide, indicating a general platelet hyperreactivity. In a univariate analysis, hypertension, previous IS, glucose intolerance, pulse pressure above median, and presence of moderate to extensive cSVD were associated with the NR phenotype.

CONCLUSIONS

Nonresponsiveness to clopidogrel after minor IS or TIA is associated with radiological cSVD but not with carotid atherosclerosis.

PRACTICE/IMPLICATIONS

Measurement of platelet function is warranted in patients with cSVD. Larger studies on alternative or tailored antiplatelet treatment for these patients should be initiated.

Glucose intolerance and insulin resistance as predictors of low platelet response to clopidogrel in patients with minor ischemic stroke or TIA

The relation between high on-treatment platelet reactivity (HPR), and the level of glucose intolerance and insulin resistance (IR) was studied in clopidogrel-treated patients with minor ischemic stroke or TIA. The cohort consisted of 66 patients, 11 of which had known type 2 diabetes mellitus (DM). Platelet aggregation in whole blood (Multiplate™) and metabolic variables were measured 1 month after acute onset of neurological symptoms. Glucose tolerance was measured by Oral Glucose Tolerance Test (OGTT). IR was estimated by homeostasis model assessment HOMA-IR. Patients were categorized as "responders" (R) or "non-responders" (NR) to clopidogrel according to an established cut-off in platelet aggregation induced by adenosine diphosphate (ADP). In total, 14/66 (21%) patients were NR. Impaired glucose tolerance (IGT), impaired fasting glucose (IFG) or DM was seen in 13/14 NR (93%), while for R this was the case in 25/52 (48%), p = 0.001. The percentage of NR was 33% in patients with DM and 35% in patients with IGT or IFG. In the group with normal glucose tolerance (NGT) the percentage of NR was low, 4% (1/28). Fasting plasma glucose (f-PG) was higher for NR than for R, 6.0 (5.5-6.7) mM vs. 5.3 (5.0-6.0) mM, p = 0.023. Glycated hemoglobin (HbA1c) did not differ between NR and R. NR also had higher arachidonic acid-induced platelet aggregation than R, and a tendency towards higher aggregation induced by thrombin receptor agonist peptide (TRAP), indicating that HPR reflects a global platelet hyper-reactivity. HOMA-IR was calculated for 52 of the patients above without known diabetes, 9 of which were NR (17%). NR were significantly more insulin resistant than R, with median HOMA-IR 4.5 (3.0-7.4) compared to 2.1 (1.5-3.2) for R, p = 0.001. HOMA-IR and fasting plasma insulin were the only metabolic variables with significant relationships to ADP-induced platelet aggregation. The results suggest that HPR develops in the pre-diabetic phase. A metabolic disturbance with glucose intolerance and/or high level of IR was a pre-requisite for HPR in the tested cohort. Conversely, normal glucose tolerance combined with normal or mildly elevated HOMA-IR excluded HPR. NR are likely to constitute a high-risk group among patients with ischemic cerebrovascular disease. Measurement of f-PG or HbA1c is insufficient to identify NR, while OGTT and HOMA-IR are more predictive.

Vilse, a conserved Rac/Cdc42 GAP mediating Robo repulsion in tracheal cells and axons

Slit proteins steer the migration of many cell types through their binding to Robo receptors, but how Robo controls cell motility is not clear. We describe the functional analysis of vilse, a Drosophila gene required for Robo repulsion in epithelial cells and axons. Vilse defines a conserved family of RhoGAPs (Rho GTPase-activating proteins), with representatives in flies and vertebrates. The phenotypes of vilse mutants resemble the tracheal and axonal phenotypes of Slit and Robo mutants at the CNS midline. Dosage-sensitive genetic interactions between vilse, slit, and robo mutants suggest that vilse is a component of robo signaling. Moreover, overexpression of Vilse in the trachea of robo mutants ameliorates the phenotypes of robo, indicating that Vilse acts downstream of Robo to mediate midline repulsion. Vilse and its human homolog bind directly to the intracellular domains of the corresponding Robo receptors and promote the hydrolysis of RacGTP and, less efficiently, of Cdc42GTP. These results together with genetic interaction experiments with robo, vilse, and rac mutants suggest a mechanism whereby Robo repulsion is mediated by the localized inactivation of Rac through Vilse.

