Hyaluronic acid in Dentoalveolar regeneration: Biological rationale and clinical applications

Background

Hyaluronic acid (HA) is found in different locations in the periodontium, including mineralized tissues (i.e., cementum and alveolar bone) and non-mineralized tissues (i.e., gingiva and periodontal ligament). In addition, it seems to play an essential part in regulating the underlying mechanisms involved in tissue inflammatory reactions and wound healing. HA has the potential to regulate periodontal tissue regeneration and treat periodontal disease.

Aim

The current review of the literature was conducted to assess how HA plays its part in periodontal therapy and examine the contemporary literature's viewpoint on its use in periodontal regeneration.

Conclusion

HA has a multifunctional character in periodontal regeneration, and healing and appears to provide promising outcomes in different periodontal regenerative applications.

vNOTEsHC : Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery versus laparoscopic for large uteri: study protocol for a multicentre randomised controlled trial

Background

In France, 62,000 hysterectomies are performed per year, 70% of which are benign. The choice of approach (laparotomy, laparoscopy or vaginal route) is particularly important in the case of large uterus (> 280g) which are associated with a higher risk of complications. The current data are not sufficient to favour one or other approach. A new medical device, the vNOTES (Natural Vaginal Orifice Transluminal Endoscopy System), offers the advantage of both laparoscopic and vaginal route for pelvic surgery.

Objectives

To demonstrate the superiority in terms of intraoperative and postoperative complications of the use of a natural orifice transluminal endoscopic hysterectomy system (vNOTES) versus laparoscopic hysterectomy for benign pathologies on estimated large volume uteri (>280g).

Materials and Methods

A randomised, double-blind, superiority trial will be performed at five hospital centres. Women with benign uterine pathology requiring hysterectomy and with a large uterus (> 280g) will be randomised to receive either laparoscopic or vNOTES hysterectomy.

Main outcome measures

The primary outcome will be the occurrence of intraoperative and postoperative complications within 6 weeks of surgery. Secondary outcomes will be conversion during surgery, duration of surgery and hospitalisation, postoperative pain, postoperative complications, resumption of sexual life and satisfaction with the surgical team.

Results

248 women will be randomised.

Conclusion

This trial will provide a better understanding of the approach to large uteri optimise the care of these thousands of women undergoing hysterectomy.

What’s new?

This trial will evaluate the vNotes for large uteri.

Dirofilariasis mouse models for heartworm preclinical research

Introduction

Dirofilariasis, including heartworm disease, is a major emergent veterinary parasitic infection and a human zoonosis. Currently, experimental infections of cats and dogs are used in veterinary heartworm preclinical drug research.

Methods

As a refined alternative in vivo heartworm preventative drug screen, we assessed lymphopenic mouse strains with ablation of the interleukin-2/7 common gamma chain (γc) as susceptible to the larval development phase of Dirofilaria immitis.

Results

Non-obese diabetic (NOD) severe combined immunodeficiency (SCID)γc^-/- (NSG and NXG) and recombination-activating gene (RAG)2^-/-γc^-/- mouse strains yielded viable D. immitis larvae at 2-4 weeks post-infection, including the use of different batches of D. immitis infectious larvae, different D. immitis isolates, and at different laboratories. Mice did not display any clinical signs associated with infection for up to 4 weeks. Developing larvae were found in subcutaneous and muscle fascia tissues, which is the natural site of this stage of heartworm in dogs. Compared with in vitro-propagated larvae at day 14, in vivo-derived larvae had completed the L4 molt, were significantly larger, and contained expanded Wolbachia endobacteria titres. We established an ex vivo L4 paralytic screening system whereby assays with moxidectin or levamisole highlighted discrepancies in relative drug sensitivities in comparison with in vitro-reared L4 D. immitis. We demonstrated effective depletion of Wolbachia by 70%-90% in D. immitis L4 following 2- to 7-day oral in vivo exposures of NSG- or NXG-infected mice with doxycycline or the rapid-acting investigational drug, AWZ1066S. We validated NSG and NXG D. immitis mouse models as a filaricide screen by in vivo treatments with single injections of moxidectin, which mediated a 60%-88% reduction in L4 larvae at 14-28 days.

