Peri-articular bone formation involving the temporomandibular joint: a narrative summary and Delphi consensus of a new classification system

Heterotopic ossification (HO) is defined as 'bone where it does not belong'. Given the historical variety of nomenclature and eponyms, there is significant confusion about the etiology, pathogenesis, classification, and treatment of HO related to the temporomandibular joint (TMJ). The existing classifications for TMJ HO have shortcomings: they relate to specific populations, use differing imaging studies and demographic data, do not universally include alloplastic/autologous replacements, are based variously on radiological and/or clinical presentations that cannot always be combined, and were largely developed to assist oral and maxillofacial surgeons in surgical management. These deficiencies make it problematic to compare studies, draw valid conclusions, and pursue research. The aim of this study was to develop a new, more inclusive classification for TMJ HO. Currently available classifications were evaluated and a Delphi-type system used to build consensus from clinicians and researchers to develop a new system. Fourteen unique classifications for TMJ ankylosis/HO were identified. In light of the biological specifics related to heterotopic calcification of extracellular matrix versus heterotopic formation of actual bone, the group recommends a more unambiguous term - peri-articular bone formation - and proposes a new classification. This will help clinicians and researchers to study, describe, and manage various types of ectopic bone associated with the TMJ.

Which comorbid conditions and risk factors affect the outcome of and progression to total temporomandibular joint replacement?

Surgery is an effective modality to reduce pain and increase range of motion (ROM) in TMJ disorders. The aim of this study was to determine which comorbidities and risk factors affect outcomes and progression to total joint replacement (TJR). A retrospective cohort study of patients who underwent TJR between 2000- 2018 at MGH was conducted. Primary outcome was successful vs unsuccessful surgery. Success was defined as pain score ≤ 4 and ROM ≥ 30 mm; failure was defined as lack of either or both. Secondary outcome was differences between patients undergoing TJR only (group A) and those undergoing multiple surgeries progressing to TJR (group B). 99 patients (82 females, 17 males) were included. Mean follow-up was 4.1 years; mean age at first surgery was 34.2 (range 14-71) years. Unsuccessful outcomes were associated with high preoperative pain, low preoperative ROM, and higher number of surgeries. Male sex favored successful outcome. 75.0% group A and 47.6% group B had successful outcome. Group B had more females, higher postoperative pain, lower postoperative ROM, and used more opioids compared to group A. High preoperative pain, low preoperative ROM, and more surgeries were associated with poorer outcomes and frequent opioid use.

No evidence of resistance to itraconazole in a prospective real-world trial of dermatomycosis in India

BACKGROUND

The prevalence of superficial fungal infections in India is believed to have increased substantially in the past decade. We evaluated the treatment outcomes and risk factors associated with clinical response to a treatment course of itraconazole for the management of dermatomycosis in India.

METHODS

In this real-world, prospective pilot study (August 2019 to March 2020), adult participants (18-60 years), diagnosed with T. cruris or T. corporis, received itraconazole 200 mg/day (any formulation) orally for 7 days, and were followed for an additional 7 days.

RESULTS

The study was terminated early due to the COVID-19 pandemic. Of 40 enrolled participants (mean [SD] age, 35.5 [12.73] years; {62.5%}] male; 37 received itraconazole and 20 (50%) completed the study. The median (range) Clinical Evaluation Tool Signs and Symptoms total score at baseline was 5.5 (2-10). Clinical response of "healed" or "markedly improved" based on the Investigator Global Evaluation Tool at day 7 (primary objective) was 42.9% (12/28; 95% CI: 24.53%, 61.19%). Itraconazole minimum inhibitory concentration for identified microorganisms, T. mentagrophytes species complex (91.7%) and T. rubrum (8.3%), was within the susceptibility range (0.015-0.25 mcg/mL). At day 14, 8/13 (61.5%) participants achieved a mycological response, 2/13 participants (15.4%) had a mycological failure and 90% showed a clinical response.

CONCLUSION

COVID-19 pandemic affected patient recruitment and follow-up, so the findings call for a careful interpretation. Nevertheless, this real-world study reconfirmed the clinical efficacy and microbial susceptibility to itraconazole for the fungi causing dermatophytosis in India.

TRIAL REGISTRATION

Trial registration number: Clinicaltrials.gov NCT03923010.