A protein from the cabbage looper, Trichoplusia ni, regulated by a bacterial infection is homologous to 3-dehydroecdysone 3beta-reductase

During the screening of immune-regulated genes from the cabbage looper, Trichoplusia ni, a 3-dehydroecdysone 3beta-reductase homologue (DERH) was cloned. In the course of development, 3-dehydroecdysone 3beta-reductase mediates the conversion of 3-dehydroecdysone (3dE) secreted from the prothoracic glands to ecdysone (E), which is subsequently converted to 20-hydroxyecdysone (20E), the major insect molting hormone. The cloned gene is upregulated in fat body during development and is strongly induced after the larva is challenged with bacteria. The gene codes for a 308 amino acid residue protein which shows 42.5% identity to Spodoptera littoralis 3-dehydroecdysone 3beta-reductase. Using the baculovirus expression system, the recombinant DERH was expressed. The purified protein mediates the reduction of 3-dehydromakisterone A to makisterone A, and requires NADPH as a cofactor. Western blots using an antiserum to T. ni DERH revealed the presence of the protein in larval hemolymph and integument. The data indicate that the protein is regulated developmentally and is induced after a challenge with bacteria. Immunohistochemical studies localized the enzyme exclusively in the epidermis and the cuticle.

An azurocidin-like protein is induced in Trichoplusia ni larval gut cells after bacterial challenge

Trichoplusia ni immune genes up-regulated in response to bacterial infection have been isolated using differential display polymerase chain reaction. Here we report the cloning and characterisation of a gut-specific immune gene encoding an azurocidin-like protein. The deduced protein is 317 amino acid residues long with a hydrophobic C-terminus and a predicted 17-residue signal peptide. The mature T. ni protein shows 30% identity to human azurocidin, an antibacterial protein. Like azurocidin, the T. ni protein contains two amino acid substitutions in the active site triad normally present in serine proteases. The T. ni protein was synthesised with a six-histidine C-terminal extension using the baculovirus expression system. Sequencing of the recombinant azurocidin-like protein confirmed the predicted cleavage of the signal peptide. Northern blots show that T. ni azurocidin-like protein is expressed solely in the larval gut and that expression is up-regulated by injecting or feeding bacteria. Expression reaches its highest level at 10 h after bacteria injection.

Trichoplusia ni gloverin, an inducible immune gene encoding an antibacterial insect protein

By using differential display PCR, we obtained a cDNA clone encoding a gloverin homologue from the cabbage looper, Trichoplusia ni. The expression of the gene was induced by bacterial infections. The gene codes for a 174 amino acid residue protein, including a signal sequence and a prosegment. The deduced mature protein is 14 kDa and shows 58% and 49% identity to P2 from Helicoverpa armigera and to Hyalophora gloveri gloverin, respectively. The protein was detected in hemolymph and hemocytes from bacteria-immunized animals. We expressed gloverin using the baculovirus expression system. N-terminal amino acid sequence analysis showed that the purified protein contained a propart. This progloverin inhibited the growth of E. coli and the activity is comparable to that of H. gloveri mature gloverin. Processing of progloverin was possible in vitro, using human furin.