Discussion

Future adoption of these mouse models will benefit end-user laboratories conducting research and development of novel heartworm preventatives via increased access, rapid turnaround, and reduced costs and may simultaneously decrease the need for experimental cat or dog use.

Socioeconomic risk factors for low birth weight newborns: A population-based study

Low birth weight (LBW) is an important indicator of maternal health and poverty. This study explored the socioeconomic factors associated with LBW.

METHODS

Data was collected from a 4-year maternal-newborn registry.

RESULTS

There were 5,316 LBW and 54,029 normal birth weight (NBW). The prevalence of LBW was 9%. The Native women in the LBW group compared to non-native women were 10.4% (1784/5316) vs. 8.4% (3532/5316) with a P-value of 0.001. There were more illiterate mothers in the LBW compared to the NBW, respectively: 8.1% (1597/19497) vs. 7.5% (1763/23230) with a P-value of 0.001. Working mothers tend to have more LBW infants compared to mothers with NBW, 8.4% (1588/17217) vs. 7.9% (2532/31891) and P-value 0.001. Young mothers (<20 years old) with early childbearing had more LBW compared to older mothers, respectively 12.7% (180/1414) vs. 8.9% (5149/52919) P-value <0.001. Women with no antenatal care reported a high rate of LBW compared to women with regular antenatal care: 14.2% (516/3696) vs. 8.6% (4741/55691) P-value <0.001. LBW babies were born more from assisted conception pregnancies (38% compared to 8.4% of normal pregnancies) P-value <0.001. Smoking mothers scored higher with LBW at 13.6% vs. 8.3% and a P-value of 0.001. There were no differences between the two groups regarding religion, consanguinity, marital status, or family income.

CONCLUSION

Risk factors for low birth weight can be improved by providing antenatal care, smoking cessation, optimizing high-risk pregnancy care, and governing assisted reproduction regulations.

A Combination of Platelet-Rich Fibrin and Collagen Membranes for Sinus Membrane Repair: A Case Report (Repair of Sinus Membrane Perforation)

Maxillary sinus lift surgery is applied to compensate for the reduced vertical height in the posterior maxilla to facilitate placing a dental implant of a suitable length. Pathological conditions may be accidentally discovered, which necessitate careful assessment and management to prevent the infection of the maxillofacial complex and eventually bone grafting and dental implant failure. This case report describes an approach for the management of Schneiderian membrane perforation associated with the removal of an antral pseudocyst for successful dental implant therapy. A 70-year-old healthy Caucasian male presented for implant therapy to replace a non-restorable maxillary molar. Initial examination revealed the need for a sinus lift procedure to prepare the site for implant placement. A 3D CBCT evaluation before surgery revealed an incidental finding of a pathological lesion at the surgical site. The histological analysis of a biopsy specimen retrieved during implant site preparation showed findings consistent with antral pseudocyst. The resulting perforation of the sinus membrane was treated, and an adequate period of healing was given. A thickened sinus membrane was detected upon surgical exposure for implant placement. The novel technique illustrated could result in a fibrotic repaired sinus membrane and help shorten the time required for dental implant treatment.

Drug Delivery Systems in Regenerative Medicine: An Updated Review

Modern drug discovery methods led to evolving new agents with significant therapeutic potential. However, their properties, such as solubility and administration-related challenges, may hinder their benefits. Moreover, advances in biotechnology resulted in the development of a new generation of molecules with a short half-life that necessitates frequent administration. In this context, controlled release systems are required to enhance treatment efficacy and improve patient compliance. Innovative drug delivery systems are promising tools that protect therapeutic proteins and peptides against proteolytic degradation where controlled delivery is achievable. The present review provides an overview of different approaches used for drug delivery.

Comparison of Sub-epithelial Connective Tissue Graft and Platelet Rich Fibrin in Peri-implant Soft Tissue Augmentation: A Randomized Clinical Split-mouth Study

Aims and Background:

Gingival phenotype has a crucial impact on the peri-implant marginal bone stability. The aim of this clinical trial is to assess and compare the efficacy of the sub-epithelial connective tissue graft (SCTG) and platelet-rich fibrin (PRF) in improving the peri-implant soft tissue phenotype and enhancing esthetic outcomes.

