Potency of a small molecule that targets the molluscum contagiosum virus processivity factor increases when conjugated to a tripeptide

We recently developed compound FC-7269 for targeting the Molluscum contagiosum virus processivity factor (mD4) and demonstrated its ability to inhibit viral processive DNA synthesis in vitro and cellular infection of an mD4-dependent virus (Antiviral Res 211, 2023,105520). However, despite a thorough medicinal chemistry campaign we were unable to generate a potent second analog as a requisite for drug development. We overcame this impasse, by conjugating a short hydrophobic trivaline peptide to FC-7269 to produce FC-TriVal-7269 which significantly increased antiviral potency and reduced cellular toxicity.

A small molecule that targets the processivity factor of molluscum contagiosum virus has therapeutic potential

Molluscum contagiosum (MC) is an infectious disease that occurs only in humans with a tropism that is narrowly restricted to the outermost epidermal layer of the skin. Molluscum contagiosum virus (MCV) is the causative agent of MC which produces skin lesions that can persist for months to several years. MCV is efficiently transmitted by direct physical contact or by indirect contact with fomites. MC is most prevalent in children and immune compromised patients. The failure to develop a drug that targets MCV replication has been hampered for decades by the inability to propagate MCV in cell culture. To address this dilemma, we recently engineered a surrogate poxvirus expressing the MCV processivity factor (mD4) as the drug target. The mD4 protein is essential for viral replication by keeping the viral polymerase tethered to the DNA template. In this study we have designed and synthesized a lead compound (7269) that is able to prevent mD4 dependent processive DNA synthesis in vitro (IC50 = 6.8 μM) and effectively inhibit propagation of the mD4-VV surrogate virus in BSC-1 cells (EC50 = 13.2 μM) with negligible cytotoxicity. In human liver microsomes, 7269 was shown to be stable for almost 2 h. When tested for penetration into human cadaver skin in a formulated gel, the level of 7269 in the epidermal layer was nearly 100 times the concentration (EC50) needed to inhibit propagation of the mD4-VV surrogate virus in BSC-1 cells. The gel formulated 7269 was scored as a non-irritant on skin and shown to have a shelf-life that was completely stable after several months. In summary, 7269 is a potential Lead for becoming the first MCV anti-viral compound to treat MC and thereby, addresses this unmet medical need that has persisted for many decades.

A novel technique using long segment patch angioplasty maturation to increase the maturation rate of arteriovenous fistulas

OBJECTIVE

Given the superior patency of arteriovenous fistulas (AVFs) and the decreased risk of infection compared with arteriovenous grafts, the Kidney Disease Outcomes Quality Initiative guidelines have recommended the fistula-first approach. However, ∼20% to 60% of all fistulas will fail to mature. We have described our experience with a novel technique using bovine pericardial patch angioplasty to increase the rate of AVF maturation.

METHODS

We used 2-cm × 9-cm-long or 2.5-cm × 15-cm-long segment pericardial patch angioplasty to assist in the maturation of AVFs. A single-center, retrospective cohort study was conducted of all patients who had undergone patch angioplasty maturation (PAM) for AVFs that had failed to mature. The outcomes of interest were maturation status and patency, censored by the death and last known follow-up dates.

RESULTS

From March 2007 to October 2019, 139 patients had undergone PAM. Follow-up data were available for 137 of the 139 patients (98.6%), with 126 AVFs (92.0%) progressing to maturation. Of the 126 patients with AVFs that had progressed to maturity, the previous hemodialysis (HD) method was known for 88 patients (69.8%). Of these 88 patients, 70 (79.5%) had previously been receiving HD via an HD catheter. Using a Kaplan-Meier estimator censored for death and loss to follow-up, the assisted primary patency rates at 1, 2, and 3 years were 87.3%, 78.1%, and 68.0%, respectively. Of the 137 patients, 69 (54.8%) had required no additional interventions after patch angioplasty. The complications requiring intervention were stenosis (n = 45; 32.8%), thrombosis (n = 10; 7.3%), infection (n = 3; 2.2%), steal syndrome (n = 3; 2.2%), noninfected wound complications (n = 1; 0.8%), and pseudoaneurysm (n = 1; 0.8%). The average interval to intervention after patch angioplasty was 4.56 months.

CONCLUSIONS

Long-segment bovine pericardial PAM can be performed safely to treat nonmaturing AVFs, with a 92.0% successful maturation rate and patency rates comparable to those for AVFs. PAM should be a consideration for patients with nonmaturing AVFs.

Herpes Simplex Virus-1 infection in human primary corneal epithelial cells is blocked by a stapled peptide that targets processive DNA synthesis

PURPOSE

Acyclovir is most commonly used for treating ocular Herpes Keratitis, a leading cause of infectious blindness. However, emerging resistance to Acyclovir resulting from mutations in the thymidine kinase gene of Herpes Simplex Virus -1 (HSV-1), has prompted the need for new therapeutics directed against a different viral protein. One novel target is the HSV-1 Processivity Factor which is essential for tethering HSV-1 Polymerase to the viral genome to enable long-chain DNA synthesis.

METHODS

A series of peptides, based on the crystal structure of the C-terminus of HSV-1 Polymerase, were constructed with hydrocarbon staples to retain their alpha-helical conformation. The stapled peptides were tested for blocking both HSV-1 DNA synthesis and infection. The most effective peptide was further optimized by replacing its negative N-terminus with two hydrophobic valine residues. This di-valine stapled peptide was tested for inhibiting HSV-1 infection of human primary corneal epithelial cells.

RESULTS

The stapled peptides blocked HSV-1 DNA synthesis and HSV-1 infection. The unstapled control peptide had no inhibitory effects. Specificity of the stapled peptides was confirmed by their inabilities to block infection by an unrelated virus. Significantly, the optimized di-valine stapled peptide effectively blocked HSV-1 infection in human primary corneal epithelial cells with selectivity index of 11.6.

CONCLUSIONS

Hydrocarbon stapled peptides that simulate the α-helix from the C-terminus of HSV-1 DNA polymerase can specifically block DNA synthesis and infection of HSV-1 in human primary corneal epithelial cells. These stapled peptides provide a foundation for developing a topical therapeutic for treating human ocular Herpes Keratitis.