Periodontal conditions in 70-year-old women with osteoporosis

The aim of the present study was to examine the periodontal conditions in an age cohort of 70-year-old women and compare an osteoporosis group with a control group with normal bone mineral density. 210 women 70 years old and randomly sampled from the population register of the community of Linköping were examined. Bone mineral density (BMD) of the hip was measured by dual energy X-ray absorptiometry. 19 women were diagnosed with osteoporosis (BMD below 0.640 g/cm2 in total hip). 15 of them accepted to participate in the study. As a control group 21 women with normal bone mineral density (BMD exceeding 0.881 g/cm2) were randomly selected from the initial population. The clinical examination included registration of the number of remaining teeth, dental plaque and periodontal conditions. The radiographic examination included a dental panorama and vertical bite-wing radiographs. The subjects also answered a questionnaire about their general health, age at menopause, concurrent medication, smoking and oral hygiene habits. The results from this study showed no statistically significant differences in gingival bleeding, probing pocket depths, gingival recession and marginal bone level between the women with osteoporosis and the women with normal bone mineral density. In conclusion, the present randomly selected and controlled study of osteoporotic and non-osteoporotic women, showed no statistically significant differences in periodontal conditions or marginal bone level. As periodontitis as well as osteoporosis are associated with age, our study of a well-defined age cohort is of interest, but the results should be interpreted with caution since the compared groups are small.

The role of alpha2 beta1 and alpha3 beta1 integrin receptors in the initial anchoring of MDA-MB-231 human breast cancer cells to cortical bone matrix

Molecular mechanisms involved in the rapid attachment of the human breast cancer cell line MDA-MD-231 to cortical bone matrix were studied. The attachment of MDA-MD-231 cells to cortical bone disks could be blocked by 75% when cells were pretreated with a monoclonal antibody to the beta1-subunit of the integrin family. Monoclonal antibodies against the alpha2, alpha3, and alpha5 integrin subunits inhibited the attachment by 76, 26, and 8 % respectively. Collagenase type I and collagen type I antibody blocked the cell attachment by 45 and 50 % whereas pretreatment of the cells with soluble collagen type I blocked the attachment by 85 %. Our study with a panel of cancer cell lines further showed a close correlation between alpha2 beta1 and alpha3 beta1 integrin receptor expression and the capability to attach to cortical bone. These receptors appear to be the key receptors utilized by cancer cells for the initial attachment to cortical bone, and this could facilitate the localization of alpha2 beta1 and alpha3 beta1 expressing cancer cells to the skeleton.

A peptidoglycan recognition protein in innate immunity conserved from insects to humans

Innate nonself recognition must rely on common structures of invading microbes. In a differential display screen for up-regulated immune genes in the moth Trichoplusia ni we have found mechanisms for recognition of bacterial cell wall fragments. One bacteria-induced gene encodes a protein that, after expression in the baculovirus system, was shown to be a peptidoglycan recognition protein (PGRP). It binds strongly to Gram-positive bacteria. We have also cloned the corresponding cDNA from mouse and human and shown this gene to be expressed in a variety of organs, notably organs of the immune system-i.e., bone marrow and spleen. In addition, purified recombinant murine PGRP was shown to possess peptidoglycan affinity. From our results and the sequence homology, we conclude that PGRP is a ubiquitous protein involved in innate immunity, conserved from insects to humans.

A proportional analysis of some facial height and depth variables in 10 to 16 year old children

A method for analysing the horizontal and vertical proportions of the face is described, based on natural head orientation (NHO). It demonstrates how individual deviations from the mean proportions can be quantified both horizontally and vertically. Correlation between facial depth to height (index 1) and the mandibular plane angle was determined and found to be fairly strong and highly significant (r = 0.5, P < 0.001). Facial depth to height and lower facial height to total facial height (index 2) relationships were found to be strongly correlated at each age between 10 and 16 years, with only small mean differences. For this reason the norm values presented for 12-year-old children for indices 1 and 2 should be applicable to orthodontic patients within this age range. The relationship between mandible and maxilla (index 3) increases continually between 10 and 16 years in boys, and between 10 and 14 years in girls, about 0.3 units a year. It can provide supplementary information for individual case analysis. For boys the increase was 2.2 units per year between 14 and 16 years of age.

