Diuretic Strategies in Acute Decompensated Heart Failure: A Narrative Review

Background

Heart failure is a common condition with considerable associated costs, morbidity, and mortality. Patients often present to hospital with dyspnea and edema. Inadequate inpatient decongestion is an important contributor to high readmission rates. There is little evidence concerning diuresis to guide clinicians in caring for patients with acute decompensated heart failure. Contemporary diuretic strategies have been defined by expert opinion and older landmark clinical trials.

Objective

To present a narrative review of contemporary recommendations, along with their underlying evidence and pharmacologic rationale, for diuretic strategies in inpatients with acute decompensated heart failure.

Data Sources

PubMed, OVID, and Embase databases were searched from inception to December 22, 2022, with the following search terms: heart failure, acute heart failure, decompensated heart failure, furosemide, bumetanide, ethacrynic acid, hydrochlorothiazide, indapamide, metolazone, chlorthalidone, spironolactone, eplerenone, and acetazolamide.

Study Selection

Randomized controlled trials and systematic reviews involving at least 100 adult patients (> 18 years) were included. Trials involving torsemide, chlorothiazide, and tolvaptan were excluded.

Data Synthesis

Early, aggressive administration of a loop diuretic has been associated with expedited symptom resolution, shorter length of stay, and possibly reduced mortality. Guidelines make recommendations about dose and frequency but do not recommend any particular loop diuretic over another; however, furosemide is most commonly used. Guidelines recommend that the initial furosemide dose (on admission) be 2-2.5 times the patient's home dose. A satisfactory diuretic response can be defined as spot urine sodium content greater than 50-70 mmol/L at 2 hours; urine output greater than 100-150 mL/h in the first 6 hours or 3-5 L in 24 hours; or a change in weight of 0.5-1.5 kg in 24 hours. If congestion persists after the maximization of loop diuretic therapy over the first 24-48 hours, an adjunctive diuretic such as thiazide or acetazolamide should be added. If decongestion targets are not met, continuous infusion of furosemide may be considered.

Conclusions

Heart failure with congestion can be managed with careful administration of high-dose loop diuretics, supported by thiazides and acetazolamide when necessary. Clinical trials are underway to further evaluate this strategy.

Global health context for the military in Defence Engagement (Health)

Global health practice is becoming a key enabler within UK Defence and foreign policy. The definition of global health remains debated, though some important themes have been identified including: the multidisciplinary nature of global health, its ethical foundation and the political nature of global health. This paper contributes to the ongoing rational discourse that this important discipline deserves and recommends a framework and principles to apply to military health and care system strengthening in the Defence Engagement (Health) (DE(H)) practitioner role. DE(H) involves complex multiorganisational relationships and processes, and while practitioners should be mindful of the political nature of their role, the broad aims of preventing conflict and building stability mean DE(H) should contribute positively to global health.This paper forms part of a special issue of BMJ Military Health dedicated to Defence Engagement.

Rebleeding in Variceal and Nonvariceal Gastrointestinal Bleeds in Cirrhotic Patients Using Vitamin K1: The LIVER-K Study

