The oral microbiota is a reservoir for antimicrobial resistance: resistome and phenotypic resistance characteristics of oral biofilm in health, caries, and periodontitis

BACKGROUND

Antimicrobial resistance (AMR) is an ever-growing threat to modern medicine and, according to the latest reports, it causes nearly twice as many deaths globally as AIDS or malaria. Elucidating reservoirs and dissemination routes of antimicrobial resistance genes (ARGs) are essential in fighting AMR. Human commensals represent an important reservoir, which is underexplored for the oral microbiota. Here, we set out to investigate the resistome and phenotypic resistance of oral biofilm microbiota from 179 orally healthy (H), caries active (C), and periodontally diseased (P) individuals (TRN: DRKS00013119, Registration date: 22.10.2022). The samples were analysed using shotgun metagenomic sequencing combined, for the first time, with culture technique. A selection of 997 isolates was tested for resistance to relevant antibiotics.

RESULTS

The shotgun metagenomics sequencing resulted in 2,069,295,923 reads classified into 4856 species-level OTUs. PERMANOVA analysis of beta-diversity revealed significant differences between the groups regarding their microbiota composition and their ARG profile. The samples were clustered into three ecotypes based on their microbial composition. The bacterial composition of H and C samples greatly overlapped and was based on ecotypes 1 and 2 whereas ecotype 3 was only detected in periodontitis. We found 64 ARGs conveying resistance to 36 antibiotics, particularly to tetracycline, macrolide-lincosamide-streptogramin, and beta-lactam antibiotics, and a correspondingly high prevalence of phenotypic resistance. Based on the microbiota composition, these ARGs cluster in different resistotypes, and a higher prevalence is found in healthy and caries active than in periodontally diseased individuals. There was a significant association between the resistotypes and the ecotypes. Although numerous associations were found between specific antibiotic resistance and bacterial taxa, only a few taxa showed matching associations with both genotypic and phenotypic analyses.

CONCLUSIONS

Our findings show the importance of the oral microbiota from different niches within the oral cavity as a reservoir for antibiotic resistance. Additionally, the present study showed the need for using more than one method to reveal antibiotic resistance within the total oral biofilm, as a clear mismatch between the shotgun metagenomics method and the phenotypic resistance characterization was shown.

Current practice in nutrition after allogeneic hematopoietic stem cell transplantation - Results from a survey among hematopoietic stem cell transplant centers

BACKGROUND

Allogeneic hematopoietic stem cell transplantation (alloHSCT) is frequently associated with impaired oral intake and malnutrition, which potentially increases morbidity and mortality. Therefore, nutrition is one of the major challenges in the post-transplant period.

METHODS

To document the current clinical approach in nutritional treatment, we designed a questionnaire concerning the current practice in nutrition after alloHSCT and distributed it to German speaking centers performing alloHSCT in Germany, Austria and Switzerland between November 2018 and March 2020. Twenty-eight (39%) of 72 contacted centers completed the survey, 23 from Germany, two from Austria and three from Switzerland, representing 50% of alloHSCT activity within the participating countries in 2018.

RESULTS

All centers reported having nutritional guidelines for patients undergoing alloHSCT, whereby 86% (n = 24) provided a low-microbial diet during the neutropenic phase. The criteria to start parenteral nutrition (PN) directly after alloHSCT seemed to be consistent, 75% (n = 21) of the corresponding centers started PN if the oral nutritional intake or the bodyweight dropped below a certain limit. In the setting of intestinal graft-versus-host disease (GvHD) the current practice appeared to be more heterogenous. About 64% (n = 18) of the centers followed a special diet, added food stepwise modulated by GvHD symptoms, while only four centers regularly stopped oral intake completely (intestinal GvHD grade >1). Half of the centers (54%, n = 15) applied a lactose-free diet, followed by 43% (n = 12) which provided fat- and 18% (n = 5) gluten-free food in patients with intestinal GvHD. Supplementation of micronutrients in acute intestinal GvHD patients was performed by 54% (n = 15) of the centers, whereas vitamin D (89%, n = 25) and vitamin B₁₂ (68%, n = 19) was added regularly independently of the presence of GvHD. Only 5 (18%) participating centers ever observed a food-associated infection during hospitalization, whereas food-associated infections were reported to occur more often in the outpatient setting (64%, n = 18).

CONCLUSION

The survey documented a general consensus about the need for nutritional guidelines for patients undergoing alloHSCT. However, the nutritional treatment in clinical practice (i.e. lactose-, gluten- or fat-free in intestinal GvHD) as well as the use of food supplements was very heterogeneous. In line with current general recommendations the centers seemed to focus on safe food handling practice rather than providing a strict neutropenic diet. More high-quality data are required to provide evidence-based nutrition to patients during and after alloHSCT.

