Immunohistochemical expression of non-collagenous extracellular matrix molecules involved in tertiary dentinogenesis following direct pulp capping: a systematic review

BACKGROUND

Extracellular matrix molecules (ECMM) expression during tertiary dentinogenesis provides useful information for regenerative applications and efficacy of pulp capping materials.

AIM

To identify and review the expression and roles of non-collagenous ECMM after successful direct pulp capping (DPC), following mechanical pulp exposures, via immunohistochemistry (IHC). The study addressed the question of where will successful DPC impact the IHC expression of these molecules.

DATA SOURCES

In vivo animal and human original clinical studies reporting on ECMM in relation to different follow-up periods were screened and evaluated via descriptive analysis. The electronic literature search was carried out in three databases (MEDLINE/PubMed, Web of Science, Scopus), followed by manual screening of relevant journals and cross-referencing, up to December 2018.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

Randomized and non-randomized controlled trials, conducted in humans and animals, were selected. Histological evidence for tertiary dentine formation was a prerequisite for IHC evaluation.

STUDY APPRAISAL AND SYNTHESIS METHODS

The methodological quality of the included articles was independently assessed using the Systematic Review Centre for Laboratory animal Experimentation (SYRCLE) and the Cochrane risk of bias tool (RoB 1), respectively.

RESULTS

From a total of 1534 identified studies, 18 were included. Thirteen papers evaluated animal subjects and five studies were carried out on humans. In animals and humans, fibronectin and tenascin expressions were detected in pulp and odontoblast-like cells (OLC); dentine sialoprotein was expressed in both soft and newly-formed mineralized tissue. In animals, bone sialoprotein was early expressed, in association with OLC and predentin; the immunoreactivity for dentine sialophosphoprotein and dentine matrix protein-1 was associated with the OLC and dentine bridge; osteopontin was expressed in OLC, predentine and reparative dentine. A considerable heterogeneity was found in the methodologies of the included studies, as well as interspecies variability of results in terms of time.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Within the limited scientific evidence, all non-collagenous ECMM expressions during tertiary dentinogenesis are active and related to soft and hard tissues. There is a shortage of human studies, and future research directions should focus more on them. PROSPERO Protocol: CRD42019121304.

Preclinical and clinical assessment of immune checkpoint inhibitor-associated left ventricular dysfunction

Background

Immune checkpoint inhibitor (ICI) therapy has improved treatment of advanced cancers but is associated with yet incompletely characterized cardiotoxic side effects. While inflammatory cardiac complications were initially described as a rare phenomenon, emerging evidence indicates frequent cardiotoxicity, particularly latent left ventricular (LV) dysfunction. Distinct clinical characteristics and potential pathomechanisms are so far unknown.

Purpose

This study aims to investigate incidence and frequency of LV dysfunction in patients receiving ICI therapy for malignant melanoma. Using a suitable melanoma mouse model, ICI-related cardiotoxicity will be reenacted to identify potential underlying pathomechanisms.

Methods

Patients receiving ICI therapy for stage IV melanoma that presented in our cardio-oncology unit were evaluated at baseline and four weeks after initiation of therapy including echocardiography, cardiac biomarkers, and dobutamine stress echocardiography in the absence of contraindications. Patients with decreased LV ejection fraction (LVEF) were further evaluated by 18-fludeoxyglucose PET-MRI to assess manifest myocarditis. To elucidate underlying pathomechanisms, we established a melanoma mouse model that showed profound response to anti-programmed death 1 (PD1) ICI therapy. Immune cell infiltration was assessed by flow cytometry and light sheet fluorescence microscopy. Myocardial biochemical function was analyzed using a multi-omics mass spectrometry-based approach.

Results

Seven patients were included to the analysis. Six patients received a combination ICI therapy with ipilimumab and nivolumab, and one patient received nivolumab monotherapy. Echocardiography revealed significantly decreased 3D-LVEF after 4 weeks of therapy in treated patients (p=0.021). A reduced global longitudinal strain was found in six of seven patients. Remarkably, dobutamine stress echocardiography revealed a more pronounced LVEF-decrease (p=0.009) as a sign for impaired myocardial contractility with a mean decrease of 5 percentage points. Using the melanoma mouse model, we were able to recapitulate the disease phenotype as indicated by decreased LVEF and impaired response to inotropic stress during mouse pressure/volume catheterization. Increased concentrations of intramyocardial CD4+ and CD8+ T cells were found in mice treated with anti-PD1 ICI therapy compared to controls (p=0.01). Mass spectrometry revealed disrupted energy metabolism and calcium homeostasis as a putative underlying pathomechanism for impaired myocardial function.