Materials and Methods:

The present study was a split-mouth randomized controlled clinical trial. A total of ten patients who had bilateral missing teeth in the maxillary esthetic zone with a thin gingival phenotype were included in this study. For each study participant, one randomly selected site was treated with SCTG, while the other was treated with PRF membrane during dental implant placement. Treatment outcomes included the assessment of the facial gingival thickness using cone-beam computed tomography (CBCT) at the baseline (T0) and 6 months postoperatively (T1), and the Pink esthetic score (PES) at T1 and 3 months later after prosthesis placement (T2).

Results and Discussion:

Both treatment options resulted in a significant increase in gingival tissue thickness at T1 compared with T0, and in PES at T2 compared with T1 (p ˂ 0.05).

Conclusion:

PRF is an effective alternative to SCTG in augmenting peri-implant soft tissue phenotype and improving esthetic outcomes. This would help overcome the complications associated with harvesting the SCTG and increasing patients’ satisfaction.

Clinical Trial Registration ID: ISRCTN11961919.

Comparison of Sub-epithelial Connective Tissue Graft and Platelet Rich Fibrin in Peri-implant Soft Tissue Augmentation: A Randomized Clinical Split-Mouth Study

Aims and Background:

Gingival phenotype has a crucial impact on the peri-implant marginal bone stability. The aim of this clinical trial is to assess and compare the efficacy of the sub-epithelial connective tissue graft (SCTG) and platelet-rich fibrin (PRF) in improving the peri-implant soft tissue phenotype and enhancing esthetic outcomes.

Material and Methods:

The present study was a split-mouth randomized controlled clinical trial. A total of ten patients who had bilateral missing teeth in the maxillary esthetic zone with a thin gingival phenotype were included in this study. For each study participant, one randomly selected site was treated with SCTG while the other was treated with PRF membrane during dental implant placement. Treatment outcomes included the assessment of the facial gingival thickness using cone-beam computed tomography (CBCT) at the baseline (T0) and 6 months postoperatively (T1), and the Pink esthetic score (PES) at T1 and 3 months later after prosthesis placement (T2).

Results and discussion:

Both treatment options resulted in a significant increase in gingival tissue thickness at T1 compared with T0, and in PES at T2 compared with T1 (p ˂ 0.05).

Conclusion:

PRF is an effective alternative to SCTG in augmenting peri-implant soft tissue phenotype and improving the esthetic outcomes. This would help overcome the complications associated with harvesting the SCTG and increasing patients’ satisfaction.

COVID-19 Vaccine Triggered Rejection in Lung Transplant Recipients: A Case Series

Purpose

Methods

Results

Conclusion

The United States Experience of Lung Transplantation in Recipients with COVID-19 Fibrosis: A UNOS/OPTN Analysis

Purpose

Coronavirus Disease 19 (COVID-19) is a novel cause of end-stage fibrotic lung disease. Data has been limited to case series and single center reports with regards to outcomes in this unique cohort of patients. We sought to investigate the largest experience to date in patients with COVID-19 fibrosis (CVF) who underwent lung transplantation.

Methods

The United Network for Organ Sharing (UNOS) database was queried for all adult patients (≥18 years old) who underwent isolated lung transplantation between 2018 and July 2021. Recipients diagnosed with CVF were identified and compared to those with idiopathic pulmonary fibrosis (IPF). The IPF cohort included recipients from 2018, in the pre-COVID era. Baseline demographics, perioperative factors, and 30-day outcomes were examined.

Results

A total of 931 recipients were included in this study, 868 (93.2%) and 63 (6.8%) were IPF and CVF, respectively. IPF recipients were on average older (65 vs. 56 years, p<0.001), white race (83% vs. 51%, p<0.001), and less likely to be male (73% vs. 86%, p=0.04). BMI was similar between the IPF and CVF, 27.6 and 27.2 kg/m², as was the mean PAP 24 and 21 mmHg. The CVF cohort had lower predicted FVC (32% vs. 47%, p=0.01), and had less tobacco use (36% vs 61%, p<0.001). Mean creatinine level was clinically similar, though statistically higher in the IPF cohort, (0.83 vs 0.64, p<0.001). CVF recipients were on the waitlist for a shorter median duration (10 vs 32 days, p<0.001) with a higher LAS (85 vs 41, p<0.001). Notably, more CVF recipient were be on ECMO at time of listing (29% vs 2%, p<0.001) and require ventilatory support (27% vs. 2%, p<0.001). CVF recipients were more likely to receive a double lung transplantation compared to IPF (83% vs 64%, p=0.002), with similar ischemia times, 5.5 vs 5.1 hrs (p=0.17). Mortality at 30 days was comparable between CVF and IPF (7.0% vs. 2.3%, p=0.09), though 20 patients in the CVF cohort had missing data.