Overview of metal seal tests performed at BAM and implications for extended interim storage

The investigation of the long-term performance of sealing systems employed in containers of radioactive waste and spent nuclear fuel is one research focus area for division 3.4 \Safety of Storage Containers" at the Bundesanstalt für Materialforschung und -prüfung. The behaviour of metallic seals, which are employed in interim storage casks for spent nuclear fuel and high active waste, over time is of high importance for ensuring safe enclosure. Therefore, investigations on these systems were started at BAM to get a general understanding of the relevant processes. Our investigations comprise investigations on different parameters which influence the seal performance and the main part is focussed on the time and temperature dependent behaviour. Our aim is to understand the longterm behaviour of the sealing systems for evaluation of their performance during possible extended interim storage and subsequent transportation. In this contribution an overview of the performed tests and their respective results is given. A focus lies on a comparison between seals with large torus diameter in comparison to small diameters.

Diagnostic Value of the Basic Erosive Wear Examination for the Assessment of Dental Erosion on Patients, Dental Photographs, and Dental Casts

OBJECTIVES

The aim of this trial was to investigate the diagnostic value of the basic erosive wear examination (BEWE) in clinical use, on dental photographs, and on dental casts over a two-year follow-up period (2013-2015). According to the main hypothesis for longitudinal monitoring of dental erosion, the BEWE is equally reproducible by the three assessment methods.

METHODS AND MATERIALS

The clinical assessment included intraoral photographic documentation, dental impressions, oral examination, and assessment of BEWE. Clinical assessment of BEWE was done by one blinded examiner, whereas assessment on photographs and dental casts was performed by three calibrated examiners and repeated after 14 days. The three assessment methods were analyzed separately by longitudinal agreement and inter- and intrarater reliability (intraclass correlation coefficient) alongside 95% confidence intervals (CIs).

RESULTS

Comparing the longitudinal data of the years 2013-2015, clinical use and photographs showed no significant difference (p=0.0681-0.9963), whereas the statistical analysis showed a significant difference for dental casts by comparing data from 2013 vs 2014 (p=0.0266) as well as data from 2013 vs 2015 (p=0.0001). Statistical evaluation of overall BEWE showed an intrarater reliability of 0.79-0.91 for photographs and 0.60-0.87 for dental casts. The interrater reliability was 0.77 (95% CI=[0.69; 0.84]) for photographs and 0.63 (95% CI=[0.52; 0.72]) for dental casts.

CONCLUSION

This investigation showed that in longitudinal clinical monitoring, the assessment of the BEWE on patients and dental photographs yielded comparable results. In addition, based on these findings, the assessment of the BEWE on dental casts showed moderate reproducibility. Therefore, dental casts may be better used for laboratory assessment techniques.

Allogeneic donor split skin grafts for treatment of refractory ulcers in cutaneous chronic graft-versus-host disease after allogeneic hematopoietic stem cell transplantation-a retrospective analysis on seven patients

Refractory skin ulcers due to severe chronic graft-versus-host disease (cGVHD) remain to be associated with significant morbidity and mortality.We performed an allogeneic donor skin transplantation in seven adult patients after allogeneic hematopoietic stem cell transplantation for cGVHD-associated refractory skin ulcers. While four patients received a split skin graft (SSG), in one patient, a full thickness skin graft for two small refractory ulcers of the ankle was performed, and one patient received in vitro expanded donor keratinocyte grafts derived from hair roots of the original unrelated donor. In one additional patient, a large deep fascial defect of the lower leg was covered with an autologous greater omentum free graft before coverage with an allogeneic SSG. An additional patient was treated with an autologous scrotal skin graft for a refractory ulcer associated with deep sclerosis of cGVHD after unrelated donor transplantation.All skin grafts engrafted and resulted in permanent coverage of the grafted ulcers without any signs of immunological mediated damage. In the patient receiving in vitro expanded keratinocyte grafts, two localized ulcers were permanently covered by donor skin while this approach failed to cover extensive circular ulcers of the lower legs.Allogeneic donor skin grafts are a valuable treatment option in refractory ulcers due to cGVHD but are restricted mainly to related donors while keratinocyte grafts from unrelated donors remain experimental. In male patients lacking a related donor, autologous scrotal skin graft may be an alternative option.

Clinical management and prevention of dental caries in athletes: A four-year randomized controlled clinical trial

The aims of this four-year randomized controlled clinical trial were to gain insights into management and prevention of dental caries and the effect of stannous fluoride products in athletes. Fifty-four participants were randomized into test and control groups. The test group used special stannous fluoride products. The primary endpoint dental caries was assessed by the ICDAS-II-System and analyzed both by a linear mixed model for repeated measures and a generalized linear mixed model. During the observation period an increase in caries-free surfaces from 64.91 ± 6.42 at baseline to 73.22 ± 4.43 was observed. In surfaces with caries superficialis and caries media, a decrease from 13.94 ± 5.70 and 2.96 ± 2.55 surfaces at baseline to 7.89 ± 3.18 and 0.46 ± 0.78 after 2.5 years was noted, respectively. The analysis showed no effect of stannous fluoride products, but a significant difference for the time of examination (p < 0.0001). In addition, it could be shown that at any time of examination, the odds of developing caries media on a new surface was significantly lower than at baseline (up to 25-times). Due to biannual dental examinations, professional tooth cleaning and restorative treatment the number of caries-free surfaces increased and the odds of a new surface to be afflicted with caries media decreased 25-fold.