Conclusions

ICI-related left ventricular dysfunction may affect a large proportion of patients and potentially increase cardiac morbidity and mortality. Preclinical data proposes myocardial lymphocyte infiltration and disruption of cardiomyocyte metabolism as the underlying pathomechanism. Prospective studies are now needed for a further characterization of this novel form of ICI-related cardiotoxicity.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): IFORES research grant, Medical Faculty, University Duisburg-Essen, Germany

Rapid single-cell detection and identification of pathogens by using surface-enhanced Raman spectroscopy

For the successful treatment of infections, real-time analysis and enhanced multiplex capacity, sensitivity and cost-effectiveness of the developed detection method are critical.

Epicardial fat thickness significantly decreases after short-term growth hormone (GH) replacement therapy in adults with GH deficiency

BACKGROUND AND AIM

Growth Hormone Deficiency (GHD) is characterized by increased visceral fat accumulation. Echocardiographic epicardial fat thickness is a new marker of visceral adiposity. Aim of the present study was to evaluate whether epicardial fat thickness can significantly change and therefore serve as a marker of visceral fat reduction after short-term rhGH replacement therapy in patients with adult-onset GHD.

METHODS AND RESULTS

Echocardiographic epicardial fat thickness was measured in 18 patients (10 M, 8 F, age 48 ± 11.8 yrs, BMI 29 ± 5.9 kg/m(2)) with adult-onset GHD, at baseline and after 6 and 12 months of rhGH therapy and in 18 healthy matched controls, at baseline. Echocardiographic epicardial fat thickness, conventional anthropometric and metabolic parameters, body fat percentage and quality of life were also evaluated. Epicardial fat thickness in adult GHD patients was higher than in controls (9.8 ± 2.8 vs 8 ± 3 mm, p < 0.05). Epicardial fat thickness significantly decreased after 6-months of rhGH replacement therapy (from 9.8 ± 2.8 to 7.0 ± 2.3 mm, P < 0.01, i.e. -29% from baseline). After 12 months of rhGH replacement therapy, epicardial fat thickness showed a further significant decrease (from 7.0 ± 2.3 to 5.9 ± 3.1 mm, P < 0.01, i.e. -40% from baseline). No significant changes in BMI or waist circumference after 6 or 12 months of rhGH therapy were observed.

CONCLUSIONS

Echocardiographic epicardial fat thickness may represent a valuable and easy marker of visceral fat and visceral fat changes during rhGH replacement treatment in patients with adult-onset growth hormone deficiency.

Transplantation of composite tissue allograft: scientific bases and clinical applications

Plastic surgery is by excellence a surgery in permanent search for new reconstructive options. In the last 50 years researches in the field of allotransplantation led to obtaining promising results for solving difficult cases when autologous tissues are not available for reconstruction, despite all the bioethical issues of this subject. This field of composite tissue transplantation evolved constantly, the top of it being total face transplantation, successfully accomplished while being based on the knowledge accumulated. There are many clinical applications of CTA, hand transplantation or only flexor tendon apparatus, lower limb, partial or complete face transplantations represent the most important part for us, plastic surgeons for obtaining the best reconstruction possible.

[Tricophyton rubrum in a case of tinea unguium phenotypic mycological diagnostic algorithm and its limits]

Trichophyton rubrum is the most common dermatophyte isolated from human dermatophytosis. We present the mycological diagnosis algorithm and results in an onychomycosis case--tinea unguium. Biological samples have been inoculated on both usual and special culture media and incubated at both 30 degrees C and 37 degrees C for a period of fourteen days. Based on the macroscopic and microscopic characters and on the physiological and biochemical tests results, we identified a Trichophyton rubrum granular type dermatophyte. We are discussing phenotypic mycological diagnosis limits and molecular diagnostic benefits for rapid setting up of fungal therapy in order to avoid chronic mycosis and their complications.

Echocardiographic alterations in patients with non-functioning adrenal incidentaloma

OBJECTIVE

While left ventricular (LV) dysfunction has been described in patients with Cushing's syndrome (CS), data concerning morphologic and functional cardiac alterations in patients with incidentally discovered adrenal masses [adrenal "incidentaloma" (AI)], without overt hypercortisolism, are lacking. In this study the echocardiographic characteristics of patients with AI were evaluated and then compared with those of lean and obese normotensive subjects.