ABSTRACTBackground: Gastroesophageal varices are the most common cause of upper gastrointestinal bleeding (UGIB) in patients with cirrhosis. Vitamin K1 is commonly administered to patients presenting with UGIB andelevated international normalized ratio, despite limited evidence to support this practice.Objectives: The primary objective was to describe the incidence of rebleeding within 30 days after vitamin K1 administration in patients with cirrhosis and UGIB. The secondary objective was to describe prescribing patterns for vitamin K1.Methods: This retrospective, descriptive multicentre study involved patients with cirrhosis and UGIB who were admitted to any of the 4 adult acute care hospitals in Calgary, Alberta, from January 1, 2014, to December 31, 2016. Patients were divided into 2 groups: those who received vitamin K1 and those who did not.Results: A total of 370 patients met the inclusion criteria, of whom 243 received vitamin K1 and 127 did not. Baseline characteristics were similar between the groups. Greater proportions of patients in the vitamin K1 group received transfusions of packed red blood cells, fresh frozen plasma, platelets, cryoprecipitate, or prothrombin concentrate during their admissions. There was no significant difference in the duration of octreotide and pantoprazole infusions. Among patients in the vitamin K1 group, there were more admissions to the intensive care unit and longerlengths of stay. More patients in the no vitamin K1 group had esophageal varices evident on endoscopy that required endoscopic treatment. Forty of the patients (16.5%) in the vitamin K1 group and 7 (5.5%) in the novitamin K1 group had rebleeding within 30 days of the initial bleed. The median total vitamin K1 dose administered was 25 mg.Conclusions: The study results suggest that vitamin K1 does not reduce the incidence of rebleeding within 30 days of the initial bleed in patients with cirrhosis and UGIB.RÉSUMÉContexte : Les varices oesophagiennes sont la cause la plus fréquente de l’hémorragie gastro-intestinale supérieure (HGIS) parmi les patients atteints de cirrhose. On administre communément de la vitamine K1 aux patientsprésentant une HGIS et dont la mesure du rapport international normalize (RIN) est élevée, malgré le manque de preuves soutenant cette pratique.Objectifs : L’objectif principal consistait à décrire la fréquence de la reprise du saignement dans les 30 jours après l’administration de la vitamine K1 à des patients atteints de cirrhose et de HGIS. L’objectif secondaire consistait à décrire les schémas de prescription de la vitamine K1.Méthode : Cette étude multicentrique, descriptive et rétrospective comprenait des patients atteints de cirrhose et de HGIS, ayant été admis à n’importe lesquels des quatre hôpitaux de soins actifs pour adultes de Calgary, Alberta, du 1er janvier 2014 au 31 décembre 2016. Les patients étaient répartis en deux groupes : ceux ayant reçu de la vitamin K1 et ceux n’en ayant pas reçu.Résultats : Le nombre total de 370 patients correspondait aux critères d’inclusion. Parmi ceux-ci, 243 avaient reçu de la vitamine K1 et 127 n’en n’avaient pas reçu. Les caractéristiques de base étaient similaires entre lesgroupes. Un plus grand nombre de patients du groupe « Vitamine K1 » avaient reçu une transfusion d’un concentré de globules rouges, de plasma frais congelé, de plaquettes, de cryoprécipité ou de concentré de prothrombine au cours de leur séjour hospitalier. On n’a noté aucune différence significative dans la durée des injections de pantoprazole et d’octréotide. Le nombre d’admissions de patients du groupe « Vitamine K1 » à l’unité de soins intensifs était plus élevé et le séjour de ceux-ci était plus long. L’endoscopie a montré qu’un plus grand nombre de patients du groupe « Sans vitamine K1 » présentaient des varices oesophagiennes nécessitant un traitement endoscopique. Dans les 30 jours après le saignement initial, quarante (16,5 %) patients du groupe « Vitamine K1 » et 7 (5,5 %) du groupe « Sans vitamine K1 » ont subi une nouvelle hémorragie. La dose moyenne totale de vitamine K1 administrée était de 25 mg.Conclusions : Les résultats de l’étude tendent à démontrer que la vitamin K1 ne réduit pas la fréquence de la reprise du saignement dans les 30 jours qui suivent le saignement initial parmi les patients atteints de cirrhose et de HGIS.

Rebleeding in Variceal and Nonvariceal Gastrointestinal Bleeds in Cirrhotic Patients Using Vitamin K1: The LIVER-K Study

BACKGROUND

Gastroesophageal varices are the most common cause of upper gastrointestinal bleeding (UGIB) in patients with cirrhosis. Vitamin K₁ is commonly administered to patients presenting with UGIB and elevated international normalized ratio, despite limited evidence to support this practice.

OBJECTIVES

The primary objective was to describe the incidence of rebleeding within 30 days after vitamin K₁ administration in patients with cirrhosis and UGIB. The secondary objective was to describe prescribing patterns for vitamin K₁.

METHODS

This retrospective, descriptive multicentre study involved patients with cirrhosis and UGIB who were admitted to any of the 4 adult acute care hospitals in Calgary, Alberta, from January 1, 2014, to December 31, 2016. Patients were divided into 2 groups: those who received vitamin K₁ and those who did not.