Psychosocial impact, perceived stress and learning effect in undergraduate dental students during transition from pre-clinical to clinical education

INTRODUCTION

This study aimed to develop a suitable instrument for a comprehensive quantitative and qualitative assessment of perceived psychosocial impact, levels of stress and learning effect in undergraduate dental students during the transition from pre-clinical to clinical education. These findings might improve curricular structures and didactic organisation during this period.

MATERIALS AND METHODS

At the beginning of their first clinical year, undergraduate dental students were asked to complete an anonymous forty-item questionnaire. Two hundred and seventy-six undergraduate dental students were willing to participate and completed the questionnaire and participated during the years 2011-2016.

RESULTS

The response rate was between 45% and 96%. Correlational analysis (Spearman-Rho) in the field of psychosocial impact showed the dental teacher to be the most important multiplier of students' feelings. If the students feel that their teacher acts cooperatively, positive items increase and negative items decrease significantly (P < .0001). Also, students who report high levels of stress are affected significantly in their psychosocial interaction (P < .0001). Wilcoxon test yielded highest levels of stress in endodontology during the first weeks (P < .0001). During the same period, the greatest learning increment was seen for diagnostics and caries excavation.

CONCLUSION

In conclusion, teaching of undergraduate dental students during the transition period from pre-clinical to clinical education can be positively influenced by a supportive learning environment and by specific chronological modifications in the curriculum. Students should start their clinical training with diagnostics, preventive dentistry and initial periodontal treatment. Due to high levels of perceived stress, endodontology should be introduced later in the clinical curriculum.

Biomarkers in chronic graft-versus-host disease: quo vadis?

Biomarkers are increasingly used for diagnosis and treatment of transplant-related complications including the first biomarker-driven interventional trials of acute graft-versus-host disease (GvHD). In contrast, the development of biomarkers of chronic GvHD (cGvHD) has lagged behind due to a broader variety of manifestations, overlap with acute GvHD, a greater variation in time to onset and maximum severity, and lack of sufficient patient numbers within prospective trials. An international workshop organized by a North-American and European consortium was held in Marseille in March 2017 with the goal to discuss strategies for future biomarker development to guide cGvHD therapy. As a result of this meeting, two areas were prioritized: the development of prognostic biomarkers for subsequent onset of moderate/severe cGvHD, and in parallel, the development of qualified clinical-grade assays for biomarker quantification. The most promising prognostic serum biomarkers are CXCL9, ST2, matrix metalloproteinase-3, osteopontin, CXCL10, CXCL11, and CD163. Urine-proteomics and cellular subsets (CD4+ T-cell subsets, NK cell subsets, and CD19+CD21low B cells) represent additional potential prognostic biomarkers of cGvHD. A joint effort is required to verify the results of numerous exploratory trials before any of the potential candidates is ready for validation and subsequent clinical application.

Novel Microscalpels for Removing Proximal Composite Resin Overhangs on Class II Restorations

Introduction:

Limited access to interdental spaces complicates removal of excess material when placing class II composite resin restorations. Evidence-based recommendations on interproximal finishing are rare. We present novel microscalpels for this indication. The aim of the study was to test their fracture strength and cutting ability and to compare microscalpels with the use of a scaler, oscillating devices (G5-ProShape, G5-Proxocare), finishing strips and scalpels of sizes 12, 15, and 21 in a standardized in vitro model.

Methods and Materials:

Fracture strength (LOAD) and cutting forces (CUT) of microscalpels were evaluated at different angles (15, 30, 60, and 75 degrees; n=30 each) in a universal testing machine. Devices were compared in vitro using standardized composite overhangs. Marginal quality (QUAL; n=30) and quantity of excess/deficit (QUAN; n=30) were evaluated using scanning electron microscopy (SEM) for each device (explorative data analysis, Student t-test or analysis of variance; post hoc Scheffé).

Results:

Microscalpels showed the highest LOAD (95.8 [5.0] N) (mean [standard deviation]) and easiest cutting (CUT) (7.6 [1.5]) at 15 degrees. At all angles, LOAD was significantly higher than CUT (p&lt;0.001). Perfect margins were seen most often with scalpel size 12 (QUAL: 37% relative frequency), while most excess (73.4%) was observed with finishing strips. QUAN was lowest with microscalpels (19.3 [4.4] μm) and highest with finishing strips (116.0 [18.8]). Use of scalers led to fractures and crack formation.

