Artificial Intelligence-Based Clinical Decision Support Systems in Cardiovascular Diseases

Despite all the advancements in science, medical knowledge, healthcare, and the healthcare industry, cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide. The main reasons are the inadequacy of preventive health services and delays in diagnosis due to the increasing population, the failure of physicians to apply guide-based treatments, the lack of continuous patient follow-up, and the low compliance of patients with doctors' recommendations. Artificial intelligence (AI)-based clinical decision support systems (CDSSs) are systems that support complex decision-making processes by using AI techniques such as data analysis, foresight, and optimization. Artificial intelligence-based CDSSs play an important role in patient care by providing more accurate and personalized information to healthcare professionals in risk assessment, diagnosis, treatment optimization, and monitoring and early warning of CVD. These are just some examples, and the use of AI for CVD decision support systems is rapidly evolving. However, for these systems to be fully reliable and effective, they need to be trained with accurate data and carefully evaluated by medical professionals.

Perspectives on the Use of Digital Health Technologies in Cardiology Among Specialists from an ESC Member Country: Results from a Survey

OBJECTIVE

In this study, we aimed to identify the reasons for and perceived challenges associated with the use of digital health technologies (DHT) in cardiology.

METHOD

We distributed an online survey to Turkish Society of Cardiology member cardiologists (n = 2789) between January 10 and March 3, 2022.

RESULTS

A total of 308 subjects responded (27.6% females, 62.0% aged 30-44 years). Of these, 42.5% worked at university hospitals, and 44.8% at state hospitals. Smart devices were used by 44.2% (136/308) for personal health monitoring. Additionally, 40.3% (117/290) used social media to provide medical information to patients, while 64.6% (193/299) did so for communication with other physicians. The self-reported recommendation frequencies of wearables, cardiac implantable electronic device telemonitorization, mobile health applications, and teleconsultation/televisit technologies were lower than the proportion of respondents who found DHT beneficial for both patients and physicians. The most frequently mentioned barriers for physicians were increased work burden and responsibilities (78.8%, 193/245), lack of financial compensation (66.9%, 164/245), and lack of relevant training (66.5%, 163/245). For patients, low technological adaptability (81.6%, 200/245), low health literacy (80.4%, 197/245), and low affordability (79.6%, 195/245) were the most frequently mentioned barriers. Additionally, the cost of technologies (69.4%, 170/245), concerns regarding data privacy and security (57.6%, 141/245), and data storage challenges (48.2%, 118/245) were the most significant technical impediments.

CONCLUSION

The findings suggest that although the majority of physicians believe DHT to be beneficial for both themselves and their patients, the frequency of recommendations to patients remains low. A large-scale joint effort is required to address these issues and facilitate the integration of DHT into clinical practice.

Digital Technologies in Heart Failure Management

Heart Failure (HF) is an important public health problem in Turkey and in the world. Hospitalizations due to HF decompensation are associated with increased mortality. The use of digital technologies, especially wearable technologies, is increasing. As physicians, with the use of these devices, patients could be closely followed up and hospitalization, mortality are tried to be prevented by increased awareness of decomposition before clinical symptoms or at the beginning of symptoms. In this review, digital biomarkers, digital technologies, remote monitoring systems and the evidence supporting their use, artificial intelligence applications and the reasons limiting their use of digital technologies in clinical practice will be discussed.

Evaluation of Intermountain Risk Score for Short- and Long-Term Mortality in ST Elevation Myocardial Infarction Patients

The aim of this study was to examine the Intermountain Risk Score (IMRS) for short- and long-term mortality in ST elevation myocardial infarction (STEMI) patients and compare it with the well-known risk scores, such as the Thrombolysis in Myocardial Infarction (TIMI) and the Global Registry of Acute Coronary Events (GRACE). In this retrospective and cross-sectional study, 1057 consecutive patients with STEMI were evaluated. The end-points of the study were short- and long-term mortality. The overall mortality rate was 16% (n = 170 patients). The IMRS was significantly higher in STEMI patients who did not survive compared with those who survived. According to multivariable COX proportional regression analysis, the IMRS was independently related to both short- (HR: 1.482, 95% CI: 1.325-1.675, p < .001) and long-term mortality (HR: 1.915, 95% CI: 1.711-2.180, p < .001). The comparison of receiver operating characteristic curves revealed that the IMRS had non-inferior predictive capability for short- and long-term mortality than the TIMI and GRACE risk scores. To the best of our knowledge, this is the first study to show that the IMRS can predict short- and long-term prognosis of patients with STEMI. Further, the IMRS' predictive value for overall mortality was non-inferior compared with TIMI and GRACE scores.