RESULTS

A total of 370 patients met the inclusion criteria, of whom 243 received vitamin K₁ and 127 did not. Baseline characteristics were similar between the groups. Greater proportions of patients in the vitamin K₁ group received transfusions of packed red blood cells, fresh frozen plasma, platelets, cryoprecipitate, or prothrombin concentrate during their admissions. There was no significant difference in the duration of octreotide and pantoprazole infusions. Among patients in the vitamin K₁ group, there were more admissions to the intensive care unit and longer lengths of stay. More patients in the no vitamin K₁ group had esophageal varices evident on endoscopy that required endoscopic treatment. Forty of the patients (16.5%) in the vitamin K₁ group and 7 (5.5%) in the no vitamin K₁ group had rebleeding within 30 days of the initial bleed. The median total vitamin K₁ dose administered was 25 mg.

CONCLUSIONS

The study results suggest that vitamin K₁ does not reduce the incidence of rebleeding within 30 days of the initial bleed in patients with cirrhosis and UGIB.

Primary blast lung injury simulator: a new computerised model

Mathematical modelling and computational simulation are becoming increasingly important tools in many fields of medicine where in vivo studies are expensive, difficult or impractical. This is particularly the case with primary blast lung injury, and in this paper, we give a brief overview of mathematical models before describing how we generated our blast lung injury simulator and describe some early results of its use.

Neuraxial analgesia is not associated with an increased risk of post-partum relapses in MS

Background:

Obstetrical analgesia remains a matter of controversy because of the fear of neurotoxicity of local anesthetics on demyelinated fibers or their potential relationship with subsequent relapses.

Objective:

To assess the impact of neuraxial analgesia on the risk of relapse during the first 3 months post-partum, with a focus on women who experienced relapses during pregnancy.

Methods:

We analyzed data of women followed-up prospectively during their pregnancies and at least 3 months post-partum, collected in the Pregnancy in Multiple Sclerosis (PRIMS) and Prevention of Post-Partum Relapses with Progestin and Estradiol in Multiple Sclerosis (POPARTMUS) studies between 1992–1995 and 2005–2012, respectively. The association of neuraxial analgesia with the occurrence of a post-partum relapse was estimated by logistic regression analysis.

Results:

A total of 389 women were included, 215 from PRIMS and 174 from POPARTMUS. In total, 156 women (40%) had neuraxial analgesia. Overall, 24% experienced a relapse during pregnancy and 25% in the 3 months post-partum. Women with a pregnancy relapse were more likely to have a post-partum relapse (odds ratio (OR) = 1.83, p = 0.02), independently of the use of neuraxial analgesia. There was no association between neuraxial analgesia and post-partum relapse (OR = 1.08, p = 0.78).

Conclusion:

Neuraxial analgesia was not associated with an increased risk of post-partum relapses, whatever multiple sclerosis (MS) activity during pregnancy.

Rivaroxaban for a Patient with Class III Obesity: Case Report with Literature Review

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Abstract P4-02-06: Intratumoral and peritumoral MRI signatures of HER2-enriched subtype also predict pathological response to neoadjuvant chemotherapy in HER2+ breast cancers

Background: Applying the PAM50 classifier to targeted RNA-Sequencing data allows HER2+ tumors to be sub-categorized into intrinsic breast cancer subtypes. HER2+ breast cancers belonging to the HER2-enriched [HER2-E] subtype exhibit the highest rate of response to neoadjuvant therapy with combination of HER2-blockade and chemotherapy, as well as dual-HER2 blockade alone. A non-invasive predictor of PAM50 subtype from clinical dynamic contrast-enhanced MRI [DCE-MRI] could provide valuable clinical guidance in the treatment of HER2+ breast cancer. In this work, we identify a set of computer-extracted heterogeneity features computed within the lesion and its surrounding peritumoral region capable of distinguishing HER2-E from other HER2+ breast cancers [Non-HER2-E]. We then demonstrate that this imaging signature of HER2-E is also predictive of pathological complete response [pCR] in an independent HER2+ testing set, consistent with the HER2-E subtype's elevated response to HER2-targeted therapy.