Conclusion:

Microscalpels are able to cut composite at a lower force than necessary to fracture the blades at all angles. Small and/or curved scalpels yield the best-quality margins.

[Bilateral ciliary body oedema under treatment with ciclosporine]

We present the case of a 27-year-old female patient who developed bilateral ciliary body edema with secondary glaucoma and myopic shift during systemic treatment with cyclosporine for aplastic anemia. After application of topical atropine and prednisolone acetate and conversion from cyclosporine to tacrolimus, the ophthalmologic symptoms resolved completely. Since an infectious etiology was not evident, we hypothesize that ciliary body edema was caused by impairment of microvascular integrity by cyclosporine.

Altered immune reconstitution of B and T cells precedes the onset of clinical symptoms of chronic graft-versus-host disease and is influenced by the type of onset

We analyzed lymphocyte subpopulations and cytokines 3 months after allogeneic hematopoietic stem cell transplantation aiming to identify predictive cellular and serum markers for chronic graft-versus-host disease (cGVHD). Samples of 49 patients (pts) (no cGVHD (n = 14), subsequent quiescent onset (n = 16), de novo onset of cGVHD (n = 19)) were analyzed in the absence of active GVHD by flow cytometry and enzyme-linked immunosorbent assay. All mean absolute cell counts are presented as cells per microliter; relative cell counts are presented as percentage of lymphocytes. Pts with subsequent de novo cGVHD had significantly higher relative and absolute counts of CD4+ T cells including higher absolute counts of CD4+ memory T cells (22.36%; 206.55/μl; 136/μl, respectively) compared to pts with subsequent quiescent onset of cGVHD (12.41%; 83.42/μl; 54.3/μl) and pts without cGVHD (10.55%) with regard to relative counts of CD4+ T cells. Similarly, significantly more relative and absolute regulatory T cell numbers (CD4+FOXP3+) were detected in pts with de novo onset of cGVHD (3.08% and 24.63/μl) compared to those in pts without (1.25% and 9.06/μl) or with quiescent onset of cGVHD (1.15% and 6.91/μl). Finally, relative B cell counts, including naïve and memory B cells, were also significantly decreased in pts developing quiescent cGVHD (0.85, 0.73, 0.12% resp.) when compared to pts with de novo onset (5.61, 5.24, 0.38%). The results demonstrate that alterations in immune reconstitution are already present before onset of clinical symptoms and differ between de novo and quiescent onset of disease.

[Differential diagnostic considerations using ICD-10 in chronic back pain with special regard to persistent somatoform pain disorder with somatic and psychological factors (ICD-10 F45.41)]

It is often difficult to pass an expert opinion in cases of chronic back pain. This article analyses the differential diagnostic considerations related to coding various causes in line with ICD-10. It emphasises the I importance of making a careful distinction between orthopoedic and psychiatric conditions and disorders. Simultaneous coding of orthopoedic and psychiatric illnesses and disorders based on a distinct cluster of symptoms necessitates an interdisciplinary approach that consistently applies the ICD-10 definitions of mental an behavioural disorders in order to clearly identify the main reason for a functional impairment in the insurance and sociomedical context. Persistant somatoform pain disorder with somatic and psychological factors (ICD-10 F45.41) should be regarded as related to the underlying disease and be used primarily as an additional and descriptive diagnosis.

Rifaximin preserves intestinal microbiota balance in patients undergoing allogeneic stem cell transplantation

Intestinal dysbiosis has been associated with acute gastrointestinal GvHD and poor outcome following allogeneic stem cell transplantation (ASCT). To assess the effect of a switch in 2012 from ciprofloxacin/metronidazole to rifaximin for gut decontamination on intestinal microbiota composition and ASCT outcome, we retrospectively analyzed 394 patients receiving ASCT from September 2008 through June 2015. In 131 and 90 patients, respectively, urinary 3-indoxyl sulfate levels and intestinal enterococcal load were measured before conditioning and weekly within the first 28 days after ASCT. The use of rifaximin correlated with lower enterococcal positivity (6.9 vs 21.9%, P=0.05) and higher urinary 3-indoxyl sulfate concentrations (10.5 vs 4.6 μmoL/mmoL crea, P<0.001) after ASCT. Patients on rifaximin showed lower 1-year transplant-related mortality (P=0.04) and higher overall survival (P=0.008). Treatment of infectious complications with systemic antibiotics did not abrogate the beneficial effects of rifaximin on intestinal microbiota composition in the early course of ASCT and outcome. The data underscore the importance of maintaining a diverse population of symbiotic and mutualistic bacteria in the gut on ASCT outcome.