Carotid-Axillary Bypass as an Alternative to Carotid-Subclavian Bypass Following Coverage of Left Subclavian Artery During TEVAR

INTRODUCTION

Thoracic Endovascular Aortic Repair (TEVAR) has become the procedure of choice for pathology involving the descending thoracic aorta since its approval by the FDA in 2005. Left subclavian artery (LSA) coverage is commonly required to facilitate an adequate proximal landing zone for the endograft. The traditional revascularization procedure of choice is carotid-subclavian bypass, however recent studies report complication rates as high as 29%-specifically phrenic nerve palsy in 25% of patients undergoing this procedure. Our aim is to present our experience using carotid-axillary bypass as a safe alternative to carotid-subclavian bypass.

METHODS

All patients undergoing carotid-axillary bypass for TEVAR with LSA coverage between June 2016 and September 2019 at a tertiary medical center were retrospectively identified. Short-term and long-term complications were identified and analyzed including: phrenic nerve, recurrent laryngeal nerve, and axillary nerve injuries, as well as local vascular complications requiring re-intervention. All perioperative chest radiographs were reviewed for new hemidiaphragm elevation to assess for phrenic nerve injuries.

RESULTS

35 patients underwent carotid-axillary bypass in conjunction with TEVAR during this time period. The majority of bypasses were performed concurrently with TEVAR (80.0%, 28/35) utilizing GORE PROPATEN 8 mm externally supported vascular graft (91.4%, 32/35). The complication rate specific to carotid-axillary bypass was 14.3% (5/35). We observed a significantly lower (0%, 0/35, P < 0.01) rate of phrenic nerve palsy for carotid-axillary bypass compared to the previously reported 25% (27/107) for carotid-subclavian bypass. For patients with available follow-up imaging (85.7%, 30/35), there was a 100% patency rate at time intervals ranging from 0-1066 days (IQR = 3-37.8).

CONCLUSION

Carotid-axillary bypass can be performed as a safe alternative to carotid-subclavian bypass for LSA coverage during TEVAR involving a more superficial anatomic course of dissection. Phrenic nerve palsy, a well-described complication of the traditional carotid-subclavian bypass, was not observed in this retrospective series.

Management of large bore access complications in the era of trans-catheter aortic valve replacement

OBJECTIVES

Trans-catheter aortic valve replacement is a commonplace procedure for patients with aortic valvular stenosis who are at a high risk for surgery, evidenced by the 34,892 trans-catheter aortic valve replacements performed in 2016. Trans-catheter aortic valve replacement's rate of major vascular complications with second-generation closure devices is 4.5% according to a meta-analysis of 10,822 patients. To manage those complications, percutaneous approaches to arterial repairs show shorter length of stay, higher rate of direct to home discharge and equivalent outcomes at long-term follow-up. This study's goal is to show that one center's vascular access strategy can decrease open repairs and improve patient outcomes.

METHODS

Our team began accessing the mid-common femoral artery at least 1-2 cm proximal to the takeoff of the profunda femoris. This allowed an endovascular stent to be deployed if necessary via contralateral femoral access. We performed a completion angiogram following every trans-catheter aortic valve replacement to ensure no arterial complications. We conducted a retrospective review of a prospectively maintained database for all trans-catheter aortic valve replacement cases at a tertiary care center from 1 January 2016 to 30 June 2018.

RESULTS

A total of 699 trans-catheter aortic valve replacement procedures were performed with 25/31 (80.6%) cases met inclusion criteria. An increase was noted in the number of stent procedures versus cutdown procedures over time (P < 0.001). A decrease was noted in the number of vascular surgery team activations following trans-catheter aortic valve replacement (P = 0.004). A non-significant trend was noted toward a shorter median length of stay for the stent group (P = 0.149). There was no increase in 30-day mortality rate (0.0% for both groups) or 30-day readmissions (4/15 (26.7%) for stents vs. 2/10 (20.0%) for open repairs; P > 0.999).

CONCLUSIONS

This strategy is safe and feasible to implement and reduces the number of open repairs following trans-catheter aortic valve replacement, activation of surgical resources, and possibly the length of stay.

Chest Tube Management Practices by Trauma Surgeons

BACKGROUND

Chest tube (CT) placement is among the most common procedures performed by trauma surgeons; evidence guiding CT management is limited and tends toward thoracic surgery patients. The study goal was to identify current CT management practices among trauma providers.

MATERIALS AND METHODS

We designed a Web-based multiple-choice survey to assess CT management practices of trauma providers who were active, senior, or provisional members (n = 1890) of the Eastern Association for the Surgery of Trauma and distributed via e-mail. Descriptive statistics were used.

RESULTS

The response rate was 39% (n = 734). Ninety-one percent of respondents were attending surgeons, the remainder fellows or residents. Regarding experience, 36% of respondents had five or fewer years of practice, 54% 10 y or fewer, and 79% 20 y or fewer. Attendings were more likely than trainees to place pigtail catheters for stable patients with pneumothorax (PTX). Attendings with experience of <5 y were more likely to choose a pigtail than more experienced surgeons for elderly patients with PTX. Respondents preferred standard size CTs for hemothorax and unstable patients with PTX, and larger tubes for unstable patients with hemothorax. Most respondents (53%) perceived the quality of evidence for trauma CT management to be low and cited personal experience and training as the main factors driving their practice.

CONCLUSIONS

Trauma CT management is variable and nonstandardized, depending mostly on clinician training and personal experience. Few surgeons identify their practice as evidence based. We offer compelling justification for the need for trauma CT management research to determine best practices.

Mutation and structure guided discovery of an antiviral small molecule that mimics an essential C-Terminal tripeptide of the vaccinia D4 processivity factor

The smallpox virus (variola) remains a bioterrorism threat since a majority of the human population has never been vaccinated. In the event of an outbreak, at least two drugs against different targets of variola are critical to circumvent potential viral mutants that acquire resistance. Vaccinia virus (VACV) is the model virus used in the laboratory for studying smallpox. The VACV processivity factor D4 is an ideal therapeutic target since it is both essential and specific for poxvirus replication. Recently, we identified a tripeptide (Gly-Phe-Ile) motif at the C-terminus of D4 that is conserved among poxviruses and is necessary for maintaining protein function. In the current work, a virtual screening for small molecule mimics of the tripeptide identified a thiophene lead that effectively inhibited VACV, cowpox virus, and rabbitpox virus in cell culture (EC₅₀ = 8.4-19.7 μM) and blocked in vitro processive DNA synthesis (IC₅₀ = 13.4 μM). Compound-binding to D4 was demonstrated through various biophysical methods and a dose-dependent retardation of the proteolysis of D4 proteins. This study highlights an inhibitor design strategy that exploits a susceptible region of the protein and identifies a novel scaffold for a broad-spectrum poxvirus inhibitor.

