Current thinking about the management of dysfunction of the temporomandibular joint: a review

Increasingly the management of TMJ pathology is becoming a subspecialist interest. The number of patients having TMJ joint replacement had steadily increased over the last decade and there is now NICE guidance on this matter. Whilst the evidence of the management of TMJ disease is limited and there are few randomised controlled trials, the incidence of TMJ pathology has not changed and there is a requirement for guidance on the management. Whilst previously patients with TMJ pain were managed surgically, this is changing, and the vast bulk of initial management is non-surgical/medical. This paper will review the literature on TMD and provide guidance for management.

CABG - Challenging Cases in Apollo Hospitals Dhaka, A Decade of Experience

Objective: To show outcome of challenging cases of Coronary Artery Bypass Graft (CABO)Methods: A retrospective study, done in Apollo Hospitals Dhaka from 02-05-2005 to 13.12.2014. Total 1892 CABO cases were reviewed- Emergency: 22 cases, Off-pump: 1257 cases, Arrested heart: 554 cases, On-pump beating heart: 81 cases, MIDCAB: 2 cases. Female - 213 (11.25%), male -1679 (88.74%). Associated co-morbities: peripheral vascular disease: 19 cases, COPD: 78 cases, on dialysis: 17 cases, ventricular septal ruptures :10 cases, carotid occlusive disease: 88 cases, old stroke: 58 cases, permanent pacemaker: 4 cases, preoperative ventilator: 29 cases, left ventricular aneurysm: 58 cases, severe mitral regurgitation: 5 cases, EF: 31-50% =260 cases, 21-30% =147 cases, 15- 20% = 8 cases. Associated procedures -left ventricular aneurysm repair: 42 cases, mitral valve replacement: 30 cases, aortic valve replacement: 25 cases ,double valve replacement: 3 cases, RA myxoma removal: 1 case, LV aneurysm repair with mitral valve procedure: 5 cases , LV aneurysm repair with ventricular septal rupture repair: 5 cases, ventricular septal rupture repair: 10 cases, aorto-femoral bypass: 3 cases, ileo femoral bypass: 1 case, left aorto-axillary bypass: 1 case , Bentall procedure with Brachio-cephalic artery re-implantation: 1 case, Aorto-bifemoral bipopliteal bypass: 1 case, redo CABO-7, IABP preoperatively: 12 cases.Results: Overall mortality rate 2.12% (39 cases), emergency 9.09 % (2 cases) mortality, routine mortality 1.97% (37 cases).Conclusion: Challenging cases of CABO can be done with acceptable morbidity and mortality with good long term outcome.Pulse Vol.9 January-December 2016 p.6-14

Ventricular Septal Defect with Pulmonary Valve Endocarditis with Vegetation - Successful Surgical Treatment in Apollo Hospitals Dhaka

Background: Pulmonary valve vegetation with ventricular septal defect needs early surgical intervention.Case presentation: A 21 years old man got admitted in Apollo Hospitals Dhaka, with the complaints of dyspnoea on exertion since childhood. Echocardiogram revealed a large perimembranous ventricular septal defect, moderate pulmonary stenosis, vegetation attached with pulmonary valve leaflet moving during systole & diastole. During operation ventricular septal defect was closed by dacron patch. Large vegetation was excised from anterior cusp of pulmonary valve. A perforation in right cusp of pulmonary valve was repaired with pericardial patch. Transesophageal Echocardiogram revealed well functioning ventricles and no leakage through the repaired Ventricular Septal Defect and pericardial patch in pulmonary valve leaflet.Result: Culture Sensitivity from vegetation showed no growth and histopathological examination revealed tissue consistent with vegetation of Pulmonary Valve. Post- operative echocardiogram showed no residual shunt or vegetation. The patient was discharged on 8th post operative day in good general condition and is doing well till now.Conclusion: Pulmonary valve endocarditis with vegetation with ventricular septal defect is a rare association. Early surgical intervention gives good outcome.Pulse Vol.9 January-December 2016 p.69-72

Randomized assessment of imatinib in patients with acute ischaemic stroke treated with intravenous thrombolysis

BACKGROUND

Imatinib, a tyrosine kinase inhibitor, has been shown to restore blood-brain barrier integrity and reduce infarct size, haemorrhagic transformation and cerebral oedema in stroke models treated with tissue plasminogen activator. We evaluated the safety of imatinib, based on clinical and neuroradiological data, and its potential influence on neurological and functional outcomes.

METHODS

A phase II randomized trial was performed in patients with acute ischaemic stroke treated with intravenous thrombolysis. A total of 60 patients were randomly assigned to four groups [3 (active): 1 (control)]; the active treatment groups received oral imatinib for 6 days at three dose levels (400, 600 and 800 mg). Primary outcome was any adverse event; secondary outcomes were haemorrhagic transformation, cerebral oedema, neurological severity on the National Institutes of Health Stroke Scale (NIHSS) at 7 days and at 3 months and functional outcomes on the modified Rankin scale (mRS).