Perspectives on the use of digital health technologies in cardiology among specialists from an ESC member country: results from a survey

Background

Digital health technologies (DHTs) have the potential of facilitating both physicians' and patients' lives with regards to the diagnosis, treatment and follow-up of cardiovascular disease. A huge acceleration in relevant research has been noted particularly after the COVID-19 pandemic.

Purpose

The goal of this study was to determine the reasons for using DHTs in cardiology, as well as the perceived barriers to its use.

Methods

An electronic survey with 43 question multiple-choice questionnaire was conducted between January 10-March 3, 2022. National cardiac society member cardiology fellows in training and specialists were contacted via e-mail (n=2789).

Results

308/2789 (11.04%) subjects responded to the survey (72.40% males, 62.01% aged 30–44 years). 42.53% and 44.81% were affiliated with university hospitals and state hospitals, respectively. 88/297 (29.63%) stated having at least good understanding of DHTs in cardiology. 44.16% utilized smart devices to track their own health status. 117/290 (40.34%) and 193/299 (64.55%) used social media platforms to share medical information with their patients and other physicians, respectively. WhatsApp and Instagram were the most popular platforms for sharing with patients (92/117, 78.63% and 48/117, 41.03%), while WhatsApp and Twitter were the most popular platforms for sharing with other physicians (151/193, 78.24% and 91/193, 47.15%). Considerations and recommendation/utilization patterns of DHTs by physicians are summarized in Table 1. Perceived barriers to the use of DHTs in cardiology is shown on Figure 1 (A: physician-related, B: patient-related, C: technical).

Conclusion

Findings suggest that nearly half of the physicians use DHTs to collect their own health data and use social media to disseminate health information. The majority of physicians believe that DHT is beneficial to both themselves and their patients, and that DHT use in cardiology has increased as a result of the COVID-19 pandemic. To overcome the challenges to the use of DHTs in cardiology, a multilayered collaborative effort involving patient and professional organizations, as well as technical stakeholders and lawmakers, is required.

Funding Acknowledgement

Type of funding sources: None.

Downregulation of the α1- and β1-subunit of sGC in Arterial Smooth Muscle Cells of OPSCC Is HPV-Independent

The nitric oxide (NO)-sensitive soluble guanylyl cyclase (sGC) is a heterodimeric enzyme with an α and β subunit. NO binds to heme of the β₁-subunit of sGC, activates the enzyme in the reduced heme iron state in vascular smooth muscle cells (VSMCs), and generates cGMP-inducing vasodilatation and suppression of VSMC proliferation. In the complex tumor milieu with higher levels of reactive oxygen species (ROS), sGC heme iron may become oxidized and insensitive to NO. To change sGC from an NO-insensitive to NO-sensitive state or NO-independent manner, protein expression of sGC in VSMC is required. Whether sGCα₁β₁ exists at the protein level in arterial VSMCs of oropharyngeal squamous cell carcinoma (OPSCC) is unknown. In addition, whether differences in the genetic profile between human papillomavirus (HPV)-positive and HPV-negative OPSCC contributes to the regulation of sGCα₁β₁ is unclear. Therefore, we compared the effects of HPV-positive and HPV-negative OPSCC on the expression of sGCα₁β₁ in arterial VSMCs from tumor-free and tumor-containing regions of human tissue sections using quantitative immunohistochemistry. In comparison to the tumor-free region, we found a decrease in expression of both α₁- and β₁-subunits in the arterial VSMC layer of the tumor-containing areas. The OPSCC-induced significant downregulation of the α₁- and β₁-subunits of sGC in arterial VSMC was HPV-independent. We conclude that the response of sGC to NO in tumor arterial VSMCs may be impaired by oxidation of the heme of the β₁-subunit, and thus, α₁- and β₁-subunits of sGC could be targeted to degradation under oxidative stress in OPSCC in an HPV-independent manner. The degradation of sGCα₁β₁ in VSMCs may result in increased proliferation of VSMCs, promoting tumor arteriogenesis in OPSCC. This can be interrupted by preserving the active heterodimer sGCα₁β₁ in arterial VSMCs.

The effects of ozone application on genotoxic damage and wound healing in bisphosphonate-applied human gingival fibroblast cells

OBJECTIVES

Medication-related osteonecrosis of the jaws (MRONJ) is an extremely therapy-resistant disease involving the jaws especially following bisphosphonate treatment. Bisphosphonates accumulate in bone in concentrations sufficient to be directly toxic to the oral epithelium. Current therapeutic options are inadequate for the prevention and treatment of MRONJ. The aim of this study was to investigate effects of ozone gas plasma therapy on wound healing in bisphosphonate-applied human fibroblasts.

MATERIAL AND METHODS

Human primary gingival fibroblasts were cultured. Cytotoxic concentrations (IC50) of bisphosphonates (pamidronate (PAM), alendronate (ALN), and zoledronate (ZOL)) were determined by MTT test. A 60 μg/μl for 30 s of ozone gas plasma application was performed to all experimental culture flasks after drug treatment at 24-h intervals as 3 s/cm². Genotoxic damages were evaluated by comet assay and wound healing was determined by in vitro scratch assay.