Immunization with a self-assembling nanoparticle vaccine displaying EBV gH/gL protects humanized mice against lethal viral challenge

Epstein-Barr virus (EBV) is a cancer-associated pathogen responsible for 165,000 deaths annually. EBV is also the etiological agent of infectious mononucleosis and is linked to multiple sclerosis and rheumatoid arthritis. Thus, an EBV vaccine would have a significant global health impact. EBV is orally transmitted and has tropism for epithelial and B cells. Therefore, a vaccine would need to prevent infection of both in the oral cavity. Passive transfer of monoclonal antibodies against the gH/gL glycoprotein complex prevent experimental EBV infection in humanized mice and rhesus macaques, suggesting that gH/gL is an attractive vaccine candidate. Here, we evaluate the immunogenicity of several gH/gL nanoparticle vaccines. All display superior immunogenicity relative to monomeric gH/gL. A nanoparticle displaying 60 copies of gH/gL elicits antibodies that protect against lethal EBV challenge in humanized mice, whereas antibodies elicited by monomeric gH/gL do not. These data motivate further development of gH/gL nanoparticle vaccines for EBV.

Addition of oral Fexofenadine to topical therapy leads to a significantly greater reduction in the serum IL-31 levels in mild to moderate pediatric atopic dermatitis

BACKGROUND

Recent evidence has suggested that oral antihistamines could have a beneficial role in atopic dermatitis (AD) due to their anti-inflammatory action. Hence, we aimed to evaluate the effectiveness of adding an oral second generation, non-sedating, H1 antihistamine (Fexofenadine) to topical treatment in AD.

MATERIALS AND METHODS

In this prospective randomized study, a total of 50 patients with a diagnosis of mild to moderate atopic dermatitis were recruited and randomized into two groups A (appropriate topical treatment combined with oral fexofenadine) and B (appropriate topical treatment without oral fexofenadine). Both groups received the respective treatments for a duration of 8 weeks.

RESULTS

There was no significant difference between the two groups in terms of SCORAD and the 5-D Itch Score at any of the time points (2 weeks, 4 weeks, 8 weeks). However, the serum IL-31 (ng/ml) decreased significantly from baseline in the fexofenadine group after 8 weeks of treatment.

CONCLUSIONS

Although we could not conclusively confirm the clinical efficacy of adding oral fexofenadine to topical treatment in AD, serological evaluation indicates that fexofenadine treatment can lead to significant lowering of serum IL-31 levels in AD patients.

Severe epidermolysis bullosa/Kindler syndrome-like phenotype of an autoinflammatory syndrome in a child

A 5-year-old boy presented with generalized cutaneous erosions, severe scarring, depigmentation and contractures affecting major joints. The lesions had initially affected his ears, nose, feet, and the genital and ocular mucosa, leading to significant depigmentation, scarring, contractures and mutilation. The whole of the trunk and limbs were involved at the time of presentation, with the exception of some islands of spared skin on the proximal thighs, legs, nipples and external genitalia. Electron microscopy revealed a split in the sublamina densa with the absence of anchoring fibrils, suggestive of dystrophic epidermolysis bullosa (EB). Immunofluorescence antigen mapping demonstrated a broad reticulate pattern of staining with collagen IV, VII, and laminin 332 in the floor of the blister, suggestive of Kindler syndrome. Next-generation sequencing revealed a de novo heterozygous missense mutation (a variant of unknown significance) in exon 22 of the phospholipase-C gamma 2 gene (PLCG2), which resulted in a substitution of serine by asparagine at codon 798 (p.Asp798Ser), a result that was validated using Sanger sequencing. The child was diagnosed with PLCG2-associated antibody deficiency and immune dysregulation (PLAID)/autoinflammation and PLCG2-associated antibody deficiency and immune dysregulation (APLAID) syndrome. The cutaneous and corneal erosions, inflammation and scarring of this magnitude, and the eventual result of death have not been described previously for the PLAID/APLAID spectrum previously. In conclusion, this was an unusual acquired autoinflammatory severe EB-like disease that may be associated with de novo PLCG2 mutation.