Conclusion

Patients with end-stage lung disease secondary to CVF are higher acuity, and more likely to require ECMO and ventilatory support as a bridge to lung transplantation. Early mortality, while comparable to non-COVID related fibrotic lung disease, remains almost 3 times higher with CVF. In the era of publicly reported survival outcomes, the transplant community may need to reconsider how we approach this new and devastating diagnosis of CVF.

Assessment of Hygienic Status of Some Local Abattoirs and its Impact on Meat Quality

The current study was conducted to evaluate the hygienic status of some local abattoirs and its impact on meat quality through determination of aerobic plate, Enterobacteriaceae, coliforms, Staphylococcus aureus, Enterococci, molds, and yeasts counts. This study was conducted in 5 municipal slaughterhouses located in different provinces, Egypt. A total of 300 samples were collected as following: slaughtered meat, water, and air samples beside swabs from floor, wall, and workers hand (50 samples/each). Statistical analytical results of aerobic plate count clarified that the highest mean value was recorded in the floor swabs (8.9×105 CFU/g) followed by hand swabs of workers (7.41×105 CFU/g) then wall swabs and air samples (7.2×105 CFU/g) then water samples (5.2×105 CFU/g) and lastly meat samples (1.3×105 CFU/g). The highest mean value of Enterobacteriaceae count was recorded in the floor swabs (3.2×104 CFU/g) followed by wall swabs (9.3×103 CFU/g) then air samples (6.63×103 CFU/g) then hand swabs of workers (5.33×103 CFU/g) then water samples (3.19×103 CFU/g) and lastly meat samples (9.02×102 CFU/g). The highest mean value of coliforms count was recorded in the floor swabs (1.65×103 CFU/g) followed by hand swabs of workers (7.23×102 CFU/g) then meat samples (6.10×102 CFU/g) then water samples (4.10×102 CFU/g) then wall swabs (1.72×102 CFU/g) and lastly air samples (1.32×102 CFU/g). On comparison of various microbiological counts on the investigated meat samples with the Egyptian standards, it was clear that most of samples failed to comply with standards confirming the role of contaminated abattoir environment in the obtained result. Results of microbiological examination of the collected samples reflected a clear state of contamination in abattoirs environment that would affect the microbiological quality of the produced meat from these abattoirs that in turn would be harmful for human health.

Prevalence and Antimicrobial Resistance Profile of Methicillin Resistant Staphylococcus aureus strains Isolated from Food Products and Food Handlers in Egypt

The study aimed to determine the prevalence and phenotypic antimicrobial resistance pattern of Methicillin Resistant Staphylococcus aureus (MRSA) isolated from food products and food handlers at different retail outlets and superstores in Alexandria city, Egypt. A total of 100 food products including raw milk, Damietta cheese, beef burger, sausage, and chicken pane (20 of each) as well as 100 hand swabs were randomly collected from 100 food handlers and screened for the presence of MRSA using MRSA selective agar medium. MRSA isolate was confirmed from each nuc /mecA PCR-positive sample. The overall prevalence rate of MRSA in food products and food handlers was 12% and 5%, respectively. Concerning the food products samples, the highest rate of isolation was recorded in the examined samples of beef burger (20%), followed by sausage (15%) then raw milk and chicken pane (10%) and finally Damietta cheese (5%). The antimicrobial susceptibility testing of the 12 MRSA isolates from food products samples clarified that all (100%) MRSA isolates showed resistance to Cefoxitin and Penicillin G. On the contrary, 100% of the isolates were sensitive to Ceftaroline and Linezolid. Regarding food handlers, prevalence rate was 5.3% in males and 4.2% in females. The phenotypic antimicrobial resistance pattern of the 5 MRSA isolates from food handlers revealed that all (100%) MRSA isolates exhibited resistance to Cefoxitin and Penicillin G. Conversely, 100% of the isolates were sensitive to Ceftaroline and Linezolid. The results of the current study suggest that raw food products may have been contaminated with MDR MRSA strains which could be a potential public health risk. Moreover, these findings unequivocally show the need for enhanced hygiene standards to minimize the risk of occupational and food-borne illness associated with handling and/or consuming raw animal food products harboring MRSA.