SUBJECTS AND METHODS

Twenty-one patients with AI, without clinical or subclinical hypercortisolism, 18 normotensive obese subjects matched for gender and body mass index (BMI) and 20 normotensive lean subjects were studied. Echocardiography was performed in all subjects. In all patients plasma ACTH, serum cortisol, and DHEA-S levels were measured.

RESULTS

Patients with AI showed greater impairment of several echocardiographic indices of LV hypertrophy and diastolic dysfunction compared to normotensive lean subjects (p<0.05), but did not differ from those in obese subjects. Hypertensive AI patients showed a greater alteration of echocardiographic parameters (p<0.05) and higher BMI (p<0.01) and cortisol values (p<0.05) than normotensive ones. Plasma ACTH and serum cortisol were similar in AI patients and in obese controls, while DHEA-S levels were lower in AI (p<0.05). No correlations between cortisol secretion and echocardiographic parameters were found.

CONCLUSION

In patients with non-functioning AI there is an impairment of cardiac morphology and function. These data suggest that patients with AI should be carefully screened also by means of echocardiographic studies.

Stanford type A aortic dissection in a hypertensive patient with atherosclerosis of aorta and aortitis

Dissection of aorta is a serious condition; the main factors are hypertension and diseases of the connective tissue or of collagen. Aortitis syndrome in combination with hypertension and atherosclerosis in association with ascending aortic dissection is rarely seen. We present the case of a 53-year-old hypertensive patient whose ascending aortic dissection was associated with pericardial effusion without rupture of the aorta and with pleural effusion. Several unusual aspects of transesophageal echocardiography are described. The intraoperative biopsy revealed inflammatory aortitis with mural hematoma, without giant cells. The literature concerning aortic dissection and aortitis is reviewed.

[Congenital transdiaphragmatic hernia with a late manifestation]

A case of diaphragmatic pathology is presented consisting in transdiaphragmatic penetration of abdominal viscera. It raised problems of differential diagnosis with other intrapleural pathology. X-ray aspects should not be interpreted without including them into the general clinical and laboratory data in order to avoid errors of diagnosis and treatment.

[Clinico-radiologic and morphopathologic aspects of mediastinal-pulmonary hemangiopericytoma]

The paper points out the diagnosis of intrathoracic hemangiopericytoma in 13 patients in the "M.Nasta" Institute of Pneumophthisiology, a seldom seen disease considered quite serious because of its malignant form and its late finding out. This is due to its non-distinctive, small number of symptoms, which has a negative influence upon the disease prognosis and evolution.

[Mediastinal neurogenic tumors]

An analysis is presented of clinical, radiological and evolutive aspects of 106 neurogenic mediastinal tumors operated in the Clinic for Tjhoracic surgery from Bucharest. The predominance is stressed of tumours originating in the nervous sheaths (62%), and the high incidence of tumours of the nervous cells (sympatomas, ganglio-neuroblastomas) in children. An analysis is made of the various surgical aspects. and the post-operative results, mostly favourable in over 90% of the subjects that underwent surgery.

[Our experience in the surgical treatment of pleural empyema by thoracopleuroplasty]

An analysis is presented, of the experience acquired in the Clinic for Thoracic Surgery from Bucharest in the surgical treatment of thoracal empyema by the Andrews type thoracopleuroplastia. The advantages of the surgical technique are stressed, after the modifications introduced by the authors, in contrast with other surgical techniques used, such as successive-type thoracoplastia, topographical thoracoplastia, plastron removal, etc. Careful preoperative preparation is recommended, and surgical indications are indicated and the major technical and tactical principles of the intervention are described. The Clinic's experience is based on 281 interventions. Of these 206 cases were of bacillary origin and 75 were non-bacillary. The etiologic forms of these empyemas are also analyzed. In such interventions the mortality was under 1%. Recidives were noted in approximately 1% of the cases and postoperative complications were solved without raising particular difficulties. These results recommend the thoracoplastia type intervention as the choice technique in a large number of thoracic empyemas.

[Surgical treatment of endothoracic goiter]

The authors make an analysis of the experience accumulated in the Clinic for Thoracic Surgery of Bucharest as a result of the surgical treatment of 16 patients endothoracic goiters. The authors stress the fact that these goiters should be differentiated from the "plunging goiter" variety, by their symptomatology, and by the different way of approaching their treatment. The diagnostic difficulties are stressed, especially since the uptake of iodine (radioactive iodine) can be negative in the endothoracic goiter of the functional type. The authors prefer thoracotomy, while the sternotomy is reserved only for the endothoracic goiters in the median area. The immediate results have been good in 15 cases. One patient died as a result of toxi-infectious phenomena.