Acute coronary events in patients with myeloproliferative neoplasms- a nationwide analysis of patient characteristics and in-hospital outcomes

Background

Myeloproliferative neoplasms (MPN) are characterized by clonal expansion of cells belonging to the erythroid and/or myeloid lineages. Concomitant platelet dysfunction and thrombocytosis predispose these patients to arterial thromboses, causing a high burden of morbidity and mortality. With improving survival, an increasing number of patients with MPN are presenting with acute coronary syndromes (ACS). However, data regarding in-hospital outcomes and revascularization strategies utilized in these patients is limited, due to lack of representation in trials and rarity of the disease.

Methods

We conducted a retrospective cohort study using the 2016 Nationwide Inpatient Sample.Adult patients with a primary diagnosis of ACS and a secondary diagnosis of MPN, including essential thrombocytosis, polycythemia vera, primary myelofibrosis or chronic myeloproliferative disorder, were identified using the International Classification of Diseases (ICD) 10th revision codes. Outcomes of interest were compared using a multivariate logistic regression model.

Results

Out of 677,304 patients admitted for ACS, 2,485 also had a secondary diagnosis of MPN. Patients with MPN were less frequently female and diabetic but were more likely to have heart failure. No statistical difference in race, smoking or obesity was noted between the two cohorts. There was no significant difference in the in-hospital mortality in ACS patients with or without MPN. In terms of revascularization, patients with MPN were less likely to undergo percutaneous coronary intervention (PCI) and more likely to undergo coronary arterial bypass grafting (CABG). In addition, patients with MPN had a higher odds of acute pulmonary embolism, cardiogenic shock, and acute kidney injury as well as increased length of stay (LOS) and hospitalization costs

Conclusion

In patients with ACS and concomitant MPN, CABG was the preferred mode of revascularization over PCI, which may account for the increased LOS and total cost. Although the in-hospital mortality was similar, patients with MPN had higher odds of In-hospital complications.

Funding Acknowledgement

Type of funding source: None

Early detection of Pseudomonas aeruginosa and Escherichia coli. using zinc tetraphenylporphyrin

The sensory characteristics of food are considerably effected by the metabolic processes of various micro-organisms in the food stored in the field or at ambient temperature. Also, this microbial contamination can pose serious health hazards to public health. Chemical analysis of the complex mixture of volatiles produced during bacterial growth and investigation methods of these microorganisms presents a big challenge. There remains major unmet need to shorten and improve detection methods. Therefore, early detection of the microorganisms will open many frontiers for quality control in the foodstuffs industry. Accordingly, the aim of this study was to assess the feasibility and performance of chemoreceptive sensors for the rapid detection of bacterial pathogens, specifically Pseudomonas aeruginosa and Escherichia coli.

In Uv/vis study, zinc tetraphenyl porphyrin solutions (in DMF) was tested with various volatile compounds, such as propanal, hexanal and heptanal which are commonly found to be released during the growth of bacteria. These sensors were used to detect the bacterial odours of two pathogenic species (E.coli and P.aeruginosa) during their growth cycle at 4 °C and ambient temperature.

Hypochromic shifts in Uv/vis and hydrogen bonding in FT-IR studies confirmed the interaction between the volatiles and porphyrin. The porphyrin used detected the presence of microorganisms after 12 hrs incubation and showed more sensitivity for volatiles released during aerobic activity P. aeruginosa as compared to E. coli at 4 °C and ambient temperature.

Zinc tetraphenyl porphyrin based chemoreceptive membranes has been proved successful for the detection of P. aeruginosa. Hence, the present study proves wide scope of improvement over current laboratory techniques for the detection of pathogens in terms of speed, ease of use, and cost.

Key messages

The developed technique allows rapid detection of spoiled food. Chemoreceptive property of porphyrin has been exploited for the early detection of bacteria.

AB0013 HLA ASSOCIATION WITH SYSTEMIC SCLEROSIS (SSc) IN NORTH INDIAN POPULATION AND FAMILIAL INHERITANCE PATTERNS

Background:

It is widely believed that SSc develops in an individual with a permissive genetic makeup.Genetic influences have long been suspected to impact SSc. In families with a history of SSc, the incidence of disease can range from 1.5 to 1.7% (1). There are several reports of familial occurrence and certain alleles of the HLA system have been associated with the disease (2).No Indian data pertaining to genetic basis of systemic sclerosis is present. Understanding the genetic basis of the disease will help us in defining the biomarkers of the disease in the population that can help in early diagnosis and prognosis.