Melanoma in Pregnancy and Pediatrics

Rare variants of melanoma include melanoma in pregnancy and pediatric melanoma. Because of their low incidence, treatment recommendations are based on standards of treatment for cutaneous melanoma; however, each of these forms requires specific considerations during diagnosis, staging, and treatment.

Polymyositis and covid-19: A morbide association (a case report)

The COVID-19 pandemic and its impact on health systems had a significant effect on the management of inflammatory diseases in the long term and myopathies could be signs of COVID-19, making it difficult to diagnose the cause and effect relationship. An unvaccinated 62-year-old female patient followed for polymyositis was tested positive for COVID-19 on polymerase chain reaction (PCR) of nasopharyngeal swab revealed by dyspnea and rhinorrhea with fever and pulmonary involvement of 75%. She had an enlarged left ventricle with complete left branch block, inaugural diabetes mellitus with ketosis, kidney dysfunction, and inflammatory syndrome. Despite the early initiation of invasive ventilation in combination with the national protocol against covid-19, the patient died on day 4 of care. The best management should anticipate comorbidities and the evolutionary profile would guide the continuation of the treatment. Polymyositis like other rheumatic diseases was associated with a very high risk of developing a severe form of COVID-19. The combination of elder age and comorbidities led to a severe form of COVID-19 and therefore to a poor prognosis. The article aimed to show the severity of the association of covid-19 with polymyositis at the comorbid stage.

Non-steroidal anti-inflammatory drugs and bone healing in animal models-a systematic review and meta-analysis

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAID) have excellent anti-inflammatory and analgesic properties and are extensively used to treat post-traumatic or surgical musculoskeletal pain. Although an extensive literature exists on the administration of NSAID on animal bone healing, no systematic review and meta-analysis of animal studies that investigate the effect of NSAID administration on bone fracture healing. Objective of this study is to conduct a systematic review and meta-analysis to estimate the effect of NSAIDs administration on bone healing biomechanical and histomorphometric measurements in different animal models after bone fracture surgery.

METHODS

We performed a systematic review and meta-analysis of animal studies to estimate the effect of NSAID administration after bone fracture on healing outcomes. We searched eight databases without limiting the search to starting date up to 1 February 2021 for articles on fractured bone healing in animal models in which NSAID were administered.

RESULTS

Out of 6732 articles screened, 47 were included and 3 common bone healing outcomes were analysed: biomechanical properties (maximum force to break, stiffness, and work-to-failure), micro-computed tomography (μ-CT), and histomorphometric measurements. The studies were generally of low-quality scores because crucial information, especially concerning randomization, blinding, and allocation concealment, was poorly reported. Our results show that the negative effects of NSAID after bone fracture on certain biomechanical properties of the healing bones was not statistically significant in mice compared with other animals, in females compared with males, and in younger compared with older animals.

CONCLUSION

The findings demonstrated that NSAIDs administration decreased the biomechanical properties of healing bones after fracture surgery in comparison to the control group. Moreover, different effect on certain outcomes was detected among different sites, sex of the animals, and the time of assessment.

TRIAL REGISTRATION

Protocol published and registered in SYstematic Review Center for Laboratory animal Experimentation (SYRCLE) in 2017, https://www.radboudumc.nl/getmedia/757ec408-7a9e-4635-8233-ae951effea54/Non-Steroidal-Anti-inflammatory-Drugs-and-bone-healing-in-animal-Models-Systematic-Review-and-Meta-Analysis.aspx.