Methods: The training set consisted of 42 HER2+ patients with both 1.5 or 3 T DCE-MRI and targeted RNA sequencing collected prior to neoadjuvant treatment from a multicenter trial [BrUOG 211B, n=35] and The Cancer Genome Atlas-Breast Cancer project [TCGA-BRCA, n=7]. Intrinsic subtypes were assigned by unsupervised hierarchical clustering of the PAM50 gene set. 19 patients were determined to belong to the HER2-E subtype, while the remaining 23 represented non-HER2-E subtypes [19 HER2-Luminal, 4 HER2-basal]. Lesion boundaries were annotated by an expertly trained radiologist and expanded to 5 annular peritumoral regions in 3 mm increments out to a maximum radius of 15 mm. Computer-extracted heterogeneity features were computed voxelwise within intratumoral and peritumoral regions by first order statistics. A top HER2-E-associated feature from each region was identified by Wilcoxon feature selection and used to train a diagonal linear discriminant analysis [DLDA] classifier to predict HER2-E in a 3-fold cross-validation setting. This classifier was then applied to pCR prediction from DCE-MRI in a testing set of 28 HER2+ patients with available post neoadjuvant chemotherapy surgical specimens at one institution. 16 patients achieved pCR (ypT0/is), while the remainder had partial or no response (non-pCR).

Results: A combination of heterogeneity features within the intratumoral region and annular peritumoral regions out to 12 mm from the tumor yielded optimal results within the training set, with an average HER2-E prediction AUC of .77 +/- .03. When applied to response prediction in an independent testing set, this HER2-E classifier was predictive of pCR (AUC = .72).

Conclusions: Computer-extracted heterogeneity features calculated within the tumor and the surrounding peritumoral environment on DCE-MRI were able to distinguish the HER2-E PAM50 intrinsic subtype from other HER2+ breast cancers. HER2-E was characterized by elevated expression of intratumoral and peritumoral heterogeneity features, indicating a more disordered imaging phenotype within and around the tumor. Additional independent validation of these findings is needed.

Citation Format: Braman N, Prasanna P, Singh S, Beig N, Gilmore H, Etesami M, Bates D, Gallagher K, Bloch BN, Somlo G, Sikov W, Harris L, Plecha D, Varadan V, Madabhushi A. Intratumoral and peritumoral MRI signatures of HER2-enriched subtype also predict pathological response to neoadjuvant chemotherapy in HER2+ breast cancers [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-02-06.

What Affects Clinicians' Usage of Health Information Exchange?

BACKGROUND: The ability to electronically exchange health information among healthcare providers holds enormous promise to improve care coordination and reduce costs. Provider-to-provider data exchange is an explicit goal of the American Recovery and Reinvestment Act of 2009 and may be essential for the long-term success of the Affordable Care Act of 2010. However, little is known about what factors affect clinicians' usage of health information exchange (HIE) functionality. OBJECTIVE: To identify factors that affect clinicians' HIE usage - in terms of frequency of contributing data to and accessing data from aggregate patient records - and suggest policies for fostering its usage. METHODS: We performed a qualitative study using grounded theory by interviewing clinician-users and HIE staff of one operational HIE which supported aggregate patient record functionality. Fifteen clinicians were interviewed for one hour each about what factors affect their HIE usage. Five HIE staff were asked about technology and training issues to provide context. Interviews were recorded, transcribed and analyzed. Recruitment excluded clinicians with little or no familiarity with the HIE and was restricted to one community and a small number of specialties. RESULTS: Clinicians were motivated to access the HIE by perceived improvements in care quality and time savings, but their motivation was moderated by an extensive list of factors including gaps in data, workflow issues and usability issues. HIE access intensities varied widely by clinician. Data contribution intensities to the HIE also varied widely and were affected by billing concerns and time constraints. CONCLUSIONS: Clinicians, EHR and HIE product vendors and trainers should work toward integrating HIE into clinical workflows. Policies should create incentives for HIE organizations to assist clinicians in using HIE, develop measures of HIE contributions and accesses, and create incentives for clinicians to contribute data to HIEs.

PHArmacists' perspective oN the Take hOme naloxone prograM (The PHANTOM Study)

OBJECTIVE

To evaluate pharmacists' attitudes toward the Take Home Naloxone (THN) program and identify areas that could be improved to support pharmacists' involvement.

METHODS

Pharmacists on the Alberta College of Pharmacists' directory were invited to complete an online survey between July 10 and August 8, 2016. The survey consisted of 19 questions. Descriptive statistics were used to analyze the data.