Trichoplusia ni attacin A, a differentially displayed insect gene coding for an antibacterial protein

The mRNA differential display method was used to isolate antibacterial defense genes from Trichoplusia ni. The mRNA population in last-instar T. ni larvae injected with bacteria was compared to that of untreated larvae. Using a PCR amplified probe corresponding to an induced mRNA, we were able to clone an attacin homolog from a lambda cDNA library from vaccinated larvae. The corresponding protein showed 63% identity to Hyalophora cecropia acidic attacin. The induction kinetics of T. ni attacin A gave optimal mRNA levels at 20 h post-infection. Genomic analysis showed this to be a single-copy gene with two introns.

Costs of periodontal and prosthodontic treatment and evaluation of oral health in patients after treatment of advanced periodontal disease

Retrospective estimations of dental care costs of periodontal and prosthodontic treatment and evaluation of oral health in 37 patients with advanced periodontal disease were carried out. Measures of their subjective evaluation of oral health 7-10 yr after the treatment are presented as a health profile and as indices in single numbers. The relations between oral health as an index and the dimensions in the health profile are analyzed. Dental care costs for treatment in the mandible was SEK 35 550, for the maxilla SEK 45 380 and for both jaws SEK 74 230. After the treatment oral health as well as general health were in excess of 75 on a 0 to 100 scale. Chewing ability, comfort and aesthetics were the variables found to significantly affect the subjective oral health. Oral health in terms of periodontal and prosthodontic conditions was maintained over the observation period.

The Frankfort horizontal as a basis for cephalometric analysis

A random sample of 79 British 12-year-old children was studied from tracings registered in the natural head position (NHP). The angle between the Frankfort horizontal (FH) and the horizontal at right angles to the plumb line was measured. Two experienced assessors checked every tracing; for those children perceived to show unnatural head position this was adjusted to what they considered to be the natural head orientation (NHO). The NHO was defined as the head orientation of the subject perceived by the clinician, based on general experience, as the NHP in a standing, relaxed body and head posture, when the subject is looking at a distant point at eye level. The FHK horizontal angle was then measured, now related to the corrected head position. The standard deviation for the latter angle was smaller than that of the uncorrected, but still too large for the FH to be considered reliable as a basis for clinical cephalometric analysis. No statistically significant difference in variability as found between FH and the sella-nasion line. The extracranial horizontal plane related to NHO was recommended as the least variable of the references studied.

Natural head position and natural head orientation: basic considerations in cephalometric analysis and research

Natural head position (NHP) provides the key for meaningful cephalometric analysis because an extracranial reference line is used instead of intracranial reference lines, known to be subject to considerable biological variation in their inclination. Although the principle of natural head position is being recognized in the orthodontic literature, its registration may contain an element of unavoidable error that requires correction. A new concept of natural head orientation (NHO) has been introduced to maximize the contribution of NHP to cephalometrics. It is defined as the head orientation of the subject perceived by the clinician, based on general experience, as the natural head position in a standing, relaxed body and head posture, when the subject is looking at a distant point at eye level. The present study was designed to determine the accuracy and validity of NHO, using lateral profile photographs cut in a circular shape, obtained from 27 orthodontic patients, 10-14 years old. Findings among four investigators showed a high correlation (r = 0.82-0.96), in orientating these profile photographs in estimated natural head position (NHP). Moreover, investigators showed good correlation (r = 0.57-0.84) in head orientation after a 3-week interval. Mean differences for the same period varied between 0.1 and 2.9 degrees. The validity of NHO was supported also by a panel investigation. Clinicians as well as auxiliary personnel can be trained to make a critical judgement of the recorded natural head position and correct head orientation, whenever indicated, to enhance the reliability of cephalometric analysis in clinical practice and research.

The gene for diffuse palmoplantar keratoderma of the type found in northern Sweden is localized to chromosome 12q11-q13

Hereditary palmoplantar keratoderma is characterized by hyperkeratosis of the skin of palms and soles. An autosomal dominant form of diffuse non-epidermolytic palmoplantar keratoderma, frequently complicated by fungal infections, is encountered in northern Sweden with a prevalence of 0.3-0.55%. We have examined two families with this type of palmoplantar keratoderma and localized the causative genetic defect to a 14 cM interval on chromosome 12q11-q13, a region known to contain the keratin type II gene cluster as well as the retinoic acid receptor gamma gene. The palmoplantar keratoderma variant investigated in this study is thus genetically different from epidermolytic palmoplantar keratoderma, which recently has been shown to result from mutations in the gene for the type I keratin 9.