Predicting survival using clinical risk scores and non-HLA immunogenetics

Previous studies of non-histocompatibility leukocyte antigen (HLA) gene single-nucleotide polymorphisms (SNPs) on subgroups of patients undergoing allogeneic haematopoietic stem cell transplantation (HSCT) revealed an association with transplant outcome. This study further evaluated the association of non-HLA polymorphisms with overall survival in a cohort of 762 HSCT patients using data on 26 polymorphisms in 16 non-HLA genes. When viewed in addition to an already established clinical risk score (EBMT-score), three polymorphisms: rs8177374 in the gene for MyD88-adapter-like (MAL; P=0.026), rs9340799 in the oestrogen receptor gene (ESR; P=0.003) and rs1800795 in interleukin-6 (IL-6; P=0.007) were found to be associated with reduced overall survival, whereas the haplo-genotype (ACC/ACC) in IL-10 was protective (P=0.02). The addition of these non-HLA polymorphisms in a Cox regression model alongside the EBMT-score improved discrimination between risk groups and increased the level of prediction compared with the EBMT-score alone (gain in prediction capability for EBMT-genetic-score 10.8%). Results also demonstrated how changes in clinical practice through time have altered the effects of non-HLA analysis. The study illustrates the significance of non-HLA genotyping prior to HSCT and the importance of further investigation into non-HLA gene polymorphisms in risk prediction.

Consensus on performing skin biopsies, laboratory workup, evaluation of tissue samples and reporting of the results in patients with suspected cutaneous graft-versus-host disease

BACKGROUND

Histopathological diagnosis including selection of lesions, the determination of the best point of time for biopsy and workup is not trivial in cutaneous graft-versus-host disease (GvHD).

OBJECTIVES

To develop interdisciplinary recommendations on performing, the laboratory work up and reporting of the results of skin biopsies in patients with suspected cutaneous GvHD.

METHODS

A working group consisting of dermatopathologists, dermatologists, transplant-physicians and transplant-pathologists prepared recommendations for performing skin biopsies, laboratory workup and evaluation of tissue samples, and reporting of the results in patients with cutaneous GvHD. After achieving a consensus within the working group, a survey that comprised the core issues of the recommendations was electronically sent out to 72 alloHSCT centres within Germany, Austria, and Switzerland and their Departments of Pathology. The answers were discussed in a Consensus Conference and final recommendations were established.

RESULTS

Twenty-five centres responded to the clinical and 17 centres to the histopathological survey. Questions addressed to the clinicians comprised the indication for skin biopsy in chronic GvHD (cGvHD) and acute GvHD (aGvHD) and the appropriate point of time for skin biopsy. Eighty-eight per cent agreed that the skin biopsy is generally indicated in patients with suspected cGvHD lacking diagnostic features. In contrast, with suspected aGvHD, only 62% of respondents felt that skin biopsy was necessary even if GvHD had not been confirmed in another organ. Although restricted due to the fact that immunosuppression is often applied in an emergency setting most centres supported skin biopsies before initiation of topical or systemic immunosuppression. The majority of pathologists agreed that in non-sclerotic GvHD a punch biopsy is adequate, whereas in sclerotic GvHD a scalpel biopsy is preferred.

CONCLUSION

While a consensus on the need for biopsies in cGvHD was reached the value of skin biopsies in aGvHD and subsequent biopsies during therapy requires further evaluation.

Autochthonous dengue virus infection in Japan imported into Germany, September 2013

In September 2013, dengue virus (DENV) infection was diagnosed in a German traveller returning from Japan. DENV-specific IgM and IgG and DENV NS1 antigen were detected in the patient’s blood, as were DENV serotype 2-specific antibodies. Public health authorities should be aware that autochthonous transmission of this emerging virus may occur in Japan. Our findings also highlight the importance of taking a full travel history, even from travellers not returning from tropical countries, to assess potential infection risks of patients.

Target volume coverage and dose to organs at risk in prostate cancer patients. Dose calculation on daily cone-beam CT data sets

PURPOSE

On the basis of correct Hounsfield unit to electron density calibration, cone-beam computed tomography (CBCT) data provide the opportunity for retrospective dose recalculation in the patient. Therefore, the consequences of translational positioning corrections and of morphological changes in the patient anatomy can be quantified for prostate cancer patients.

MATERIALS AND METHODS

The organs at risk were newly contoured on the CBCT data sets of 7 patients so as to evaluate the actual applied dose. The daily dose to the planning target volume (PTV) was recalculated with and without the translation data, which result from the real patient repositioning.

RESULTS

A CBCT-based dose recalculation with uncertainties less than 3 % is possible. The deviations between the planning CT and the CBCT without the translational positioning correction vector show an average dose difference of - 8 % inside the PTV. An inverse proportional relation between the mean bladder dose and the actual volume of the bladder could be established. The daily applied dose to the rectum is about 1-54 % higher than predicted by the planning CT.

CONCLUSION

A dose calculation based on CBCT data is possible. The daily positioning correction of the patient is necessary to avoid an underdosage in the PTV. The new contouring of the organs at risk - the bladder and rectum - allows a better appraisal to be made of the total applied dose to these organs.