RESULTS

Four hundred seventy pharmacists completed the survey (response rate = 11.2%). A total of 76.8% of respondents strongly agreed or agreed that pharmacists should be screening patients to identify those at risk of opioid overdose. Full-time pharmacists were more likely to agree (p = 0.02). A total of 79.8% of respondents strongly agreed or agreed that pharmacists should be recommending THN kits. Pharmacists working in large population centres (p = 0.008) and full-time pharmacists (p = 0.02) were more likely to agree with this statement. Furthermore, 60.6% of pharmacists were extremely willing or very willing to participate in the THN program. Pharmacists in practice for ≤15 years were more willing to participate in the THN program than pharmacists in practice >15 years (p = 0.03). The most common perceived barriers to implementation of the THN program were lack of time in pharmacists' current work environment and education about the program.

CONCLUSIONS

Overall, pharmacists had positive attitudes toward screening patients to identify those at risk of opioid overdose, recommending THN kits and willingness to participate in the program. Factors that may facilitate increased participation in the program include addressing time issues and improving education about the THN program.

Thiamine Prescribing Practices for Adult Patients Admitted to an Internal Medicine Service

BACKGROUND

Thiamine (vitamin B₁) is an essential cofactor responsible for the breakdown of glucose, and its deficiency is associated with Wernicke encephalopathy (WE). There is a lack of evidence from systematic studies on the optimal dosing of thiamine for WE. Objectives: The primary objective was to describe the prescribing patterns for IV thiamine in adult patients admitted to a large teaching hospital. The secondary objective was to evaluate the clinical resolution of WE symptoms (confusion, ataxia, and/or ocular motor abnormalities) in relation to the dose of IV thiamine prescribed.

METHODS

A retrospective design was used to review data for adult patients admitted to an internal medicine service from June 1, 2014, to June 30, 2015. All patients included in the study received IV thiamine: low-dose therapy was defined as 100 mg IV daily and high-dose therapy was defined as dosage greater than 100 mg IV daily.

RESULTS

A total of 141 patients were included; low-dose thiamine was prescribed for 115 (81.6%) and high-dose thiamine for 26 (18.4%). Patients for whom high-dose thiamine was prescribed were more likely to be those in whom a diagnosis of WE was being considered (12/26 [46.2%] versus 5/115 [4.3%], p < 0.001). Of the total 219 IV thiamine doses ordered, 180 (82.2%) were for 100 mg, and 143 (65.3%) were prescribed for once-daily administration. There was no statistically significant difference in the time to resolution of WE symptoms for patients receiving high-dose versus low-dose thiamine.

CONCLUSIONS

A wide variety of thiamine prescribing patterns were noted. This study did not show a difference in time to resolution of WE symptoms in relation to the dose of IV thiamine. Additional large-scale studies are required to determine the optimal dosing of thiamine for WE.

Supravenous Hyperpigmentation in an HIV-Infected Patient

A 47-year-old African American man was seen for routine follow-up for his human immunodeficiency virus (HIV). The patient's medical history included insomnia, gastroesophageal reflux disease, pulmonary embolism, right shoulder musculoskeletal pain, latent tuberculosis infection, sickle cell trait (hemoglobin S variant), and HIV of 24 years' duration.

Interaction between Warfarin and Apple Juice

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Thiamine prescribing practices within university-affiliated hospitals: a multicenter retrospective review

BACKGROUND

Patients with suspected thiamine deficiency should receive treatment with parenteral thiamine to achieve the high serum thiamine levels necessary to reverse the effects of deficiency and to circumvent problems with absorption common in the medically ill.

OBJECTIVE

To quantify rates of parenteral administration of thiamine across university-affiliated hospitals and to identify factors associated with higher rates of parenteral prescribing.

DESIGN

Multicenter, retrospective observational study of thiamine prescriptions.

METHODS

Prescriptions for thiamine were captured from computerized pharmacy information systems across participating centers, providing information concerning dose, route, frequency, and duration of thiamine prescribed from January 2010 to December 2011.

SETTING

Fourteen university-affiliated tertiary care hospitals geographically distributed across Canada, including 48,806 prescriptions for thiamine provided to 32,213 hospitalized patients.

RESULTS

Parenteral thiamine accounted for a statistically significant majority of thiamine prescriptions (57.6%, P < 0.001); however, oral thiamine constituted a significant majority of the total doses prescribed (68.4%, z = 168.9; P < 0.001). Protocols prioritizing parenteral administration were associated with higher rates of parenteral prescribing (61.3% with protocol, 45.8% without protocol; P < 0.001). Patients admitted under psychiatry services were significantly more likely to be prescribed oral thiamine (P < 0.001).