Objectives:

To study HLA association with Systemic sclerosis (SSc) in North Indian Population and its genetic susceptibility to familial systemic sclerosis.

Methods:

A total of 150 SSc patients diagnosed by following ACR and EULAR criteria and 150 control subjects, were genotyped for HLA-A, B, DRB1, DQB1 loci by Luminex® 200 Instrument (USA). The association of alleles with disease susceptibility was tested by Chi-square test and Fisher’s exact test.

HLA Typing for HLA class I (A, B, C) and II(DR,DQ,DP) for familial study of systemic sclerosis in 2 families was performed by Next Generation Sequencing(NGS) with illumina MiniSeq using MIA FORA NGS Kits from IMMUCOR. Antinuclear patterns (ANA) and specific antibodies were detected by indirect Immunofluorescence and Immunoblot (Euroline, Germany).

Results:

Strong disease associations were observed for haplotypes A*24(OR=1.7;< 0.02), A*32(OR=2.8;< 0.02), B*35(OR=1.7;< 0.03), DRB1*11(OR=2.1;< 0.007). The reduced frequencies of haplotypes A*68(P< 0.05), DRB1*10(P< 0.05), DRB1*12 (P<0.00) among patients suggested a protective association. There was no statistical association found with HLA DQB*1.

Through NGS we observed that in the 1stfamily haplotypes HLA –A*11, 32, 24; B* 51, 55, 35; C*-14, 04; DRB1*15, 04; DQB1*05, 03; DPB1*04, 26 appears in affected family members with serological abnormalities.In the 2ndfamily both mother and daughter had same set of haplotypes except DQB1 with serological abnormalities. The haplotypes DPB1*04 was present in all the diseased individuals of both the families (Fig. 1 and table 1).

Table 1.

NGS HLA typing report

ABCDRB1DQB1DPB1F111 2435 1504 0415 1505 0502 26F211 3251 5514 0415 0405 0304 04F311 2435 5504 0415 1505 0526 04F432 1151 1514 0415 0405 0302 04F524 3335 4404 0715 0705 0226 14F611 2435 5504 0415 1505 0504 26F711 2435 5504 0415 1505 0504 26F824 3251 3514 0404 1503 0526 04F911 3251 5514 0415 0405 0304 04F1011 3344 5207 1211 0702 0304 13F1111 3344 5207 1211 0703 0304 13

Fig. 1

Conclusion:

The risk alleles A*24, 32; B*35; DRB1*11 were found to be associated with North Indian cohort of SSc, while the protecting alleles were A*68; DRB1*10, 12.These risk alleles were present in the SSc affected family members and the protective alleles were absent in the same. Surprisingly, even healthy members carried the same risk alleles but did not manifest the disease or have serological evidence of the same. We have not excluded occurrence of disease at a later age, as presently the healthy siblings are young. Thus our study indicates that though HLA association are found with SSc but many other factors like HLA (HLA *C, DPB1*) or non HLA genes as wells as epigenetic factors might also play a role in disease manifestation and severity.

References:

[1]Luo Y, Wang Y, Wang Q,et al. Systemic sclerosis: genetics and epigenetics. J Autoimmun.2013; 41:161–67.

[2]de Juan MD1, Belzunegui J, Belmonte I, Barado J, Figueroa M, Cancio J, Vidal S, Cuadrado E. An immunogenetic study of familial scleroderma. Ann Rheum Dis. 1994 Sep; 53(9):614-7.

Acknowledgments:

The technical help of Mr.Manoj Kumar and Mr.Vinkesh are hereby gratefully acknowledged Indian Council of Medical Research(Funding of Fellowship)

Disclosure of Interests:

None declared

Paediatric morphoea: a holistic review. Part 1: epidemiology, aetiopathogenesis and clinical classification

Morphoea, also known as localized scleroderma, is a debilitating fibrosing disorder of uncertain aetiology, affecting the skin and subcutaneous tissues. Paediatric-onset disease is not uncommon and is associated with frequent relapses. The disease has complex pathogenetic mechanisms and multiple clinical subtypes, and affects children of all ages. Recent research has focused on elucidating the disease pathophysiology and identifying measures of disease activity. We performed a literature search on PubMed, MEDLINE and Google Scholar, using keywords such as 'pediatric morphea', 'juvenile localised scleroderma' and 'juvenile systemic sclerosis'. Relevant studies, including randomized trials, reviews of standard current guidelines and original research articles, were selected, and results were analysed before being summarized. In the first of this two-part review, we provide a bird's-eye view of the current literature concerning the epidemiology, aetiopathogenesis and clinical classification of paediatric morphoea; in Part 2, we review the diagnosis, markers of disease activity, management and natural history.