Design and synthesis of a series of bioavailable fatty acid synthase (FASN) KR domain inhibitors for cancer therapy

We designed and synthesized a new series of fatty acid synthase (FASN) inhibitors with potential utility for the treatment of cancer. Extensive SAR studies led to highly active FASN inhibitors with good cellular activity and oral bioavailability, exemplified by compound 34. Compound 34 is a potent inhibitor of human FASN (IC₅₀ = 28 nM) that effectively inhibits proliferation of A2780 ovarian cells (IC₅₀ = 13 nM) in lipid-reduced serum (LRS). This cellular activity can be rescued by addition of palmitate, consistent with an on-target effect. Compound 34 is also active in many other cell types, including PC3M (IC₅₀ = 25 nM) and LnCaP-Vancouver prostate cells (IC₅₀ = 66 nM), and is highly bioavailable (F 61%) with good exposure after oral administration. In a pharmacodynamics study in H460 lung xenograft-bearing mice, oral treatment with compound 34 results in elevated tumor levels of malonyl-CoA and decreased tumor levels of palmitate, fully consistent with the desired target engagement.

Novel, broad-spectrum anticonvulsants containing a sulfamide group: pharmacological properties of (S)-N-[(6-chloro-2,3-dihydrobenzo[1,4]dioxin-2-yl)methyl]sulfamide (JNJ-26489112)

Broad-spectrum anticonvulsants are of considerable interest as antiepileptic drugs, especially because of their potential for treating refractory patients. Such "neurostabilizers" have also been used to treat other neurological disorders, including migraine, bipolar disorder, and neuropathic pain. We synthesized a series of sulfamide derivatives (4-9, 10a-i, 11a, 11b, 12) and evaluated their anticonvulsant activity. Thus, we identified promising sulfamide 4 (JNJ-26489112) and explored its pharmacological properties. Compound 4 exhibited excellent anticonvulsant activity in rodents against audiogenic, electrically induced, and chemically induced seizures. Mechanistically, 4 inhibited voltage-gated Na(+) channels and N-type Ca(2+) channels and was effective as a K(+) channel opener. The anticonvulsant profile of 4 suggests that it may be useful for treating multiple forms of epilepsy (generalized tonic-clonic, complex partial, absence seizures), including refractory (or pharmacoresistant) epilepsy, at dose levels that confer a good safety margin. On the basis of its pharmacology and other favorable characteristics, 4 was advanced into human clinical studies.

The role of sulfamide derivatives in medicinal chemistry: a patent review (2006-2008)

BACKGROUND

The sulfamide (R(2)NSO(2)NR(2)) functionality is an acceptable functional group in medicinal chemistry when incorporated into putative small-molecule therapeutics, as it has the potential to form several electrostatic interactions with protein and other targets. The clinically-useful broad spectrum antibiotic doripenem contains a mono-substituted sulfamide. The sulfamide functional group is often found to substitute for sulfonamide, sulfamate or urea functionality.

OBJECTIVE/METHOD

During the period of 2006-2008, there were nine published patents in which all or most reported compounds contained the sulfamide functional group. There are also patents in which the structures disclosed contain a cyclic sulfamide functional group. Further, there are patents published during this timeframe that contain only a few sulfamide-containing examples, typically as a bioisosteric replacement for a sulfonamide moiety. In this review, we focus on those published patents in which most compounds disclosed are sulfamides and only briefly highlight examples in which sulfamides are included among a large list of other suitable functionalities.

CONCLUSION

While the sulfamide functionality is still fairly under-represented in medicinal chemistry, it is a valuable and versatile group that will gain increasing acceptance and favor in the future.

2-Amino-3,4-dihydroquinazolines as Inhibitors of BACE-1 (β-Site APP Cleaving Enzyme): Use of Structure Based Design to Convert a Micromolar Hit into a Nanomolar Lead

A new aspartic protease inhibitory chemotype bearing a 2-amino-3,4-dihydroquinazoline ring was identified by high-throughput screening for the inhibition of BACE-1. X-ray crystallography revealed that the exocyclic amino group participated in a hydrogen bonding array with the two catalytic aspartic acids of BACE-1 (Asp(32), Asp(228)). BACE-1 inhibitory potency was increased (0.9 microM to 11 nM K(i)) by substitution into the unoccupied S(1)' pocket.

Does being against euthanasia legislation equate to being anti-euthanasia?

This study investigated issues raised in qualitative data from our previous studies of health professionals and community members, which suggested that being opposed to euthanasia legislation did not necessarily equate to being anti-euthanasia per se. A postal survey of 1002 medical practitioners, 1000 nurses and 1200 community members was undertaken. In addition to a direct question on changing the law to allow active voluntary euthanasia (AVE), four statements assessed attitudes to euthanasia with or without a change in legislation. Responses were received from 405 doctors (43%), 429 nurses (45%) and 405 community members (38%). Compared with previous studies there was a slight increase in support for a change in the law from medical practitioners, a slight decrease in support from community members and almost no change among nurses. Different interpretations of the results of the four attitude questions are possible, depending on the perspective of the interpreter.

Antibody mimics based on human fibronectin type three domain engineered for thermostability and high-affinity binding to vascular endothelial growth factor receptor two

The tenth human fibronectin type three domain ((10)Fn3) is a small (10 kDa), extremely stable and soluble protein with an immunoglobulin-like fold, but without cysteine residues. Selections from (10)Fn3-based libraries of proteins with randomized loops have yielded high-affinity, target-specific antibody mimics. However, little is known about the biophysical properties of such antibody mimics, which will determine their suitability for in vitro and medical applications. We characterized target binding and biophysical properties of two related (10)Fn3-based antibody mimics that bind vascular endothelial growth factor receptor two (VEGF-R2). The first antibody mimic, which has a dissociation constant (K(d)) of 13 nM, is highly stable [melting temperature (T(m))=62 degrees C] and soluble, whereas the second, which binds VEGF-R2 with 40 x higher affinity, is less stable (T(m) < 40 degrees C) and relatively insoluble. We used our understanding of these two (10)Fn3 derivatives and of wild-type (10)Fn3 structure to engineer the next generation of antibody mimics, which have an improved combination of high affinity (K(d)=0.59 nM), stability (T(m)=53 degrees C) and solubility. Our findings illustrate that (10)Fn3-based antibody mimics can be engineered for favorable biophysical properties even when 20% of the wild-type (10)Fn3 sequence is mutated in order to satisfy target-binding requirements.