Evidence for a role of corneodesmosin, a protein which may serve to modify desmosomes during cornification, in stratum corneum cell cohesion and desquamation

Corneodesmosin, defined as the protein recognized by the monoclonal antibody G36-19, is a recently described late differentiation protein of human cornified epithelium. In the stratum corneum it is localized in the extracellular parts of modified desmosomes (corneodesmosomes) and adjacent parts of the cornified cell envelope. The aim of the present study was to investigate whether corneodesmosin undergoes changes in the stratum corneum which can be related to the cohesive state of the tissue and to desquamation. Extracts of plantar stratum corneum from various tissue levels and tape-stripped non-palmoplantar stratum corneum were analysed by immunoblotting with G36-19. In addition, the fate of corneodesmosin during shedding of surface cells in a recently described in vitro model of desquamation in plantar stratum corneum was investigated and compared with the degradation of the desmosomal protein desmoglein I in this system. The apparent molecular weights of the major G36-19-positive components in plantar stratum corneum ranged between 33 and 48 kDa. The components with the highest molecular weights were predominant in the deepest tissue layers. In the intermediate tissue layers G36-19-positive components of molecular weight 33-36, 39 and 44-48 kDa were found. There seemed to be a further degradation of the 33 to 36-kDa components in the most superficial parts of the tissue. In surface cells dissociated in vivo as well as in vitro no G36-19-positive components with molecular weights above 36 kDa were detected. Results from analyses of nonpalmoplantar stratum corneum suggested that corneodesmosin is degraded in this tissue in a way that may be similar to that in plantar stratum corneum.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative evaluation of the soft tissue profile in the planning of orthognathic surgery

The clinical application of a proportional soft tissue profile analysis based on natural head position is presented. The analysis provides data concerning the morphological basis of facial disharmony in individual cases. The use of this information during treatment planning and evaluation of treatment results after orthognathic surgery is demonstrated in four patients with severe deviation from midnormal profiles.

Natural head position as a basis for cephalometric analysis

In a sample of orthodontic patients (27 boys and 25 girls, 10 to 14 years old), natural head position (NHP) was photographically recorded. A vertical axis was recorded on the photographs with a plumb line and transferred to the lateral head radiographs of the patients. Three cephalometric reference lines (sella-nasion, basion-nasion, and porion-orbitale) were compared with regard to their inclination to the horizontal plane. These angles showed standard deviations of between 4.5 degrees and 5.6 degrees. Reproducibility of NHP, assessed as the error of a single observation, was close to 2 degrees. These findings, in combination with the fact that the NHP represents a realistic appearance of patients, support its use as a basis for cephalometric analysis of dentofacial anomalies. A strong correlation was found between the inclinations of the three cephalometric reference lines to the horizontal plane. The close anatomic relationship between these lines, in combination with the small random movements of the head around NHP, were believed to explain the covariation.

A chymotrypsin-like proteinase that may be involved in desquamation in plantar stratum corneum