Biomimetic trace metals improve bone regenerative properties of calcium phosphate bioceramics

The bone regenerative capacity of synthetic calcium phosphates (CaPs) can be enhanced through the enrichment with selected metal trace ions. However, defining the optimal elemental composition required for bone formation is challenging due to many possible concentrations and combinations of these elements. We hypothesized that the ideal elemental composition exists in the inorganic phase of the bone extracellular matrix (ECM). To study our hypothesis, we first obtained natural hydroxyapatite through the calcination of bovine bone, which was then investigated its reactivity with acidic phosphates to produce CaP cements. Bioceramic scaffolds fabricated using these cements were assessed for their composition, properties, and in vivo regenerative performance and compared with controls. We found that natural hydroxyapatite could react with phosphoric acid to produce CaP cements with biomimetic trace metals. These cements present significantly superior in vivo bone regenerative performance compared with cements prepared using synthetic apatite. In summary, this study opens new avenues for further advancements in the field of CaP bone biomaterials by introducing a simple approach to develop biomimetic CaPs. This work also sheds light on the role of the inorganic phase of bone and its composition in defining the regenerative properties of natural bone xenografts.

High strength brushite bioceramics obtained by selective regulation of crystal growth with chiral biomolecules

Chirality seems to play a key role in mineralization. Indeed, in biominerals, the biomolecules that guide the formation and organization of inorganic crystals and help construct materials with exceptional mechanical properties, are homochiral. Here, we show that addition of homochiral l-(+)-tartaric acid improved the mechanical properties of brushite bioceramics by decreasing their crystal size, following the classic Hall-Petch strengthening effect; d-(-)-tartaric acid had the opposite effect. Adding l-(+)-Tar increased both the compressive strength (26 MPa) and the fracture toughness (0.3 MPa m^1/2) of brushite bioceramics, by 33% and 62%, respectively, compared to brushite bioceramics without additives. In addition, l-(+)-tartaric acid enabled the fabrication of cements with high powder-to-liquid ratios, reaching a compressive strength and fracture toughness as high as 32.2 MPa and 0.6 MPa m^1/2, respectively, approximately 62% and 268% higher than that of brushite bioceramics prepared without additives, respectively. Characterization of brushite crystals from the macro- to the atomic-level revealed that this regulation is attributable to a stereochemical matching between l-(+)-tartaric acid and the chiral steps of brushite crystals, which results in inhibition of brushite crystallization. These findings provide insight into understanding the role of chirality in mineralization, and how to control the crystallographic structure of bioceramics to achieve high-performance mechanical properties. STATEMENT OF SIGNIFICANCE: Calcium-phosphate cements are promising bone repair materials. However, their suboptimal mechanical properties limit their clinical use. Natural biominerals have remarkable mechanical properties that are the result of controlled size, shape and organization of their inorganic crystals. This is achieved by biomineralization proteins that are homochiral, composed of l- amino acids. Despite the importance of chiral l-biomolecules in biominerals, using homochiral molecules to fabricate bone cements has not been studied yet. In this study, we showed that homochiral l-(+)-tartaric acid can regulate the crystal structure and improve the mechanical properties of a calcium-phosphate cement. Hence, these findings open the door for a new way of designing strong bone cement and highlight the importance of chirality in bioceramics.

Chronotherapy of Non-Steroidal Anti-Inflammatory Drugs May Enhance Postoperative Recovery

Postoperative pain relief is crucial for full recovery. With the ongoing opioid epidemic and the insufficient effect of acetaminophen on severe pain; non-steroidal anti-inflammatory drugs (NSAIDs) are heavily used to alleviate this pain. However, NSAIDs are known to inhibit postoperative healing of connective tissues by inhibiting prostaglandin signaling. Pain intensity, inflammatory mediators associated with wound healing and the pharmacological action of NSAIDs vary throughout the day due to the circadian rhythm regulated by the clock genes. According to this rhythm, most of wound healing mediators and connective tissue formation occurs during the resting phase, while pain, inflammation and tissue resorption occur during the active period of the day. Here we show, in a murine tibia fracture surgical model, that NSAIDs are most effective in managing postoperative pain, healing and recovery when drug administration is limited to the active phase of the circadian rhythm. Limiting NSAID treatment to the active phase of the circadian rhythm resulted in overexpression of circadian clock genes, such as Period 2 (Per2) at the healing callus, and increased serum levels of anti-inflammatory cytokines interleukin-13 (IL-13), interleukin-4 (IL-4) and vascular endothelial growth factor. By contrast, NSAID administration during the resting phase resulted in severe bone healing impairment.