Synthesis of (-)-5,8-dihydroxy-3R-methyl-2R-(dipropylamino)-1,2,3,4-tetrahydronaphthalene: an inhibitor of beta-amyloid(1-42) aggregation

A concise synthesis of the beta-amyloid(1-42 )aggregation inhibitor (-)-5,8-dihydroxy-3R-methyl-2R-(dipropylamino)-1,2,3,4-tetrahydronaphthalene [(-)-2] has been developed. The key step is a regio- and diastereoselective hydroboration-amination sequence to convert alkene into amine. Enantiomeric resolution was achieved by recrystallization of amine as the dibenzoyl-D-tartaric acid salt. Hydroquinone is a potent inhibitor of the fibrillar aggregation of beta-amyloid as determined in two different assay systems.

Crystal structure of calcium-free human sorcin: a member of the penta-EF-hand protein family

Sorcin is a 22 kD calcium-binding protein that is found in a wide variety of cell types, such as heart, muscle, brain and adrenal medulla. It belongs to the penta-EF-hand (PEF) protein family, which contains five EF-hand motifs that associate with membranes in a calcium-dependent manner. Prototypic members of this family are the calcium-binding domains of calpain, such as calpain dVI. Full-length human sorcin has been crystallized in the absence of calcium and the structure determined at 2.2 A resolution. Apart from an extended N-terminal portion, the sorcin molecule has a globular shape. The C-terminal domain is predominantly alpha-helical, containing eight alpha-helices and connecting loops incorporating five EF hands. Sorcin forms dimers through the association of the unpaired EF5, confirming this as the mode of association in the dimerization of PEF proteins. Comparison with calpain dVI reveals that the general folds of the individual EF-hand motifs are conserved, especially that of EF1, the novel EF-hand motif characteristic of the family. Detailed structural comparisons of sorcin with other members of PEF indicate that the EF-hand pair EF1-EF2 is likely to correspond to the two physiologically relevant calcium-binding sites and that the calcium-induced conformational change may be modest and localized within this pair of EF-hands. Overall, the results derived from the structural observations support the view that, in sorcin, calcium signaling takes place through the first pair of EF-hands.

Antimalarial simplified 3-aryltrioxanes: synthesis and preclinical efficacy/toxicity testing in rodents

A streamlined five-step chemical synthesis of rationally designed, simplified 3-aryltrioxane 8a is described. A noteworthy feature of this synthetic scheme is use of air rather than expensive molecular oxygen as the source of the pharmacologically critical peroxide unit in trioxane 8a. This simplified acetal trioxane carboxylic acid 8a is thermally stable, and it is hydrolytically stable in water even at 40 degrees C and pH 7.4 for at least 7 days. Preclinical evaluation of this water-soluble synthetic trioxane 8a in rodents shows it to have at least as good a therapeutic index (efficacy/toxicity) as that of water-soluble semisynthetic trioxane artelinic acid (5).

Synthesis and fungicidal activity of a series of novel aryloxylepidines

A series of novel (hetero) aryloxylepidine derivatives was devised as hybrid structures of the phenoxyquinoline and phenethoxyquin(az)oline fungicides. Synthesis of these targets required the development of several new routes to derivatised 4-hydroxymethylquinolines, and subsequent coupling with phenols or haloarenes. The aryloxylepidines generally showed moderate broad-spectrum fungicidal activity across several diseases of cereals. Substitution of the quinoline ring with chlorine at the 7- and/or 5-positions gave molecules with high levels of protectant activity against Erysiphe graminis f sp tritici (powdery mildew of wheat), but this did not improve the level of fungicidal activity against other diseases. In vitro activity against mitochondrial electron transport complex I (MET) derived from Ustilago maydis showed that 8-fluorolepidine analogues were moderately active at this target site, while the more fungicidally active 7- and 5,7-substituted compounds were inactive. This indicates that MET is not the primary target of these highly active powdery mildewicides.

The effect of dental implant spacing on peri-implant bone using the rabbit (Oryctolagus cuniculus) tibia model

PURPOSE

This study investigated the effects of implant proximity on inter-implant bone height, density, and osseointegration using digital radiography and histology.

MATERIALS AND METHODS

After a feasibility study, a total of 80 endosteal implants were placed in 20 New Zealand White Rabbit tibias. With the aid of a surgical jig, four 8.5-mm implants were placed in the medial aspect of the tibial crest at inter-implant distances of approximately 1, 1.5, and 3 mm. Standardized digital radiographs using a paralleling device were made immediately after placement of implants. Implants were allowed to osseointegrate for 90 days. After this healing period, the animals were sacrificed, and the standardized radiographs were repeated. The tibias were harvested, processed, and invested in epoxy. Sagittal sections were made from each specimen for histologic evaluation. The initial and postmortem digital radiographs were evaluated for inter-implant distances, vertical bone height changes over time and between implant pairs, and bone density changes over time and between implant pairs using a computer image analysis program and computer statistics program.

RESULTS

The actual inter-implant distances were consistent in a range of 0.2 mm. Bone height increased significantly from presurgical levels at all 3 locations (p < .0005). Repeated measures analysis of variance comparing change in bone height at the 3 implant pair distances showed significant differences among the 3 (p = .002). Paired t tests showed that the amount of bone growth at the 1-mm separation site was significantly greater than the 1.5-mm site (p = .026) and the 3-mm site (p = .001), whereas bone growth at the 1.5- and 3-mm sites did not show significant differences (p = .162). A repeated measures analysis of variance comparing change in bone density showed no significant differences (p > .05) among the 3 inter-implant distances for either the 8-mm position (approximately crestal bone height) or the 6-mm position (approximately 2 mm subcrestal).

CONCLUSION

Within the limits of this study, it seems placing implants closely together does not adversely affect bone height or density. Conversely, it seems that placing implants closer together may increase bone growth.

An ethics core curriculum for Australasian medical Schools

Teaching ethics incorporates teaching of knowledge as well as skills and attitudes. Each of these requires different teaching and assessment methods. A core curriculum of ethics knowledge must address both the foundations of ethics and specific ethical topics. Ethical skills teaching focuses on the development of ethical awareness, moral reasoning, communication and collaborative action skills. Attitudes that are important for medical students to develop include honesty, integrity and trustworthiness, empathy and compassion, respect, and responsibility, as well as critical self-appraisal and commitment to lifelong education.