We have recently reported that unipolar cell shedding from plantar stratum corneum incubated in vitro, and the associated degradation of the desmosomal protein desmoglein I, are dependent on the activity of a proteinase that can be inhibited by aprotinin, chymostatin and zinc ion. The aim of this work was to find a proteinase in plantar stratum corneum that fulfils the criteria for being the responsible enzyme. Dissociated plantar corneocytes were incubated with the chymotrypsin substrate 3-carbomethoxypropionyl-L-Arg-L-Pro-L-Tyr-p-nitroanilide hydrochloride (S-2586) and H-D-Ile-Pro-Arg-p-nitroanilide dihydrochloride (S-2288), a substrate for a wide range of serine proteinases with arginine specificity. There was a significant rate of hydrolysis of S-2586, but S-2288 was hydrolysed only very slowly. Extraction of dissociated corneocytes with buffers containing KCl or sodium dodecyl sulphate released one major proteinase that could be detected by electrophoresis in polyacrylamide gels with copolymerized casein and subsequent incubations of the gels. Both the caseinolytic activity and the S-2586-hydrolysing activities were inhibited by aprotinin, chymostatin and zinc ion, but not by leupeptin. The S-2586-hydrolysing activity was also inhibited by soybean trypsin inhibitor and phenylmethylsulphonyl fluoride. Both activities were optimal at pH 7-8 but were also significant at pH 5.5. On gel exclusion chromatography, the S-2586-hydrolysing and caseinolytic activities were eluted with an apparent molecular weight of around 18 kDa. When analyzed by electrophoresis in the presence of sodium dodecyl sulphate under non-reducing conditions the caseinolytic enzyme had an apparent molecular weight of around 25 kDa.(ABSTRACT TRUNCATED AT 250 WORDS)

Proportional analysis of the facial profile in natural head position in Caucasian and Chinese children

A proportional analysis of the facial soft tissue profile in natural head position involving 11 indices (ratios), was applied to 80 Caucasian, and 80 Chinese male and female 12-year-old children in Hong Kong. The analysis is based on the true horizontal and the porion vertical, and has the advantage that its foundation lies on a more stable (less growth affected) region of the head compared to profile soft tissue landmarks. Measurements were made on cephalograms recorded in natural head position. Male subjects were larger than the females for most of the horizontal measurements, but for both population samples the vertical measurements displayed virtually no significant intersex differences at 12 years. No very significant intersex differences were found for the proportional indices. Ethnic differences were mainly found with the horizontal measurements. Relative to the porion vertical the Caucasian children were more protrusive over soft tissue nasion, nose tip, and sulcus labialis superior, whilst the Chinese displayed more protrusion over the lower lip and sulcus labialis inferior. Ethnic proportional differences relative to nasion were combined with a shorter porion-nasion distance in the Chinese as compared with the Caucasian children. The sella-nasion line was found to be more forwards-upwards inclined in Chinese than Caucasian children. It was concluded that a proportional soft tissue profile analysis, based on natural head position, is a useful method for the comparison of ethnic population groups. This study amplified ethnic differences previously reported by Cooke (1986) and Cooke and Wei (1989).

A comparison between estimated and registered natural head posture

Using tracings of facial profiles, four observers made two independent, subjective estimations of natural head posture (NHP) in 28 adults. The results of these estimations were compared with recordings of NHP obtained through photographic registration of the same subjects. Only minor average differences (between 0 and 1.4 degrees) were found between the two methods. The differences between estimated and registered head posture found at the first and second observation, were positively correlated for both intra- and inter-observer registrations (r = 0.59-0.80 and r = 0.50-0.71, respectively). The inclination of the basion-nasion line was measured; first, in relation to the photographically registered horizontal line and, secondly, in relation to the horizontal line derived from the estimation of NHP. Both methods of measurement gave similar mean values and standard deviations. A panel comprising 18 persons was asked to compare the head orientations of two subjects in whom a marked difference between estimated and registered NHP had been recorded. In the majority of these comparisons, the profiles orientated according to the subjective estimation were judged to have a more 'natural posture' than those orientated by the photographic method. This unexpected finding is discussed.