RESULTS

PAM, ALN, and ZOL applications caused genotoxic damage on primary human gingival fibroblast DNA. Ozone gas plasma therapy significantly decreased the genotoxic damage (p < 0.05), and this application provided 25, 29, and 27% less genotoxic damage in order of ALN, PAM, and ZOL groups. Ozone gas plasma therapy significantly increased wound healing rates both in postsurgical 24th and 48th hours for all doses of experimental drug groups (p < 0.05).

CONCLUSION

The ozone gas plasma application decreased genotoxic damage effect of bisphosphonate usage while improved the wound closure rate on human gingival fibroblasts.

CLINICAL RELEVANCE

Ozone gas plasma therapy may be helpful in prevention of gingival healing delay in MRONJ pathogenesis especially when applied simultaneously with surgical intervention.

Impact of Endodontic Treatments on the Rigidity of the Root

The destabilizing effect of endodontic treatment upon teeth is still controversial. The purpose of this study was to investigate the effects of different steps of endodontic treatments upon the rigidity of teeth. Extracted untreated central maxillary anterior teeth were loaded (3.75 N), and deformations of the root were assessed by Speckle pattern interferometry. The following treatments (with subsequent determination of deformability) were conducted sequentially: access preparation, manual instrumentation (Kerr files ISO-40, ISO-60, ISO-80, ISO-110), and tapered and parallel-sided post preparation. It was found that the teeth were increasingly destabilized by any treatment. While the increased deformability was not significant with the manual enlargement (p > 0.05), we found a significant destabilization after access preparation and post preparation (p < 0.05). A corresponding difference was found after conversion of the post preparation from tapered to parallel-sided (p < 0.05). Both substance loss and modifications of the natural root canal geometry play an important role in tooth rigidity.

Bradykinin Mediates Phosphorylation of eNOS in Odontoblasts

While the activation of eNOS by Akt/PKB-dependent phosphorylation, leading to NO release, and the inhibition of enzyme activity by bradykinin (BK)-mediated phosphorylation of eNOS in endothelial cells are established, the phosphorylation of eNOS in odontoblasts is unknown. To clarify the regulation of eNOS in odontoblasts by BK, we examined the phosphorylation of eNOS, Akt/PKB, and ERK1/2 in odontoblasts of rat molars. BK (10−7 M) transiently induced the phosphorylation of eNOS at Ser1177, Akt/PKB in odontoblasts, while it induced the phosphorylation of eNOS at Thr495 throughout the entire period of BK treatment. BK receptor 2 antagonist HOE 140 (10−6 M) significantly reduced signal intensities of phosphorylated-eNOS at Ser1177, Thr495, and phosphorylated-Akt/PKB. These results suggest that BK has dual effects on the activation of eNOS in odontoblasts, the Akt/PKB-dependent up-regulation of eNOS by the transient phosphorylation at Ser1177, and the ERK1/2-independent down-regulation of eNOS by the phosphorylation at Thr495.

Primary cardiac hydatid cyst presenting as noncompaction cardiomyopathy

We report a case of cyst was initially labeled as left ventricular noncompaction cardiomyopathy. An accurate diagnosis is essential to establish the most effective treatment strategy. In particular, echocardiographic examination assists in identifying the correct diagnosis. In this case, two-dimensional and three-dimensional echocardiography and computed tomography were used for definitive diagnosis of cardiac hydatid cyst.

Chemical Analysis of Enamel and Dentin Following the Application of Three Different At-home Bleaching Systems

Purpose

To determine the change in the chemical composition of enamel and dentin as well as to evaluate the differences in surface texture of the same dental hard tissues following three at-home bleaching systems in vitro.

Methods

Sixty extracted intact human anterior teeth were used in this study. Thirty teeth were used as samples for enamel, and the buccal surfaces of the remaining 30 teeth were abraded and used as dentin samples. Prior to bleaching treatments, calcium (Ca), phosphorus (P), potassium (K), sodium (Na), magnesium (Mg), fluoride (F), and oxygen (O) levels of each sample were measured using an energy dispersive spectrometer. The teeth were then randomly allocated into three groups according to the bleaching system used, as follows: GI, 10% carbamide peroxide (CP); GII, 20% CP; GIII, and 35% CP. Following the bleaching treatments, Ca, P, K, Na, Mg, F, and O measurements were repeated. The surface configurations were examined using scanning electron microscopy (SEM). The data were analyzed using Wilcoxon signed rank and Kruskal-Wallis tests followed by the Dunn test.