Activated MEK1 binds the nuclear MyoD transcriptional complex to repress transactivation

To elucidate the mechanism through which MAPK signaling regulates the MyoD family of transcription factors, we investigated the role of the signaling intermediate MEK1 in myogenesis. Transfection of activated MEK1 strongly repressed gene activation and myogenic conversion by the MyoD family. This repression was not mediated by direct phosphorylation of MyoD or by changes in MyoD stability or subcellular distribution. Deletion mapping revealed that MEK1-mediated repression required the MyoD amino-terminal transactivation domain. Moreover, activated MEK1 was nuclearly localized and bound a complex containing MyoD in a manner that is dependent on the presence of the MyoD amino terminus. Together, these data demonstrate that MEK1 signaling has a strong negative effect on MyoD activity via a novel mechanism involving binding of MEK1 to the nuclear MyoD transcriptional complex.

Kinetic and calorimetric evidence for two distinct scaffolding protein binding populations within the bacteriophage P22 procapsid

A wide variety of viruses require the transient presence of scaffolding proteins to direct capsid assembly. In the case of bacteriophage P22, a model in which the scaffolding protein selectively stabilizes on-pathway growing intermediates has been proposed. The stoichiometry and thermodynamics of binding of the bacteriophage P22 scaffolding protein within the procapsid were analyzed by light scattering and isothermal titration calorimetry. Calorimetric experiments carried out between 10 and 37 degrees C were consistent with the presence of at least two distinct populations of binding sites, in agreement with kinetic evidence obtained by a light scattering assay. Binding to the high-affinity sites occurred at 20 degrees C with a stoichiometry of approximately 60 scaffolding molecules per procapsid and an apparent K(d) of approximately 100-300 nM and was almost completely enthalpy-driven. For the second binding population, precise fitting of the data was impossible due to small heats of binding, but the thermodynamics of binding were clearly distinct from the high-affinity phase. The heat capacity change (DeltaC(p)()) of binding was large for the high-affinity sites and negative for both sets of sites. Addition of sodium chloride (1 M) greatly reduced the magnitude of the apparent DeltaH, in agreement with previous evidence that electrostatic interactions play a major role in binding. A mutant scaffolding protein that forms covalent dimers (R74C/L177I) bound only to the high-affinity sites. These data comprise the first quantitative measurements of the energetics of the coat protein/scaffolding protein interaction.

Refusal of treatment

Patients' thoughts, feelings and desires are communicated in a variety of ways, and require sympathetic, critical interpretation. Patients need clear, evidence-based medical information so that they can make their own decisions about whether to consent to or refuse medical treatment. Treatment refusal may provide an opportunity to introduce patients to advance care planning. Unconscious motivations in doctors may obstruct good clinical decision-making. Although respect for the patient's responsibility to make healthcare decisions should be a condition of the clinical relationship, healthcare decision-making is a collaborative process.

Stereoselective binding of an enantiomeric pair of stromelysin-1 inhibitors caused by conformational entropy factors

Isothermal titration calorimetry was used to analyze the binding of an enantiomeric pair of inhibitors to the stromelysin-1 catalytic domain. Differences in binding affinity are attributable to different conformational entropy penalties suffered upon binding. Two possible explanations for these differences are proposed.

Screening gamete donors for cystic fibrosis status

Gamete donors are currently not tested for cystic fibrosis, even though carriers have a very high risk of producing children with the disease. We recommend that gamete donors be routinely tested for cystic fibrosis. Similar arguments exist for antenatal screening for cystic fibrosis.

Design, characterization, and structure of a biologically active single-chain mutant of human IFN-gamma

A mutant form of human interferon-gamma (IFN-gamma SC1) that binds one IFN-gamma receptor alpha chain (IFN-gamma R alpha) has been designed and characterized. IFN-gamma SC1 was derived by linking the two peptide chains of the IFN-gamma dimer by a seven-residue linker and changing His111 in the first chain to an aspartic acid residue. Isothermal titration calorimetry shows that IFN-gamma SC1 forms a 1:1 complex with its high-affinity receptor (IFN-gamma R alpha) with an affinity of 27(+/- 9) nM. The crystal structure of IFN-gamma SC1 has been determined at 2.9 A resolution from crystals grown in 1.4 M citrate solutions at pH 7.6. Comparison of the wild-type receptor-binding domain and the Asp111-containing domain of IFN-gamma SC1 show that they are structurally equivalent but have very different electrostatic surface potentials. As a result, surface charge rather than structural changes is likely responsible for the inability of the His111-->Asp domain of to bind IFN-gamma R alpha. The AB loops of IFN-gamma SC1 adopt conformations similar to the ordered loops of IFN-gamma observed in the crystal structure of the IFN-gamma/IFN-gamma R alpha complex. Thus, IFN-gamma R alpha binding does not result in a large conformational change in the AB loop as previously suggested. The structure also reveals the final six C-terminal amino acid residues of IFN-gamma SC1 (residues 253-258) that have not been observed in any other reported IFN-gamma structures. Despite binding to only one IFN-gamma R alpha, IFN-gamma SC1 is biologically active in cell proliferation, MHC class I induction, and anti-viral assays. This suggests that one domain of IFN-gamma is sufficient to recruit IFN-gamma R alpha and IFN-gamma R beta into a complex competent for eliciting biological activity. The current data are consistent with the main role of the IFN-gamma dimer being to decrease the dissociation constant of IFN-gamma for its cellular receptors.

Design and analysis of an engineered human interleukin-10 monomer

A monomeric form of human interleukin 10 (IL-10M1) has been engineered for detailed structure-function studies on IL-10 and its receptor complexes. Wild type IL-10 (wtIL-10) is a domain swapped dimer whose structural integrity depends on the intertwining of two peptide chains. wtIL-10 was converted to a monomeric isomer by inserting 6 amino acids into the loop connecting the swapped secondary structural elements. Characterization of IL-10M1 by mass spectroscopy, size exclusion chromatography, cross-linking, and circular dichroism shows that IL-10M1 is a stable alpha-helical monomer at physiological pH whose three-dimensional structure closely resembles one domain of wtIL-10. As previously reported, incubation of wtIL-10 with a soluble form of the IL-10Ralpha (sIL-10Ralpha) generates a complex that consists of 2 wtIL-10 molecules and 4 sIL-10Ralphas. In contrast, IL-10M1 forms a 1:1 complex with the sIL-10Ralpha. Characterization of the interaction using isothermal titration calorimetry confirmed the 1:1 stoichiometry and yielded a dissociation constant of 30 nm with an apparent binding enthalpy of -12.2 kcal/mol. Despite forming a 1:1 complex, IL-10M1 is biologically active in cellular proliferation assays. These results indicate that the 1:1 interaction between IL-10M1 and IL-10Ralpha is sufficient for recruiting the signal transducing receptor chain (IL-10Rbeta) into the signaling complex and eliciting IL-10 cellular responses.