CONCLUSIONS

Although parenteral thiamine accounted for a statistically significant majority of prescriptions, oral thiamine was commonly prescribed within academic hospitals. Additional strategies are needed to promote parenteral thiamine prescribing to patients with suspected thiamine deficiency.

A guide to facilitate the early treatment of patients with idiopathic demyelinating disease (multiple sclerosis and neuromyelitis optica)

Definite diagnosis of inflammatory demyelinating disease (multiple sclerosis (MS) and neuromyelitis optica (NMO)) may require time, but early treatment offers the opportunity to maximize patient outcomes. The purpose of this report is to provide guidance to facilitate early treatment decisions for patients with inflammatory demyelinating disease, before definitive diagnosis. Neurology experts reviewed the existing literature and clinical evidence. A treatment decision pathway was developed, defining patients for whom first-line MS disease-modifying therapies (a) are unlikely to be effective, (b) may be effective but require careful monitoring and (c) are likely to provide benefit. This algorithm seeks to ensure that patients, particularly those in Asia, receive appropriate treatment early in inflammatory demyelinating disease.

Predicting dysglycaemia in patients under investigation for acute coronary syndrome

AIMS

To examine methods for the identification of previously undetected dysglycaemia [diabetes and impaired glucose tolerance (IGT)] in patients investigated for possible acute coronary syndrome. Specifically, we wished to examine whether the recently advocated use of glycosylated haemoglobin (HbA1c) would enhance detection rates for diabetes in these patients.

METHODS

Patients (n = 200) investigated for possible acute coronary syndrome and not previously known to have diabetes were recruited and anthropometric data collected. Random plasma glucose concentrations followed by oral glucose tolerance tests, HbA1c, fasting lipids, high sensitivity C-reactive protein and homeostatic modular assessment-insulin resistance were obtained during admission. Following discharge, the fasting plasma glucose (FPG) was repeated to determine the importance of sequential fasting levels. The accuracy of individual tests, combinations and sequential testing was assessed using receiver operating characteristic curves. A predictive index (PI) was generated using stepwise logistic regression models.

RESULTS

The prevalence of diabetes and IGT were 21 and 32%, respectively. FPG >6.0 mmol/l and HbA1c ≥ 6.0% had specificities of 94.9% and 93.6% but sensitivities of only 31.7 and 39.0%, respectively. Combination and sequential testing provided little additional benefit. Use of a PI comprising FPG, HbA1c and age provided the best overall performance (75.6% sensitivity, 77.1% specificity, negative predictive value 92.4%).

CONCLUSION

Our data confirm the high prevalence of dysglycaemia in this cohort. The commonly advocated screening tools have significant limitations if used in isolation, combination or sequentially. Our approach using a PI offers improved performance partly as it uses continuous data rather than arbitrary cut-off values.

Angiogenic biomarkers and healing of living cellular constructs

The use of intra-oral soft-tissue-engineered devices has demonstrated potential for oral mucosa regeneration. The aim of this study was to investigate the temporal expression of angiogenic biomarkers during wound healing of soft tissue reconstructive procedures comparing living cellular constructs (LCC) with autogenous free gingival grafts. Forty-four human participants bilaterally lacking sufficient zones of attached keratinized gingiva were randomly assigned to soft tissue surgery plus either LCC or autograft. Wound fluid samples were collected at baseline and weeks 1, 2, 3, and 4 post-operatively and analyzed for a panel of angiogenic biomarkers: angiogenin (ANG), angiostatin (ANT), PDGF-BB, VEGF, FGF-2, IL-8, TIMP-1, TIMP-2, GM-CSF, and IP-10. Results demonstrated a significant increase in expression of ANT, PDGF-BB, VEGF, FGF-2, and IL-8 for the LCC group over the autograft group at the early stages of wound repair. Although angiogenic biomarkers were modestly elevated for the LCC group, no clinical correlation with wound healing was found. This human investigation demonstrates that, during early wound-healing events, expression of angiogenic-related biomarkers is up-regulated in sites treated with LCC compared with autogenous free gingival grafts, which may provide a safe and effective alternative for regenerating intra-oral soft tissues (ClinicalTrials.gov number, NCT01134081).