Paediatric morphoea: a holistic review. Part 2: diagnosis, measures of disease activity, management and natural history

Paediatric morphoea is a debilitating fibrosing disorder of uncertain aetiology, affecting the skin and subcutaneous tissues. Defining optimum management strategies in paediatric morphoea remains an ongoing challenge, owing to the varied presentations and a relative paucity of paediatric-specific studies. We performed a literature search on PubMed, MEDLINE and Google Scholar, using keywords such as 'pediatric morphea', 'juvenile localised scleroderma' and 'juvenile systemic sclerosis'. Relevant studies, including randomized trials, reviews of standard current guidelines and original research articles, were selected and results analysed before summarizing them. In Part 1 of this review, we described the epidemiology, aetiopathogenesis and clinical classification; in this part, we discuss the diagnosis, markers of disease activity, management and natural history in paediatric morphoea.

An ABCG Transporter Functions in Rab Localization and Lysosome-Related Organelle Biogenesis in Caenorhabditis elegans

ABC transporters couple ATP hydrolysis to the transport of substrates across cellular membranes. This protein superfamily has diverse activities resulting from differences in their cargo and subcellular localization. Our work investigates the role of the ABCG family member WHT-2 in the biogenesis of gut granules, a Caenorhabditis elegans lysosome-related organelle. In addition to being required for the accumulation of birefringent material within gut granules, WHT-2 is necessary for the localization of gut granule proteins when trafficking pathways to this organelle are partially disrupted. The role of WHT-2 in gut granule protein targeting is likely linked to its function in Rab GTPase localization. We show that WHT-2 promotes the gut granule association of the Rab32 family member GLO-1 and the endolysosomal RAB-7, identifying a novel function for an ABC transporter. WHT-2 localizes to gut granules where it could play a direct role in controlling Rab localization. Loss of CCZ-1 and GLO-3, which likely function as a guanine nucleotide exchange factor (GEF) for GLO-1, lead to similar disruption of GLO-1 localization. We show that CCZ-1, like GLO-3, is localized to gut granules. WHT-2 does not direct the gut granule association of the GLO-1 GEF and our results point to WHT-2 functioning differently than GLO-3 and CCZ-1 Point mutations in WHT-2 that inhibit its transport activity, but not its subcellular localization, lead to the loss of GLO-1 from gut granules, while other WHT-2 activities are not completely disrupted, suggesting that WHT-2 functions in organelle biogenesis through transport-dependent and transport-independent activities.

An Interferon-Driven Oxysterol-Based Defense against Tumor-Derived Extracellular Vesicles

Tumor-derived extracellular vesicles (TEV) "educate" healthy cells to promote metastases. We found that melanoma TEV downregulated type I interferon (IFN) receptor and expression of IFN-inducible cholesterol 25-hydroxylase (CH25H). CH25H produces 25-hydroxycholesterol, which inhibited TEV uptake. Low CH25H levels in leukocytes from melanoma patients correlated with poor prognosis. Mice incapable of downregulating the IFN receptor and Ch25h were resistant to TEV uptake, TEV-induced pre-metastatic niche, and melanoma lung metastases; however, ablation of Ch25h reversed these phenotypes. An anti-hypertensive drug, reserpine, suppressed TEV uptake and disrupted TEV-induced formation of the pre-metastatic niche and melanoma lung metastases. These results suggest the importance of CH25H in defense against education of normal cells by TEV and argue for the use of reserpine in adjuvant melanoma therapy.