Structure of the coat protein-binding domain of the scaffolding protein from a double-stranded DNA virus

Scaffolding proteins are required for high fidelity assembly of most high T number dsDNA viruses such as the large bacteriophages, and the herpesvirus family. They function by transiently binding and positioning the coat protein subunits during capsid assembly. In both bacteriophage P22 and the herpesviruses the extreme scaffold C terminus is highly charged, is predicted to be an amphipathic alpha-helix, and is sufficient to bind the coat protein, suggesting a common mode of action. NMR studies show that the coat protein-binding domain of P22 scaffolding protein exhibits a helix-loop-helix motif stabilized by a hydrophobic core. One face of the motif is characterized by a high density of positive charges that could interact with the coat protein through electrostatic interactions. Results from previous studies with a truncation fragment and the observed salt sensitivity of the assembly process are explained by the NMR structure.

Nightguard vital bleaching beneath existing porcelain veneers: a case report

Dentist-prescribed, at-home bleaching with 10% carbamide peroxide was used to lighten the apparent color of teeth with preexisting porcelain veneers. Veneers had been placed over unprepared, tetracycline-stained teeth; the translucency of the veneers over the discolored teeth resulted in a graying of the veneers. A custom-fitted tray with no reservoirs and no gingival scalloping was fabricated. A 10% carbamide peroxide material was applied nightly for 9 months to achieve the maximum change in the underlying tooth color. The patient was pleased with the apparent color change. Tooth sensitivity during treatment was minimal (lasting 4 days total); the patient treated sensitivity by brushing with a potassium nitrate-containing toothpaste or applying fluoride in the tray.

Antimalarial, antiproliferative, and antitumor activities of artemisinin-derived, chemically robust, trioxane dimers

Nine C-10 non-acetal derivatives of the natural trioxane artemisinin (1) were prepared as dimers using some novel chemistry. As designed, each dimer was stable chemically. C-10 Olefinic dimers 7 and C-10 saturated dimers 8-13 all showed good to excellent antimalarial and antiproliferative activities in vitro. Dimers 8, 10, and 12 were especially potent and selective at inhibiting growth of some human cancer cell lines in the NCI in vitro 60-cell line assay.

Analysis of the binding of hydroxamic acid and carboxylic acid inhibitors to the stromelysin-1 (matrix metalloproteinase-3) catalytic domain by isothermal titration calorimetry

Matrix metalloproteinases (MMPs) are implicated in diseases such as arthritis and cancer. Among these enzymes, stromelysin-1 can also activate the proenzymes of other MMPs, making it an attractive target for pharmaceutical design. Isothermal titration calorimetry (ITC) was used to analyze the binding of three inhibitors to the stromelysin catalytic domain (SCD). One inhibitor (Galardin) uses a hydroxamic acid group (pK(a) congruent with 8.7) to bind the active site zinc; the others (PD180557 and PD166793) use a carboxylic acid group (pK(a) congruent with 4.7). Binding affinity increased dramatically as the pH was decreased over the range 5.5-7.5. Experiments carried out at pH 6.7 in several different buffers revealed that approximately one and two protons are transferred to the enzyme-inhibitor complexes for the hydroxamic and carboxylic acid inhibitors, respectively. This suggests that both classes of inhibitors bind in the protonated state, and that one amino acid residue of the enzyme also becomes protonated upon binding. Similar experiments carried out with the H224N mutant gave strong evidence that this residue is histidine 224. DeltaG, DeltaH, DeltaS, and DeltaC(p) were determined for the three inhibitors at pH 6.7, and DeltaC(p) was used to obtain estimates of the solvational, translational, and conformational components of the entropy term. The results suggest that: (1) a polar group at the P1 position can contribute a large favorable enthalpy, (2) a hydrophobic group at P2' can contribute a favorable entropy of desolvation, and (3) P1' substituents of certain sizes may trigger an entropically unfavorable conformational change in the enzyme upon binding. These findings illustrate the value of complete thermodynamic profiles generated by ITC in discovering binding interactions that might go undetected when relying on binding affinities alone.

Characterization of MB-1. A dimeric helical protein with a compact core

MB-1 is a de-novo protein designed to incorporate a large number of the nutritionally important amino acids methionine, lysine, leucine and threonine into a stable four-helix bundle protein. MB-1 has been expressed and purified from Escherichia coli, indicating it was resistant to intracellular proteases [Beauregard, M., Dupont, C., Teather, R.M. & Hefford, M.A. (1995) Bio/Technology 13, 974]. Here we report an analysis of the secondary, tertiary and quaternary structures in MB-1 using circular dichroism, fluorospectroscopy and size-exclusion chromatography. Our data indicate that the MB-1 structure is close to the target structure, an alpha-helical bundle, in many respects and is highly helical in solution. The single tyrosine incorporated into the designed protein as a spectrocopic probe of tertiary structure, is buried in a compact, folded core and becomes accessible on protein denaturation, as per design. Furthermore, MB-1 was found to be native-like in many respects: (a) protein denaturation induced by urea is cooperative and fully reversible; (b) its oligomeric state at moderate concentration is well defined; and (c) MB-1 has very low affinity for 8-anilino-1-naphthalenesulfonic acid (ANSA), leading to enhancement of ANSA fluorescence that resembles that of other native proteins. On the other hand, our analysis revealed two aspects that command further attention. The folding stability of MB-1 as assessed by urea and thermal denaturation is somewhat less than that found for natural globular proteins of similar size. Size-exclusion chromatography experiments and analysis of MB-1 denaturation indicate that MB-1 is dimeric, not monomeric as designed. In light of these results, the utility and the current limitations of our design approach are discussed.