The dependence of detergent-induced cell dissociation in non-palmo-plantar stratum corneum on endogenous proteolysis

We have recently shown that cell cohesion in plantar stratum corneum is mediated to a significant extent by protein structures, and that endogenous proteolysis plays an important role in desquamation in this tissue. This paper is a report of our investigations into whether similar mechanisms for cell cohesion and desquamation can be found in non-palmo-plantar stratum corneum. Biopsies of non-palmo-plantar human skin were incubated at 37 degrees C, pH 8, in a buffer with and without additions of detergents (a mixture of N,N-dimethyldodecylamine oxide and sodium dodecyl sulphate), ethylene diamine tetraacetate (EDTA), and the proteinase inhibitor aprotinin. Released cells were examined by phase contrast microscopy and counted. The incubated biopsies were examined by light microscopy. As has been previously shown by others, we found that in the presence of detergents there was a dissociation of stratum corneum cells. This dissociation was stimulated by EDTA and inhibited by aprotinin. After 36 h of incubation the entire stratum corneum and, on some parts of the biopsies, the stratum granulosum had dissociated. There was no evidence of cell dissociation in the spinous or basal epidermal layers. We conclude that the detergent-induced cell dissociation in non-palmo-plantar human stratum corneum is dependent on the action of proteinases present in the tissue on protein structures. These structures may be of significant importance for non-palmo-plantar stratum corneum cell cohesion.

Cell shedding from human plantar skin in vitro: evidence that two different types of protein structures are degraded by a chymotrypsin-like enzyme

A recently described endogenous proteolytic process in pieces of human plantar stratum corneum incubated in vitro has been further studied. This process leads to a decrease in cohesion between the cells that had been facing outwards in vivo. Using two methods, that differed with respect to efficiency, to detach surface cells with decreased cohesion, the process could be divided into two steps. The first step took place irrespective of the presence of ethylenediaminetetraacetate (EDTA) and led to a moderate decrease in cohesion between surface cells. The second step occurred only in the presence of EDTA and advanced to a point where the surface cells could be separated from the remaining cohesive tissue pieces by simple agitation. Both degradation steps could be inhibited by aprotinin and chymostatin but not by leupeptin. Zinc sulfate inhibited the first step. The results indicate that there are two different types of protein structures being degraded during the process of cell shedding in vitro. A chymotrypsin-like enzyme may be involved in the process.

Evidence that cell shedding from plantar stratum corneum in vitro involves endogenous proteolysis of the desmosomal protein desmoglein I

We have recently described a process leading to a unipolar cell shedding from pieces of plantar stratum corneum incubated in vitro, which seems to be dependent on the activity of a serine proteinase. This process has been studied further. Electron microscopy studies suggest that cell dissociation is preceded by a degradation of the intercellular parts of desmosomes. An antiserum was raised against the transmembrane protein desmoglein I (DG I) of bovine desmosomes. In extracts of layers of plantar stratum corneum with strong intercellular cohesion, this antiserum reacted with a protein of the same apparent molecular weight as bovine DG I. In dissociated cells this DG I-like protein could not be detected; instead components with molecular weights lower than DG I which reacted with the antiserum were found. During incubation of pieces of plantar stratum corneum, under conditions leading to unipolar cell shedding, there was a progressive decrease in the amounts of the DG I-like protein, and the appearance of the lower molecular weight components with DG I-like immunoreactivity. This apparent degradation of the DG I-like protein was inhibited by aprotinin, chymostatin, and zinc ion, but not by leupeptin. The results suggest that proteolytic degradation of desmosomes may be an important part of the process leading to cell dissociation in plantar stratum corneum in vitro, and that desmosomes may play an important role in plantar stratum corneum cell cohesion.

Gingival blood flow and temperature changes in young humans with a history of periodontitis

Whether such individuals have different gingival blood flow and temperature responses to local cooling than age- and sex-matched healthy controls was tested. Ten patients with a history of localized juvenile periodontitis or rapidly progressive periodontitis were selected from a periodontal clinic and matched with healthy controls. Gingival blood flow and temperature were monitored continuously before and after cooling via a twin probe placed in the gingival sulcus on the buccal of tooth No. 26. Blood flow was assessed by laser Doppler flowmetry and temperature by a small metal thermistor. Resting values were first recorded for 5 min, followed by 3 min of cooling to 19 degrees C by a gentle stream of cool air, then 12 min of rewarming was allowed. This protocol was repeated twice. Blood flow changes were analysed as the slope of the line formed between the last 2 min of cooling and the last 2 min of rewarming; temperature curves were analysed by a least-squares curve fit of a bi-exponential function. Patients with localized juvenile periodontitis and rapidly progressive periodontitis had similar rewarming temperature curves, but significantly faster blood flow recovery curves than controls (p less than 0.03). Thus, gingival blood flow in young periodontitis patients recovered more rapidly after local cooling than in healthy controls.