Proximal Box Elevation With Resin Composite and the Dogma of Biological Width: Clinical R2-Technique and Critical Review

Provided that moisture control is possible, today's resin composite materials can be applied successfully in the restorative treatment of extensively decayed teeth. This suggests that restorative margins will be increasingly located below the cementoenamel junction, probably invading biological width. The recently introduced technique of proximal box elevation (PBE) offers the possibility of performing a stepwise elevation of deep proximal cavities to create more favorable preparation margins for direct or indirect restorations. Clinical instructions for the restoration of extensively damaged teeth are given through this presentation. A two-step R2-technique will be shown, and a critical review of the dogma of biological width will be presented.

Histopathological diagnosis of graft-versus-host disease of the skin: an interobserver comparison

BACKGROUND

Histopathology is an important tool in diagnosing cutaneous graft-versus-host disease (GvHD). Minimum diagnostic criteria for active chronic GvHD have recently been defined. However, they are not specific and their interpretation is dependent on observer judgement.

OBJECTIVE

AIMS OF THE STUDY

i) to explore interobserver variability in the interpretation of histopathological changes in GvHD, and ii) to analyse the impact of detailed clinical data on histopathological diagnosis of GvHD.

METHODS

Histopathological slides from 15 skin biopsies of GvHD and from dermatoses with histopathologically similar appearance were sent in two phases to four dermatopathologists experienced in cutaneous GvHD in France, Germany, Italy and Switzerland (first round of 'blind' review followed by a second round with complete clinical information provided).

RESULTS

Interface dermatitis, especially vacuolar alteration, was the most inconsistently evaluated, particularly in cases with minor alterations. Interestingly, for vacuolar alteration and apoptotic keratinocytes, interobserver variability was lower in the adnexal epithelia than in the interfollicular epidermis. Complete clinical information resulted in increased diagnostic confidence and greater concordance on the final diagnosis, rising from 53% (first round, k = 0.345, fair agreement) to 80% (second round, k = 0.529, moderate agreement). The percentage of correct diagnoses increased from 33.3% to 80%.

CONCLUSION

For the diagnosis of GvHD, histopathological analysis is of importance, but, for correct diagnosis, the correlation of pathological findings with clinical results is crucial. In cases of minor alteration, histopathologists should focus on the interpretation of vacuolar changes and apoptotic keratinocytes, possibly on the adnexal epithelia.

[The value of drug level testing in the assessment of chronic pain syndromes]

Objective or objectifiable clinical findings are essential and of great value to the medical expert to evaluate the state of illness or disability. Drug level testing provides objective data and therefore has to be performed to rate drug therapy and compliance and to reveal attempted deceptions by the test person in the assessment of chronic pain syndromes.

Bacterial biofilm composition in caries and caries-free subjects

BACKGROUND

Certain major pathogens such as Streptococcus mutans, Lactobacillus spp. and others have been reported to be involved in caries initiation and progression. Yet, in addition to those leading pathogens, microbial communities seem to be much more diverse and individually differing. The aim of this study, therefore, was to analyze the bacterial composition of carious dentin and the plaque of caries-free patients by using a custom-made, real-time quantitative polymerase chain reaction assay (RQ-PCR).

METHODS

The study included 26 patients with caries and 28 caries-free controls. Decayed tooth substance and plaque samples were harvested. Bacterial DNA was extracted and tested for the presence of 43 bacterial species or species groups using RQ-PCR.

RESULTS

Relative quantification revealed that Propionibacterium acidifaciens was significantly more abundant in caries samples than were other microorganisms (fold change 169.12, p = 0.023). In the caries-free samples, typical health-associated species were significantly more prevalent. Unsupervised hierarchical cluster analysis showed a high abundance of P. acidifaciens in caries subjects and distinct but individually differing bacterial clusters in the caries-free subjects. The distribution of 11 bacteria allowed full discrimination between caries and caries-free subjects.

CONCLUSION

Within the investigated cohort, P. acidifaciens was the only pathogen significantly more abundant in caries subjects. Cluster analysis yielded a diverse flora in caries-free subjects, whereas it was narrowed down to a small range of a few outcompeting members in caries subjects.