RESULTS

Four serious adverse events were reported, which resulted in three deaths (one in the control group and two in the 400-mg dose group; one patient in the latter group did not receive active treatment and the other received two doses). Nonserious adverse events were mostly mild, resulting in full recovery. Imatinib ameliorated neurological outcomes with an improvement of 0.6 NIHSS points per 100 mg imatinib (P = 0.02). For the 800-mg group, the mean unadjusted and adjusted NIHSS improvements were 4 (P = 0.037) and 5 points (P = 0.012), respectively, versus controls. Functional independence (mRS 0-2) increased by 18% versus controls (61 vs. 79; P = 0.296).

CONCLUSION

This phase II study showed that imatinib is safe and tolerable and may reduce neurological disability in patients treated with intravenous thrombolysis after ischaemic stroke. A confirmatory randomized trial is currently underway.

Association of single nucleotide polymorphisms in pro-inflammatory cytokine and toll-like receptor genes with pediatric hematogenous osteomyelitis

Hematogenous osteomyelitis (HO) is a bone infection wherein bacteria penetrate to the bone through the blood stream. Several single nucleotide polymorphisms (SNPs) have been associated with susceptibility to infectious diseases. In this study, we investigated the contribution of SNPs in interleukin (IL)-1B1 (rs16944), IL1A (rs1800587), IL1B (rs1143634), toll-like receptor (TLR)-2 (rs3804099), TLR4 (rs4986790), TLR4 (rs4986791), IL1R (rs2234650), tumor necrosis factor (TNF)-α (rs1800629), TNF (rs361525), and IL1RN (rs315952) towards the development of HO in Saudi patients and compared to healthy controls. Fifty-two patients diagnosed with HO and 103 healthy individuals were genotyped. The frequencies of genotypes GG (rs16944) and AA (rs16944) were lower and higher in patients [odds ratio (OR) = 0.34, Pc = 0.05] and controls (OR = 1.33, Pc = 0.05), respectively, suggesting that SNPs at this locus could alter HO susceptibility. In addition, the patients and controls exhibited lower and higher frequencies of the alleles G (rs16944) (OR = 0.43, Pc = 0.007) and A (rs16944) (OR = 2.32, Pc = 0.007), respectively. The expression of alleles C (rs3804099) and T (rs3804099) were higher in patients (OR = 2.05, Pc = 0.04) and controls (OR = 0.49, Pc = 0.04), respectively. In conclusion, SNPs at rs16944 and rs3804099 were found to be associated with HO in the Saudi population.

Pattern of induced estrus and conception rate following Ovsynch and Ovsynch based gonadotropin-releasing hormone treatments initiated on day 6 of estrous cycle in repeat breeding crossbred cows

Aim:

The aim was to evaluate the estrus response, incidence of accessory corpus luteum formation and fertility following different hormonal protocols in repeat breeding crossbred cows.

Materials and Methods:

This study was carried out on 24 repeat breeding crossbred cows allotted into four groups. Cows of Group I was not given any treatment, Group II was treated with gonadotropin-releasing hormone (GnRH) injection on day 6 post-estrus, Group III was treated with Ovsynch protocol, and Group IV was treated with Ovsynch based GnRH treatment. Estrus responses such as duration, onset, percentage, and intensity of estrus were recorded during the study. The incidence of accessory corpus luteum was recorded per rectally on day 7 after first and additional GnRH of Ovsynch treatment. The conception rate for all groups was calculated by the absence of estrus and on day 45 after artificial insemination (AI) per rectum. Serum samples were collected at AI and day 12 post-AI in Group I and II. Serum samples were also collected at GnRH, Prostaglandin F_2α (PGF_2α), timed AI (TAI) and day 12 post-TAI in Group III and IV.

Results:

Ovsynch and Ovsynch based GnRH treatments are resulted in 100.00% induction of estrus after the PGF_2α injection. Onset of induced estrus after the PGF_2α injection for Group III and IV was recorded as 48.750±0.713 and 51.472±1.989 h, respectively, and it was not significant. There was no significant difference in duration of estrus among the groups. The incidence of intermediate estrus intensity was found to be highest. All the cows showed the incidence of formation of accessory corpus luteum subsequent to GnRH treatment on day 6 of the estrous cycle in Group II, III, and IV. The conception rate was 0.00%, 16.67%, 50.00%, and 50.00% in Group I, II, III, and IV, respectively.

Conclusion:

Ovsynch and Ovsynch based GnRH treatments initiated on day 6 of estrous cycle capable of responding with a higher percentage of ovulation and formation of accessory corpus luteum which helped in higher conception rate over single post-AI GnRH treatment in repeat breeders. These treatments responded with better estrus response but did not significantly improve estrus intensity.