Orally active, hydrolytically stable, semisynthetic, antimalarial trioxanes in the artemisinin family

In only three chemical operations, natural trioxane lactone artemisinin (1) was converted into a series of C-10 carbon-substituted 10-deoxoartemisinin compounds 4-9. The three steps involved lactone reduction, replacement of the anomeric lactol OH by F using diethylaminosulfur trifluoride, and finally boron trifluoride-promoted substitution of F by aryl, heteroaryl, and acetylide nucleophiles. All of these C-10 nonacetal, chemically robust, enantiomerically pure compounds 4-9 have high antimalarial potencies in vitro against Plasmodium falciparum malaria parasites, and furans 5a and 5b and pyrrole 7a are antimalarially potent also in vivo even when administered to rodents orally.

An in vivo study of voluntary mandibular lateral translation concerning its existence, magnitude, and timing

STATEMENT OF PROBLEM

The existence of mandibular lateral translation and the approaches to its measurement and interpretation by using a pantograph are controversial.

PURPOSE

This study evaluated the validity of using a pantograph to measure mandibular lateral translation and analyzed human pantographic tracings to determine whether they exhibited mandibular lateral translation.

MATERIAL AND METHODS

A pantograph was modified by adding 2 posterior horizontal recording tables and styli at the transverse horizontal axis. Pantographic tracings of 25 human subjects were compared with the corresponding theoretically determined values for tracings that exhibited only rotation with no translation. Differences in the tracings at 2 pantographic recording table locations, relative to the transverse horizontal axis, were also compared.

RESULTS

The character of the lateral component of 100 pantographic tracings all differed from the lateral component of theoretically determined values for pure rotation. In 64% of tracings, over 50% of the total mandibular lateral translation occurred by the first 1 mm of forward movement of the nonworking side condyle. In 94% of tracings, more than 50% of the translation had occurred in the first 3 mm of forward movement. For the pantographic system used, the amount of mandibular translation represented in the tracing was not changed by altering the posterior horizontal recording table position in the anterior-posterior direction, relative to the transverse horizontal axis.

CONCLUSION

All subjects showed evidence of mandibular lateral translation. New definitions for timing of mandibular lateral translation are proposed. Of the tracings, 64% were classified as exhibiting early translation, 30% as intermediate, and 4% as late mandibular lateral translation.

Electrostatic interactions drive scaffolding/coat protein binding and procapsid maturation in bacteriophage P22

The first step in assembly of the bacteriophage P22 is the formation of a T=7 icosahedral "procapsid," the major components of which are the coat protein and an inner core composed of the scaffolding protein. Although not present in the mature virion, the scaffolding protein is required for procapsid assembly. Eleven amino-acid residues at the extreme carboxyl terminus of the scaffolding protein are required for binding to the coat protein, and upon deletion of these residues, approximately 20 additional residues become disordered. Sequence analysis and NMR data suggest that the 30 residues at the carboxyl terminus form a helix-loop-helix motif which is stabilized by interhelical hydrophobic interactions. This "coat protein recognition domain" presents an unusually high number of positively charged residues on one face, suggesting that electrostatic interactions between this domain and the coat protein may contribute to recognition and binding. We report here that high ionic strength (1 M NaCl) completely inhibited procapsid assembly in vitro. When scaffolding protein was added to empty procapsid "shells" of coat protein, 1 M NaCl partially inhibited the binding of scaffolding protein to the shells. This suggests that the positively charged coat protein recognition domain at the carboxyl terminus of the scaffolding protein binds to a negatively charged region on the coat protein. During DNA packaging, the scaffolding protein exits the procapsid; scaffolding protein exit is followed by the expansion of the procapsid into a mature capsid. Procapsid shells can be induced to undergo a similar expansion reaction in vitro by heating (45-70 degreesC); this process was also inhibited by 1 M NaCl. These results are consistent with a model in which negatively charged scaffold protein-binding domains in the coat proteins move apart during procapsid expansion; this relief of electrostatic repulsion could provide a driving force for expansion and subsequent maturation. High-salt concentrations would screen this repulsion, while packaging of DNA (a polyanion) in vivo may increase the instability of the procapsid enough to trigger its expansion.

Evaluation of resistance form of dislodged crowns and retainers

STATEMENT OF PROBLEM

The concept of limiting taper has been described as a boundary between tapers that do and those that do not provide resistance form for a preparation. There is controversy as to whether this boundary that divides preparations with from those without resistance form translates clinically into a boundary for success.

PURPOSE

This investigation evaluated the resistance form of abutments of crowns or retainers that have been dislodged to determine the clinical correlation between restoration dislodgment and lack of resistance form in the preparation.

MATERIAL AND METHODS

Dies were fabricated from single crowns and retainers of fixed partial dentures that came loose and evaluated for resistance form. A total of 44 abutments were evaluated and included 1 incisor, 15 premolars, and 28 molars. Data from a previous study on the percentage of abutments lacking resistance form for restorations leaving a large dental laboratory was used for comparative statistical tests.

RESULTS

Forty-two of the 44 abutments (95%) lacked resistance form. All molar abutments and 93% of premolar abutments lacked resistance form in one or more directions. The one incisor abutment did not lack resistance form. Chi-square test revealed a statistically significant difference in the percentage lacking resistance form between the group composed of clinical failure (uncemented crowns) and the group leaving a dental laboratory with P = .0005 for the molars, and P = .0005 for the premolars.

CONCLUSION

The clinical dislodgment of cast restorations is associated with the lack of resistance form in the preparations. In this study, there was a relationship between clinical success or failure and the all-or-none nature of resistance form; dislodged crowns come almost exclusively from preparations with tapers that did not provide resistance form.

Functional domains of bacteriophage P22 scaffolding protein

Assembly of the bacteriophage P22 requires a 303 amino acid residue scaffolding protein. Two scaffolding protein deletion mutants, consisting of residues 141 to 303 and 141 to 292, have been described. We report here that the 141-303 fragment, but not the 141-292 fragment, promoted procapsid assembly in vitro, bound to preformed shells of coat protein, and bound to a coat protein affinity column. These findings suggest that the carboxyl-terminal half of the scaffolding protein is sufficient for promoting assembly, and that the 11 amino acid residues at the extreme carboxyl terminus are required for binding to the coat protein. Analysis of the products of in vitro assembly reactions suggests that the maximum amount of scaffolding protein that can pack into a procapsid is dictated by the internal volume of the procapsid rather than by a finite number of binding sites. However, when the amount of scaffolding protein was reduced to limiting values, both the wild-type protein and the 141-303 fragment assembled procapsids with the same number, rather than the same mass, of scaffolding protein molecules. When the 141-292 fragment was added to a mixture of coat and scaffolding proteins, the initial phase of procapsid assembly was inhibited, but the final yield and composition of the procapsids were not affected. Assembly by a covalent dimeric mutant scaffolding protein (R74C/L177I) was not inhibited by the 141-292 fragment, which suggests that the inhibition is due to the formation of inactive heterodimers between the 141-292 fragment and the monomeric scaffolding protein. The 141-303 fragment, which has less tendency to self-associate than the wild-type protein, formed aberrant species as well as normal procapsid-like particles when the rate of assembly was high, suggesting that scaffolding protein dimerization may play a role in ensuring fidelity of assembly. Alternatively, residues 1 to 140 may play a direct structural role in preventing inappropriate scaffolding/coat protein interactions.