Personality influences quality-of-life assessments in adult patients after allogeneic hematopoietic SCT: results from a joint evaluation of the prospective German Multicenter Validation Trial and the Fred Hutchinson Cancer Research Center

The influence of personality on health related quality of life (QoL) and physical functioning in the setting of allogeneic hematopoietic SCT (alloHSCT) is unknown. We conducted a joint evaluation within two independent cohorts of alloHSCT recipients to investigate the impact of personality on reported QoL and physical functioning. Two-hundred-eight patients (median age 44 years, range 18-72) of cohort 1 and 93 patients (median age 55 years, range 19-79) of cohort 2 after alloHSCT were evaluated. Personality was assessed using the 24-adjective measure (AM), which measures the Big-Five personality domains and the Life Orientation Test-Revised (LOT-R), measuring optimism and pessimism. QoL was measured using the Functional Assessment of Cancer Therapy with bone marrow transplantation subscale (FACT-BMT), Short Form 36 (SF-36), the human activity profile (HAP), as well as the NIH criteria-based cGVHD activity assessment form and the Lee cGVHD symptom scale. Neuroticism was significantly associated with worse function measured by the HAP and FACT-BMT. Optimism significantly improved QoL captured by the FACT-BMT. Pessimism significantly impaired physical function captured by the HAP and SF-36. Extraversion was significantly associated with reduced depression and lower severity of cGVHD symptoms reported by the patient and the physician. The results suggest that personality traits and pre-treatment QoL assessments should be measured in clinical trials to facilitate the interpretation of QoL data.

In-Frame Deletion and Missense Mutations of the C-Terminal Helicase Domain of SMARCA2 in Three Patients with Nicolaides-Baraitser Syndrome

Using high-resolution molecular karyotyping with SNP arrays to identify candidate genes for etiologically unexplained intellectual disability, we identified a 32-kb de novo in-frame deletion of the C-terminal helicase domain of the SMARCA2 gene in a patient with severe intellectual disability, epilepsy, sparse hair, prominent joints, and distinct facial anomalies. Sequencing of the gene in patients with a similar phenotype revealed de novo missense mutations in this domain in 2 further patients, pointing to a crucial role of the SMARCA2 C-terminal helicase domain. The clinical features observed in all 3 patients are typical of Nicolaides-Baraitser syndrome, an only rarely reported syndrome with mainly moderate to severe intellectual disability. Notably, one of our patients with a p.Gly1132Asp mutation showed typical morphological features but an exceptional good development with borderline overall IQ and learning difficulties, thus expanding the phenotypic spectrum of Nicolaides-Baraitser syndrome.

Vaccination against pandemic H1N1 (2009) in patients after allogeneic hematopoietic stem cell transplantation: a retrospective analysis

Purpose

Limited data are available on immunologic responses to primary pandemic H1N1 (2009) vaccination in recipients of allogeneic hematopoietic stem cell transplantation (HSCT) recipients. In 2009 serologic responses to either pandemic H1N1 (2009) vaccine (n = 36) or pandemic H1N1 (2009) infection (n = 2) were studied in 38 HSCT recipients.

Methods

Responses were measured with a standard hemagglutination-inhibition assay. Fourteen patients had active chronic graft-versus-host disease (cGvHD) at the time of vaccination/infection and seven patients had cGvHD in remission; 11 patients had no immunosuppressive therapy, and 27 patients were on immunosuppressive therapy. Nineteen patients (53%) responded to pandemic H1N1 (2009) vaccination. Two patients had pandemic H1N1 (2009) infection without prior vaccination, and one patient had severe pandemic H1N1 (2009) infection with acute respiratory distress syndrome despite prior single vaccination.

Results

Non-responders to pandemic H1N1 (2009) vaccination more often had cGvHD (65 vs. 53%) and received second- or third-line therapy (53 vs. 11%), while responders mostly had first-line therapy for cGvHD. While vaccine responders had no or single agent immunosuppressive therapy, non-responders frequently received moderate or intense immunosuppressive therapy. All vaccine recipients previously treated with rituximab were non-responders.

Conclusions

In summary, the overall response to pandemic H1N1 (2009) vaccination in HSCT recipients was modest. Patients receiving combined immunosuppressive therapy for steroid-refractory cGvHD barely responded to pandemic H1N1 (2009) vaccination.

Diagnosis and treatment of pulmonary chronic GVHD: report from the consensus conference on clinical practice in chronic GVHD

This consensus statement established under the auspices of the German working group on BM and blood stem cell transplantation (DAG-KBT), the German Society of Hematology and Oncology (DGHO), the Austrian Stem Cell Transplant Working Group, the Swiss Blood Stem Cell Transplantation Group (SBST) and the German-Austrian Pediatric Working Group on SCT (Päd-Ag-KBT) summarizes current evidence for diagnosis, immunosuppressive and supportive therapy to provide practical guidelines for the care and treatment of patients with pulmonary manifestations of chronic GVHD (cGVHD). Pulmonary cGVHD can present with obstructive and/or restrictive changes. Disease severity ranges from subclinical pulmonary function test (PFT) impairment to respiratory insufficiency with bronchiolitis obliterans being the only pulmonary complication currently considered diagnostic of cGVHD. Early diagnosis may improve clinical outcome, and regular post-transplant follow-up PFTs are recommended. Diagnostic work-up includes high-resolution computed tomography, bronchoalveolar lavage and histology. Topical treatment is based on inhalative steroids plus beta-agonists. Early addition of azithromycin is suggested. Systemic first-line treatment consists of corticosteroids plus, if any, continuation of other immunosuppressive therapy. Second-line therapy and beyond includes extracorporeal photopheresis, mammalian target of rapamycin inhibitors, mycophenolate, etanercept, imatinib and TLI, but efficacy is limited. Clinical trials are urgently needed to improve understanding and treatment of this deleterious complication.