Bone extracts immunomodulate and enhance the regenerative performance of dicalcium phosphates bioceramics

Immunomodulation strategies are believed to improve the integration and clinical performance of synthetic bone substitutes. One potential approach is the modification of biomaterial surface chemistry to mimic bone extracellular matrix (ECM). In this sense, we hypothesized that coating synthetic dicalcium phosphate (DCP) bioceramics with bone ECM proteins would modulate the host immune reactions and improve their regenerative performance. To test this, we evaluated the in vitro proteomic surface interactions and the in vivo performance of ECM-coated bioceramic scaffolds. Our results demonstrated that coating DCP scaffolds with bone extracts, specifically those containing calcium-binding proteins, dramatically modulated their interaction with plasma proteins in vitro, especially those relating to the innate immune response. In vivo, we observed an attenuated inflammatory response against the bioceramic scaffolds and enhanced peri-scaffold new bone formation supported by the increased osteoblastogenesis and reduced osteoclastogenesis. Furthermore, the bone extract rich in calcium-binding proteins can be 3D-printed to produce customized hydrogels with improved regeneration capabilities. In summary, bone extracts containing calcium-binding proteins can enhance the integration of synthetic biomaterials and improve their ability to regenerate bone probably by modulating the host immune reaction. This finding helps understand how bone allografts regenerate bone and opens the door for new advances in tissue engineering and bone regeneration. STATEMENT OF SIGNIFICANCE: Foreign-body reaction is an important determinant of in vivo biomaterial integration, as an undesired host immune response can compromise the performance of an implanted biomaterial. For this reason, applying immunomodulation strategies to enhance biomaterial engraftment is of great interest in the field of regenerative medicine. In this article, we illustrated that coating dicalcium phosphate bioceramic scaffolds with bone-ECM extracts, especially those rich in calcium-binding proteins, is a promising approach to improve their surface proteomic interactions and modulate the immune responses towards such biomaterials in a way that improves their bone regeneration performance. Collectively, the results of this study may provide a conceivable explanation for the mechanisms involved in presenting the excellent regenerative efficacy of natural bone grafts.

National Home Care Initiative in Jordan: A Demonstration Project

Background and context: The home healthcare market in Jordan is nascent with little service offered. It suffers from a highly fragmented and underregulated landscape. The limited access to qualified trustworthy home care services, lack of professional home care training, and lack of home health care insurance coverage have added to the heavy in-patient bed demand and delayed hospital discharges especially for disabled or terminally ill patients. Aim: To establish a comprehensive national home care program to improve the delivery of palliative and home care services in Jordan, and to conduct a situational analysis and generate policy recommendations. Strategy/Tactics: We used multiple strategies to reach our objectives. 1. Expansion of home care services at King Hussein Cancer Center (KHCC) to create a local demonstration project. 2. Building health care professional capacity by offering variety of educational programs. 3. Improving quality of service delivery by generating clinical practice guidelines, such as standards operating procedures and patient and family educational materials. 4. Use the pilot operational and financial data to generate an economic model to inform the development of similar home health care units in hospitals across Jordan. 5. National advocacy and building effective partnership with all related stakeholders to advance national policy. Program/Policy process: Between May 2016 and May 2017, 7818 home care visits were conducted by KHCC. For capacity building; 678 health care professionals were trained in palliative and home care, out of which 366 participants were females (54%). Palliative care was successfully recognized as a specialty by the Jordan Nursing Council and recognized as a subspecialty by the Jordan Medical Council. The palliative and home care standards of practice were included in the health care accreditation council. The analysis of economic evaluation data suggested that home care services decreased in-patient utilization and costs which is advantageous to a country with limited resources. As a result of the advocacy stream and a collaborative network, the national palliative and home care strategic framework was generated, and endorsed by the Ministry of Health. Outcomes: The NHCI resulted in a very successful pilot project and achieved specialty and subspecialty recognition. Furthermore, we were able to build the capacity of health care professionals and policy makers in the palliative and home care sector from public, private and academic institutions. In the advocacy and policy dimension, the Minister of Health officially approved and adapted the palliative and home care strategic framework that was developed by this initiative. What was learned: Cross-sector collaboration and effective partnership resulted in system change and policy advancement. Developing effective economic systems is essential in low resourced countries. The initiative was supported by a joint grant from the USAID and KHCC.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Camel molar tooth enamel response to gamma rays using EPR spectroscopy