Function and regulation of the Caenorhabditis elegans Rab32 family member GLO-1 in lysosome-related organelle biogenesis

Cell type-specific modifications of conventional endosomal trafficking pathways lead to the formation of lysosome-related organelles (LROs). C. elegans gut granules are intestinally restricted LROs that coexist with conventional degradative lysosomes. The formation of gut granules requires the Rab32 family member GLO-1. We show that the loss of glo-1 leads to the mistrafficking of gut granule proteins but does not significantly alter conventional endolysosome biogenesis. GLO-3 directly binds to CCZ-1 and they both function to promote the gut granule association of GLO-1, strongly suggesting that together, GLO-3 and CCZ-1 activate GLO-1. We found that a point mutation in GLO-1 predicted to spontaneously activate, and function independently of it guanine nucleotide exchange factor (GEF), localizes to gut granules and partially restores gut granule protein localization in ccz-1(-) and glo-3(-) mutants. CCZ-1 forms a heterodimeric complex with SAND-1(MON1), which does not function in gut granule formation, to activate RAB-7 in trafficking pathways to conventional lysosomes. Therefore, our data suggest a model whereby the function of a Rab GEF can be altered by subunit exchange. glo-3(-) mutants, which retain low levels of GLO-3 activity, generate gut granules that lack GLO-1 and improperly accumulate RAB-7 in a SAND-1 dependent process. We show that GLO-1 and GLO-3 restrict the distribution of RAB-7 to conventional endolysosomes, providing insights into the segregation of pathways leading to conventional lysosomes and LROs.

Identification of factors associated with treatment refractoriness of oral lesions in pemphigus vulgaris

BACKGROUND

The oral mucosal lesions of patients with pemphigus vulgaris are known to show more treatment refractoriness than skin lesions.

OBJECTIVES

To identify which clinical and laboratory parameters may indicate treatment refractoriness of oral lesions in pemphigus vulgaris.

METHODS

This was a prospective study of 50 adults with pemphigus vulgaris and oral lesions; patients were given treatment appropriate for overall disease severity. Treatment refractoriness was defined arbitrarily as less than 75% reduction in oral objective Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) after treatment for 6 months.

RESULTS

Of 46 patients who completed the study, 17 (37%) were treatment refractory whereas 29 (63%) were treatment responsive. At baseline, the treatment refractory group had a significantly longer mean duration of disease (P = 0·02) and mean duration of oral lesions (P = 0·01), a higher percentage of lesions in the retromolar trigone (P = 0·05) and on the occlusion line along the buccal mucosa (P = 0·04), a higher percentage of deep/crateriform ulcers (P < 0·001) and erosions with a lichenoid hue (P < 0·001). Herpes simplex virus (HSV) DNA positivity, assessed by polymerase chain reaction in oral tissue scrapings (P = 0·02), was also significantly higher in the treatment refractory group. No other factors we tested for were statistically significant.

CONCLUSIONS

Treatment refractoriness of oral lesions was significantly associated with duration of disease/oral lesions; specific morphology and location of oral lesions; and the presence of HSV DNA in the oral cavity. These factors may forewarn the treating physician about a refractory course of oral lesions that may help with counselling patients.

Correlation between salivary and serum anti-desmoglein 1 and 3 antibody titres using ELISA and between anti-desmoglein levels and disease severity in pemphigus vulgaris

ELISA for anti-desmoglein antibodies (Dsg) is commonly used for diagnosis and assessment of treatment response in pemphigus vulgaris (PV). The present study was conducted to assess the relationship between salivary and serum Dsg1 and Dsg3 levels, and whether salivary Dsg1 and Dsg3 levels correlate with clinical disease severity of oral mucosal lesions in PV. In total 43, patients with PV with predominantly mucosal involvement were recruited. Both serum and salivary samples were collected from the cases, and salivary samples were also collected from five controls. There was a statistically significant correlation between serum and salivary Dsg1 levels and between serum and salivary Dsg3 levels. There was no correlation between serum or salivary Dsg1 and Dsg3 levels with the objective component of the oral mucosal Autoimmune Bullous Skin Disorder Intensity Score (ABSIS). Serum Dsg1 levels significantly correlated with cutaneous ABSIS, but there was no correlation between cutaneous ABSIS and either salivary Dsg1, salivary Dsg3 or serum Dsg3. As salivary Dsg titres correlate with serum levels, saliva can serve as a simple and noninvasive alternative to serum for Dsg ELISA.