[Graft-versus-host disease (GvHD) - an update. Part 2: prognosis and therapy of GvHD]

Graft-versus-host disease (GvHD) remains one of the major complications after allogeneic stem cell transplantation (SCT) and is responsible for morbidity, mortality and decrease in quality of life of patients after SCT. The most important preventive approach is the selection of a donor with best possible HLA compatibility between donor and recipient. Basic prophylaxis of acute GvHD begins already prior to transplantation and usually consists of cyclosporine with or without methotrexate. In the past few years, many new therapies have been introduced for the treatment of acute and chronic GvHD. Extracorporeal photopheresis (ECP), for example, represents a promising treatment option for acute and chronic GvHD with very few side effects. For chronic GvHD mTOR inhibitors (sirolimus, everolimus) may replace calcineurin-inhibitors with the advantage of not inducing malignant skin tumors. Guidelines are available ort he management of acute and chronic GvHD. While pathophysiology, classification and skin manifestations of GvHD have been already presented in the first part of this article, this second part covers the prognosis, prevention and treatment of GvHD.

Analysis of quality and feasibility of an objective structured clinical examination (OSCE) in preclinical dental education

INTRODUCTION

An objective structured clinical examination (OSCE) has been implemented in preclinical dentistry. It was taken at an early stage (propaedeutics course). The objectives of this study were to evaluate the reliability, validity, and feasibility of the examination, and the effect of circuit number on OSCE score.

METHODS

The OSCE was designed by an expert committee on the basis of pre-reviewed blueprints and checklists. Eleven stations formed an interdisciplinary circuit. Six groups of students (n = 62) passed sequentially round the same circuit. Statistical analysis was performed by using SPSS. Reliability was determined by measurement of internal consistency (Cronbach's α, Guttman's λ(2) ), standard error of measurement (SEM) (comprising generalisability index α, dependability index ϕ and pass 150;fail reliability p(c) ), consistency coefficient κ, item 150;scale correlation (Pearson correlation), and, because the unidimensionality of the stations could not be assumed, factor analysis including varimax rotation. Convergent validity (Pearson correlation, t-test), and predictive validity for future preclinical courses and the final preclinical examination were assessed by analysis of variance (ANOVA). The effect of the circuit number on score improvement was calculated, including a correction for the general competence of the students (ANOVA). Cost was calculated on the basis of the time invested.

RESULTS

Fifty-three out of sixty-two students passed the OSCE (mean score: 67%, SD 7.7, range, 47-81). Scores for each station correlated significantly with total scores (r = 0.35-0.54, P < 0.01). For internal consistency, α = 0.75 (relative SEM 3.8) and λ(2) = 0.766. The dependability index was ϕ = 0.694 (absolute SEM 4.4), p(c) = 0.89 and κ = 0.61. Factor analysis yielded two components: dental-materials-oriented stations and all other stations (explained variance 43%). Scores correlated significantly with success in passing practical tests (i.e. performing dental procedures under examination conditions) (known group validity, P < 0.01) and with scores for subsequent courses and the final preclinical examination (Physikum) (predictive validity, P < 0.001). Later groups performed 4% better on average (CI 95%: 1.2-6.8%; P < 0.01). The cost was 181 Euro per student.

CONCLUSIONS

The OSCE is reliable and valid in the context of preclinical dentistry. The cost is substantial. The problem of improvement of students' results with ascending circuit number has to be addressed.

[Graft-versus-Host Disease (GvHD) - an update : Part 1: Pathophysiology, clinical features and classification of GvHD]

GvHD remains associated with significant morbidity and mortality despite new techniques for allogeneic stem cell transplantation (SCT), such as optimized conditioning regimens. Within the past ten years, the incidence of acute GvHD has remained unchanged and the incidence of chronic GvHD has even increased. The traditional classification of GvHD according to the time of clinical manifestation is now out-dated. Acute GvHD symptoms may even occur after 100 days; vice versa, primary chronic GvHD may already be observed one month after stem cell transplantation. The current classification introduced by the National Institutes of Health includes classic acute GvHD (up to 100 days), late-onset acute GvHD (after 100 days), as well as an overlap syndrome showing features of acute and chronic GvHD and classic chronic GvHD without any time limit. Diagnosis of GvHD of the skin remains difficult because of histological similarities to drug eruptions and viral exanthems. In this first part of the article the pathophysiology, classification, skin manifestations of acute and chronic GvHD and the histopathology will be presented. In a second part the prognosis, prophylaxis and therapy of GvHD will be discussed.