Tooth enamel samples from molar teeth of camel were prepared using a combined procedure of mechanical and chemical tooth treatment. Based on electron paramagnetic resonance (EPR) spectroscopy, the dose response of tooth enamel samples was examined and compared to that of human enamel. The EPR dose response of the tooth enamel samples was obtained through irradiation to gamma doses from 1 Gy up to 100 kGy. It was found that the radiation-induced EPR signal increased linearly with gamma dose for all studied tooth enamel samples, up to about 15 kGy. At higher doses, the dose response curve leveled off. The results revealed that the location of the native signal of camel tooth enamel was similar to that of enamel from human molars at 2.00644, but different from that of enamel from cows and goats. In addition, the peak-to-peak width (ΔH _pp) for human and camel molar teeth was similar. It was also found that the response of camel enamel to gamma radiation was 36% lower than that of human enamel. In conclusion, the results indicate the suitability of camel teeth for retrospective gamma dosimetry.

Effect of early adjunctive use of oral sildenafil and inhaled nitric oxide on the outcome of pulmonary hypertension in newborn infants. A feasibility study

INTRODUCTION

Inhaled nitric oxide (iNO) is the standard therapy for infants with persistent pulmonary hypertension of the newborn (PPHN). Recently, sildenafil has been evaluated as an alternative or adjunctive pulmonary vasodilator.

OBJECTIVE

To assess the effectiveness of adding sildenafil as an early adjunctive therapy together with iNO when treating newborns with PPHN and/or hypoxemic respiratory failure.

METHODS

This is a randomized placebo trial on newborns with gestational age > 34 weeks, postnatal age < 48 hours, and diagnosed with PPHN (oxygen index (OI) ≥ 20). Newborns were randomized to two groups: Group A- received oral sildenafil and iNO, and group B- received placebo and iNO. Initial and follow up echocardiography were performed over 14 days period.

RESULTS

A total of 24 newborns were recruited; 13 of them received sildenafil in addition to iNO and 11 received iNO and placebo. The most common causes of PPHN were meconium aspiration syndrome, pneumonia, and RDS. At the starting point, OI was marginally higher in the intervention group without statistical significance (29 vs 28). There were no differences between the two groups regarding surfactant administration, incidence of pneumothoraces, and the underlying causes of PPHN. Sildenafil or placebo treatment started within 12 hours after starting iNO (8 vs 6 hours).

CONCLUSION

Early use of oral sildenafil next to iNO in cases of PPHN was tolerated well by newborns and it did not show significant adverse effects. Further studies with a larger sample size is needed to assess its effecacy.

* Extracellular Matrices for Bone Regeneration: A Literature Review

The gold standard material for bone regeneration is still autologous bone, a mesenchymal tissue that consists mainly of extracellular matrix (ECM) (90% v/v) and little cellular content (10% v/v). However, the fact that decellularized allogenic bone grafts often present a clinical performance comparable to autologous bone grafts demonstrates the crucial role of ECM in bone regeneration. For long, the mechanism by which bone allografts function was not clear, but recent research has unveiled many unique characteristics of ECM that seem to play a key role in tissue regeneration. This is further confirmed by the fact that synthetic biomaterials with composition and properties resembling bone ECM present excellent bone regeneration properties. In this context, ECM molecules such as glycosaminoglycans (GAGs) and self-assembly peptides (SAPs) can improve the performance of bone regeneration biomaterials. Moreover, decellularized ECM derived either from native tissues such as bone, cartilage, skin, and tooth germs or from cells such as osteoblasts, chondrocytes, and stem cells has shown promising results in bone regeneration applications. Understanding the role of ECM in bone regeneration is crucial for the development of the next generation of biomaterials for bone tissue engineering. In this sense, this review addresses the state-of-the-art on this subject matter.