A helical coat protein recognition domain of the bacteriophage P22 scaffolding protein

The scaffolding protein of bacteriophage P22 directs the assembly of an icosahedral procapsid, a metastable shell that is the precursor for DNA packaging. The full-length protein has been shown previously to exist in a monomer-dimer-tetramer equilibrium of elongated and predominantly alpha-helical molecules. Two deletion-mutant fragments of the scaffolding protein, comprising amino acid residues 141 to 303 and 141 to 292, respectively, have been constructed, overexpressed in Escherichia coli, and purified. Removal of residues 1 to 140 yields a protein that is assembly-active both in vitro and in vivo, while the removal of the C-terminal 11 residues (293 to 303) leads to complete loss of scaffolding activity. Sedimentation analysis reveals that both scaffolding fragments exist in a monomer-dimer equilibrium governed by apparent dissociation constants Kd(141-303)=640 microM and Kd(141-292)=880 microM. Tetramer formation is not observed for either fragment; thus, the tetramerization domain of the scaffolding subunit resides in the N-terminal portion of the polypeptide chain. Examination of both fragments by circular dichroism, Raman and NMR spectroscopies indicates a highly alpha-helical fold in each case. Nonetheless, pronounced differences are observed between spectral signatures of the two fragments. Notably, Raman spectra of fragments 141-292 and 141-303 indicate that elimination of residues 293 to 303 results in unfolding of an alpha-helical coat protein "recognition" domain encompassing about 20 to 30 residues. The thermostability of fragment 141-303, monitored over a wide concentration range by circular dichroism and Raman spectroscopy, indicates a broad denaturation transition for the monomeric (low concentration) form, while more cooperative unfolding is observed for the dimeric (high concentration) form. A lesser increase in cooperativity upon dimerization is obtained for fragment 141-292. Additionally, the C-terminal recognition domain constitutes the most stable and cooperative unit in the 141-303 fragment. Measurement of hydrogen-isotope exchange kinetics in scaffolding fragments by time-resolved Raman spectroscopy shows that the C terminus is the only protected segment of the polypeptide chain. On the basis of the measured hydrodynamic and spectroscopic properties, a domain structure is proposed for the scaffolding subunit. The roles of these domains in P22 procapsid assembly are discussed.

Introduction of potential helix-capping residues into an engineered helical protein

MB-1 is an engineered protein that was designed to incorporate high percentages of four amino acid residues and to fold into a four-alpha-helix bundle motif. Mutations were made in the putative loop I and III regions of this protein with the aim of increasing the stability of the helix ends. Four variants, MB-3, MB-5, MB-11 and MB-13, have replacements intended to promote formation of an 'N-capping box'. The loop I and III sequences of MB-3 (both GDLST) and MB-11 (GGDST) were designed to cause alphaL C-terminal 'capping' motifs to form in helices I and III. MB-5 has a sequence, GPDST, that places proline in a favourable position for forming beta-turns, whereas MB-13 (GLDST) has the potential to form Schellman C-capping motifs. Size-exclusion chromatography suggested that MB-1, MB-3, MB-5, MB-11 and MB-13 all form dimers, or possibly trimers. Free energies for the unfolding of each of these variants were determined by urea denaturation, with the loss of secondary structure followed by CD spectroscopy. Assuming an equilibrium between folded dimer and unfolded monomer, MB-13 had the highest apparent stability (40.5 kJ/mol, with +/-2.5 kJ/mol 95% confidence limits), followed by MB-11 (39.3+/-5.9 kJ/mol), MB-3 (36.4+/-1.7 kJ/mol), MB-5 (34.7+/-2.1 kJ/mol) and MB-1 (29.3+/-1.3 kJ/mol); the same relative stabilities of the variants were found when a folded trimer to unfolded monomer model was used to calculate stabilities. All of the variants were relatively unstable for dimeric proteins, but were significantly more stable than MB-1. These findings suggest that it might be possible to increase the stability of a protein for which the three-dimensional structure is unknown by placing amino acid residues in positions that have the potential to form helix- and turn-stabilizing motifs.

Radiographic verification of implant abutment seating

STATEMENT OF PROBLEM

It is possible to incorrectly seat an abutment on an external hex implant.

PURPOSE

This study investigated the theoretical and practical limits of radiographic verification of the complete seating of implant abutments on external hex implants.

MATERIAL AND METHODS

A positioning device that could accurately place the film and/or tube head in any vertical relation desired relative to the implant and abutment was fabricated. For all records, a standard abutment was secured to the implant in both a fully seated position (closed) and with the abutment turned approximately 30 degrees and seated atop the implant external hex (open). Digital radiographs were made with the tube head fixed perpendicular to the implant and the film angled at 0, 5, 10, 15, 20, 25, 30, 35, 40, and 45 degrees. The film was then positioned parallel to the implant and the tube head was angled at 0, 5, 10, 15, 20, 25, 30, 35, 40, and 45 degrees. An image of each position was shown to 36 dentists and they were asked if the image was diagnostic for determining the status of the implant/abutment interface.

RESULTS

The data were analyzed with a computer statistics program. The group with the tube head changed was analyzed with the Cochran's Q test and revealed a statistically significant (p < 0.0001) change in the diagnostic value of radiographs beginning at 20 degrees. The group with the film angle changed was analyzed with a Pearson chi-square and showed no statistical difference (p = 0.394) for the diagnostic value of any of the film angles.

CONCLUSION

Maintaining the tube head to less than 20 degrees from perpendicular to the long axis of the implant resulted in a diagnostic radiograph, regardless of the angle of the film.