Clinical evaluation of maxillary and mandibular prognathism

This study focuses on the importance of using natural head posture as a basis for cephalometric analysis. It describes a simple method for transferring a vertical plumbline from a lateral head photograph to a profile radiograph. The method is shown to have a relatively small technical error. Means and standard deviations for the angles HOR/N-A and HOR/N-B between the horizontal line (HOR) on one side and the nasion-subspinale (A-point) and nasion-supramentale (B-point) lines on the other, in random individuals, are presented as standards from which individual cases can be evaluated.

Panel assessments of the facial frontal view as related to mandibular growth direction

This paper describes study No. 6 in a series dealing with mandibular growth direction (Lundström and Woodside, 1980). Study No. 5. (Lundström, Woodside and Popovich 1987) investigated facial harmony and disharmony of the facial profile. The present paper describes a study of the frontal views of the same children as paper No. 5. A mixed panel of 17 individuals (four categories of three, four and six people in each) made an aesthetic evaluation of the frontal facial view of 64 subjects (32 of each sex) from the Burlington serial experimental group. The sample consisted of equal numbers of individuals who displayed vertical, average or horizontal mandibular growth between the ages 6-20 years. We calculated correlations between the four assessor groups and found these to be acceptable. On average the panel found no change in frontal appearance between 12 and 18 years because of the balance between individuals improving and deteriorating. Our earlier work showed systematic differences in profile view between those with vertical growth on the one hand and average o horizontal on the other. The vertical cases were more disharmonious than the other categories. Corresponding findings were made also in the frontal view. Mean overall evaluations by all assessors showed a positive correlation between profile and front view assessments.

Cell shedding from human plantar skin in vitro: evidence of its dependence on endogenous proteolysis

Cell shedding from plantar stratum corneum was studied in vitro. Cells were shed only from the surface that had faced outwards in vivo. A quantitative measure of the cell release was obtained by determining the amount of protein that could be extracted from released and sedimented cells with 1 M sodium hydroxide. The cell release was optimal at pH 7-9 but was significant also at pH 6. The rate of cell release increased with increasing temperature, but was decreased abruptly at temperatures above 50 degrees C. The cell dissociation could be inhibited by aprotinin (Trasylol) and soybean trypsin inhibitor. Thus, it is evident that the unipolar cell dissociation in this system is mediated by an enzymatically catalyzed process, most likely with the involvement of a serine protease with an alkaline pH-optimum. The in vitro cell release shows properties indicating that it may be mediated by mechanisms also active in vivo.

Mandibular growth direction following adenoidectomy

The purpose of this article is to test the hypothesis that the establishment of nasal respiration in children with severe nasopharyngeal obstruction can be eliminated as a factor in determining mandibular growth direction. The article describes the changes in mandibular growth direction (MGD) in a 5-year period after adenoidectomies and the establishment of nasal breathing in a population of Swedish children. Measurements of mandibular growth directions were obtained from serial cephalometric radiographs after adenoidectomies in 38 Swedish children aged 7 to 12 years with previous nasopharyngeal obstructions. These were compared with the growth directions in a control sample of 37 Swedish children with clear airways and matched for age and sex. The adenoidectomy sample initially showed significantly longer lower face heights, steeper mandibular plane angles, and more retrognathic mandibles than the matched controls. Analysis showed that during the 5 years after adenoidectomies, the girls had a more horizontal MGD (P less than 0.02) than did the female controls. A corresponding but not significant trend was found for the boys. The individual growth directions that were obtained following adenoidectomies were more variable than those found in the controls.