Characterization of the ultrastructure in the uterovaginal junction of the hen

In poultry, the infundibulum is the place of fertilization, eggshell production, and sperm storage, while its uterovaginal junction (UVJ) is regarded as the most important site, which has abundant sperm storage tubules (SST). We examined the ultrastructure of the epithelium with relation to its unique secretory cytology in the UVJ of hens using transmission electron microscopy. The epithelium of the UVJ is lined with ciliated and secretory cells. Ciliated cells are characterized with light and dense secretory granules in supernuclear cytoplasm. Dense secretory granules in ciliated cells are larger in diameter (one μm), surrounded with a transparent rim and concentric layers, whereas the dense granules in the ciliated cells of SST are smaller (0.52 μm) in size and not surrounded by any transparent rim or layer. Ciliated cells also are involved in the shedding of exosomes and secretory vesicles in the lumen. Secretory exosomes are in close contact with cilia and directly release from the apical border into the lumen. Cell junctions are widely distributed between these cells. The secretory cells are associated with the release of secretions via apocrine blebs from microvilli and secretory vesicles, which protrude out from the surface of the epithelium. The dense secretory granules in these cells are smaller in size (0.6 μm), absent of a transparent rim or layers, and are released into the lumen through secretory vesicles. The intracellular multivesicular body (MVB) also is observed in the supernuclear cytoplasm of secretory cells, which are related to the production of exosomes. In general, the apical protrusion of the epithelium in the form of apocrine secretions, the releasing of exosomes, the identification of intracellular MVB, and the release of dense granules give the epithelium a distinct morphology in the UVJ of the hen oviduct.

Abstract PD3-07: TEM8 specific CAR T cells serve as a novel targeted therapy for triple negative breast cancer and its supporting endothelium

Background: Triple Negative Breast Cancer (TNBC) refers to an aggressive subtype of breast cancer negative for HER2, estrogen and progesterone receptors. Lacking these receptors, individuals with TNBC do not benefit from many of the targeted therapies for breast cancer. Tumor endothelial marker 8 (TEM8), originally identified as a tumor endothelium associated antigen, has more recently been implicated in TNBC pathogenesis and as a marker of breast cancer stem like cells. Here we report that T cells expressing a TEM8-specific chimeric antigen receptor (CAR) serve as a novel approach to target both TNBC cells and its supporting endothelium. CARs combine the specificity of a monoclonal antibody with the signaling properties of a T cell. Methods: We designed two novel TEM8-specific CAR molecules. A CAR molecule containing an exodomain derived from the anti-TEM8 L2 antibody, followed by CD28 and CD3-zeta signaling domains (second generation CAR) and CD28, 41BB and CD3-zeta signaling domains (third generation CAR), respectively. Retroviral transduction was used to express the TEM8 CAR transgene constructs on HEK 293T cells, then on primary T cells. Results: Immunofluorescence staining revealed that in a panel of primary TNBC breast cancer samples, TEM8 was overexpressed in comparison to normal adjacent breast tissue (6/6). Costaining with the pan-endothelial cell marker CD31 revealed that this overexpression was not confined to the endothelial compartment, but also present on tumor parenchymal cells. The immortalized TNBC cell lines (MDA-MB-231, MDA-MB-436, MDA-MB-468 and Hs578T) expressed endogenous levels of TEM8 protein as revealed by western blot. Greater than 90% transduction of primary human T cells was achieved using both of our CAR constructs, as detected by flow cytometry. TEM8 specific T cells displayed significantly higher killing of TEM8 positive TNBC and tumor endothelial cells (2H11 and bEND.3) in standard four hour chromium release assays when compared to both non-transduced or irrelevant (CD19) CAR T cells and secreted immunomostimulatory cytokines upon encounter of TEM8 positive cells in coculture assays. In a vascularized xenograft model, MDA MB468 cells were injected subcutaneously with matrigel into athymic nude mice and followed via bioluminescence imaging over the course of two months. Established tumors were treated with either, second or third generation TEM8 specific T cells, HER2 specific T cells, non-transduced T cells or left untreated. Relative to non-transduced T cells, TEM8 specific second and third generation CAR T cells significantly delayed tumor growth by 36 days and 50 days, respectively. Conclusion: TEM8 specific CAR T cells could serve as a novel targeted therapy for TNBC and supporting endothelium.

Citation Format: Byrd T, Fousek K, Pignata A, Szot C, Bielamowicz K, Wakefield A, Koch J, Landi D, Seaman S, Wels W, Fletcher B, Hegde M, St Croix B, Ahmed N. TEM8 specific CAR T cells serve as a novel targeted therapy for triple negative breast cancer and its supporting endothelium. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD3-07.

Ilizarov frame delayed internal fixation of Lisfranc fracture dislocation with severe soft tissue injury: New technique

We describe a new technique of temporary stabilisation of a divergent Lisfranc fracture dislocation of foot with severe crush injury using an Ilizarov frame. A 69-year-old man presented with severe crush injury and complete disruption of the midfoot. Examination revealed full thickness skin necrosis, haemorrhagic blisters and extensive swelling. A staged technique was used with temporary application of an Ilizarov frame followed by delayed limited internal fixation. Excellent result was achieved with restoration of medial arch, complete pain relief and good functional outcome. A staged treatment initially using an Ilizarov frame prior to limited internal fixation allows soft tissue to settle in severe crush injury.