[Surgical treatment of mediastinal tumors]

Based on a statistic which included 700 cases of mediastinal tumours (of which 460 underwent surgery), hospitalized in the Clinic for Thoracic Surgery of the Phtysiology Institute from Bucharest, the authors stress the particularities of the surgical interventions, which were due to particularities of the surgical interventions, which were due to particularities and extension of the tumours themselves. The mortality of 2,7 percent is explained by the careful indications for surgery, and this was due to a careful preoperative diagnosis.

[Study of the indications for surgical treatment of pleuropulmonary tuberculosis at the present time]

On a large personal experience basis the authors discuss the present stage of surgical treatment of pleuropulmonary tuberculosis. Stress is laid on the fact that, owing to technical surgical progress and continuous improving of equipments in the thoracic surgery departments, practically there are no contraindications for surgical treatment of pleuropulmonary tuberculosis provided the functional lung and heart parameters are satisfactory. It is emphasized too the requirement of a timely indication for surgery in cases of chemotherapy failures, prior to lung and heart function impairment.

[Current problems in thoracic injuries]

The authors stress the increased frequency in the recent years of single thoracic trauma and of thoracic trauma in the frame of polytraumatic lesions. The fact is stressed that the severity of thoracic trauma is usually determined by pathophysiological syndromes generated sometimes by minor anatomical lesions. An original classification is presented, of thoracic trauma, the present etiopathogenetic concept is discussed, as well as pathophysiologic syndromes consecutive to thoracic trauma. The major types of lesions are illustrated by clinical cases. The treatment of thoracic trauma should respect in the first place the principle of re-equilibration of vital functions that have been disturbed. Only after this has been achieved integrity of the anatomic structures of the organs involved should be attempted. Surgical indications are justified only if the anatomical lesions are the origin of a cardio-respiratory imbalance that cannot be eliminated but by surgical procedures. An original procedure is presented, that of Prof. C. Coman, which achieves immobilization of the flaps with the aid of blades, and the advantages of this system are stressed.

[Indications and results of surgical treatment of the post-tuberculosis syndrome]

The post-tuberculous syndromes are more numerous and more severe following the present treatments with tuberculostatics, as compared with the past. Indications of the surgical treatment of these syndromes should be aimed at obtaining functional recovery, and they must be always adapted according to the patient's requirements. The results depend on the indications, on the technical performance, on the post-operative treatment (medical physical exercises, etc.). In the surgical treatment of the present post-tuberculous syndrome there is a supplementary risk, as compared with the surgical treatment of the evolutive tuberculosis. Prophylaxis of the post-tuberculous syndrome can be achieved by a correct medical treatment. If this is not successful the surgical treatment will be applied at the optimal time.

[Surgical treatment of bronchial adenomas]

The authors make an analysis of the experience acquired in the Clinic of Thoracic Surgery of Bucharest, based on interventions carried out in 42 cases of bronchial adenoma hospitalized between 1962 and 1976. The fact is stressed that in none of the 42 operated patients was the carcinoid syndrome encountered with any of its specific manifestations. Also on the basis of the experience obtained the bronchologic criteria for benignity of this type of tumour (absence of the infiltration in the mucosa, surrounding the tumour) is considered as non-significant because there are frequently areas of malignant transformation inside the tumour itself, or at its lower pole that cannot be explored by bronchoscopy. Surgical treatment of bronchial adenoma included a wide range of techniques, from simple lobectomies to bronchoanastomotic interventions, and resections of the trachea. The study of postoperative results showed a good prognosis and survivals of appreciable duration only when the intervention was carried out in the I-st and the II-nd stages of the disease. This also stresses the necessity for an early diagnosis and rapid surgery in these bronchial adenomatous tumours (most of which are of the carcinoid type).

[Current problems in the treatment of thoracic hydatid cysts]

The authors present the experience of the Clinic for Thoracic Surgery of Bucharest, based on a total of 1206 cases of patients operated for hydatic cysts. An original classification is presented, of human hydatidosis, the indications of surgical treatment are stressed, namely the evacuation of the hydatic membrane with the peri-cystic tissue, even in cases of evacuated and suppuratec cysts--the authors objecting to the pulmonary resection in cases of hydatic cysts. The authors have performed simultaneous bilateral interventions, associated or not with phrenotomy, in bilateral and hepatic localizations. In the paper is also presented a new procedure (introduced by Prof. C. Coman) for the total extirpation of the hydatic membrane, a simple procedure which practically prevents effraction of the cyst. On the other hand the results confirm the efficiency of the procedure, very good results being obtained in 98,8% of the cases.

[Technic, indications and value of pulmonary decortications (615 operated cases)]

On the basis of their experience in 615 cases of pleuropulmonary decortication, the authors discuss the indications, contraindications, approach and procedure in pleuropulmonary decortication. Surgery has the double purpose of suppressing the empyema cavity and recovering most of the functional pulmonary parenchyma. A personal procedure was applied consisting of thoracotomy through the sixth intercostal space, then along the cleavage lines outside the limits of the empyema pouch, from the periphery towards the center at the level of the pulsatile organs, zones called the key points of pleuropulmonary decortication. Very good results were obtained in 80--50% of the tuberculous empyema cases and in 90--95% of the non-tuberculous diseases. The authors consider that pleuropulmonary decortication is a widely applicable surgical method in pleural empyema, being one of the few surgical methods used for redressing the function of an organ.

[Congenital tracheoesophageal fistula: operation and cure]

On the basis of their personal experience, covering approximately 100 cases of oeso-thoracal fistulae of various origins and with different anatomo-pathological forms, the authors present a case of oeso-tracheal fistula of congenital origin, in a child aged 4 years, that recovered after surgery. The practical aspects of surgery are stressed, as well as the sequence of surgical stages, evaluating the fact that gastrostomy should be carried out simultaneously, at the end of the thoracal intervention.

[Bronchopulmonary carcinosarcomas. Therapeutic indications]

The authors make an analysis of 11 cases of carcinosarcoma that have underwent surgery in the Clinic of Thoracic Surgery. The authors stress the rarity of these cases in their statistics. Only 11 carcinosarcomas have been identified out of a total of 2.500 cases of bronchopulmonary tumors operated in the Clinic. The difficulty of pre-operatory diagnosis is also stressed. Indications for surgical treatment are mandatory in all cases, even when the expected effects are palliative.

[Emergency pneumonectomy for severe hemoptysis in pulmonary tuberculosis]

The authors present two cases of severe tuberculous hemopthysis cured by pneumectomy. The patients had repeatedly presented severe hemopthysis meanacing their life and necessitated intensive resbuscitation, with intubation and mechanical respiratory prostheses. The authors also discuss the mechanism of death in severe hemopthysis, demonstrating that death is especially due to bronchial obstruction by clots of blood.

[Treatment of spontaneous pneumothorax due to emphysema]

The authors make an analysis of 455 cases of spontaneous pneumothorax hospitalized and treated in the Clinic for Thoracic Surgery from Bucharest between 1952 and 1974. The therapeutic attitude recommended in such cases is the aspiration drainage through minimal pleurotomy (aspiration being carried out in relation with the parenchymal aerial losses). Introduction through the drainage tube of irritating substances will enhance pleural symphisis. The drainage will be maintained for 7--8 days. In the recidivating pneumothorax, or in cases where recovery is not achieved by aspiration drainage, thoracotomy becomes necessary for performing total pleurectomy and atypical resection of emphysema bubbles from the pulmonary cortical, since these are at the origin of the aerorrhagies (the Coman procedure). With the aid of these surgical techniques very good results have been obtained in all cases of spontaneous pneumothorax.

[Bilateral pulmonary resections for bilateral bronchiectasis]

The present paper reports on 6 cases of bilateral bronchiectasis in patients aged 11 to 63 years, treated by simultaneous bilateral pulmonary resection and 1 case of bilateral bronchiectasis in which 14 segments were resected successively. Surgery by simultaneous bilateral approach and associated resection of the affected areas is a procedure that should be indicated, in the authors' opinion, only in carefully selected cases in which not more than 13 segments have to be resected. The indications and contraindications of surgery in bilateral bronchiectasis are discussed, preference being given to the simultaneous approach. In the cases reported at most 11 1/2 segments of the four pulmonary lobes affected were resected in a single stage; in 1 case 14 segments were resected successively, the resection exceeding in amplitude all similar one published until now. The immediate and late postoperative evolution (lesional and functional) were favourable, which pleads for a reconsideration of the approach to bilateral bronchiectasis and the application of the surgical treatment recommended, within the limits described.