Results

All three bleaching systems tested caused similar changes in the chemical composition of enamel and dentin. Bleaching systems decreased Ca and K, while F and O levels increased in enamel. In dentin, Ca, P, and K levels decreased; however, Na, F, and O levels increased. SEM observations revealed no deleterious effect on enamel and dentin.

Conclusion

The use of home bleaching agents could affect the chemical composition of dental hard tissues, whereas the change in the chemical composition of enamel and dentin was not affected by the CP concentration of the bleaching systems used.

Irreversible inflammation is associated with decreased levels of the alpha1-, beta1-, and alpha2-subunits of sGC in human odontoblasts

The nitric oxide (NO) receptor enzyme soluble guanylate cyclase (sGC) contains one prosthetic heme group as an αβ heterodimer, and two heterodimer isoforms (α(1)β(1), α(2)β(1)) were characterized to have enzyme activity. To test the irreversible inflammation-dependent regulation of sGC in odontoblasts, we incubated decalcified frozen sections of healthy and inflamed human third molars with antibodies against β-actin, nitrotyrosine, inducible nitric oxide synthase (iNOS), α(1)-, β(1)-, and α(2)-subunits of sGC and analyzed them at protein levels by quantitative immunohistochemistry. The irreversible inflammation induced an increase in the signal intensities for nitrotyrosine and iNOS and a decrease for the α(1)-, β(1)-, and α(2)-subunits of sGC in odontoblasts. Inflammatory mediators, reactive oxygen, and nitrogen species may impair the expression of the α(1)-, β(1)-, and α(2)-subunits in odontoblasts. The decrease of sGC at the protein level in inflamed odontoblasts is compatible with a critical role for sGC to mediate biological effects of NO in health.

Time-dependent Activation of ERK1/2 in Nerve Terminals of the Dentin-Pulp Complex following Bradykinin Treatment

The extracellular signal-regulated kinases 1 and 2 (ERK1/2) have been implicated in the inflammation-dependent sensitization of nociceptors, and the inflammatory mediator bradykinin (BK) led to a reduced threshold in the nociceptor terminals, activating intracellular signaling by phosphorylating receptors and ion channels. The effects of BK on the non-transcriptional modulation of the ERK1/2 in the peripheral nociceptor terminals, including in nerve endings of the dentin-pulp complex, are unknown. The time-dependent effects of BK (10−7 M) on the ERK1/2 phosphorylation in nerve terminals of the dentin-pulp complex were investigated by quantitative and double immunolabeling with organ bath experiments. In nerve terminals, total and p-ERK1/2 were detected. In comparison with the controls, the numbers of p-ERK1/2-positive nerve endings increased after 1 and 3 min and decreased after 10 min of BK treatment. Analysis of the data indicates that BK induces phosphorylation-mediated local activation of ERK1/2 in nerve terminals modulating nociception in the dentin-pulp complex.

Healing of onlay mandibular bone grafts covered with collagen membrane or bovine bone substitutes: a microscopical and immunohistochemical study in the sheep

The objective of this study was to evaluate the role of collagen membrane and Bio-Oss coverage in healing of an onlay graft to the mandible. Twelve adult sheep each received an onlay bone graft (experiment 1), bone graft+Bio-Gide (experiment 2), and bone graft+Bio-Oss/Bio-Gide (experiment 3) on the lateral surface of the mandible. The animals were euthanized at 4, 8, 12 or 16 weeks after surgery, and findings were analysed by routine microscopy and immunohistochemistry for proliferation (Ki67) and apoptotic (Caspase-3) markers. Grafts were fully incorporated in all specimens. Pronounced resorption was observed in experiment 1. Minimal loss of graft volume was seen in experiment 2 specimens without membrane displacement. A remarkable increase in the augmented region of the mandible was observed in experiment 3. A high number of osteoclasts were expressed within the grafts during the early healing period, and thereafter declined markedly. Osteoblasts within the grafts expressed a moderate level of Ki67 at 8 weeks, which thereafter declined markedly. The strongest expression of Caspase-3 on the bone surface was observed after 16 weeks. In conclusion, the effect of collagen membrane coverage on bone graft volume maintenance was dependent on membrane stability during healing. An autogenous bone graft covered with Bio-Oss particles resulted in a remarkable increase in augmented lateral surface of the mandible. The late stage of bone graft healing was associated with a high apoptotic induction pathway of osteoblasts lining the surfaces of the new bone, demonstrated by strong positive Caspase-3 immunoreactivity.

Effect of Antibacterial Varnishes Applied to Root Dentin on Shear Bond Strength of Tooth-colored Restorative Materials

The application of antibacterial varnish affects the shear bond strength of tooth-colored restorative materials after six months.

The Influence of One-step Polishing Systems on the Surface Roughness and Microhardness of Nanocomposites

One-step polishing systems exhibited similar or better surface roughness values when compared to multi-step polishing systems. In all groups, mylar-strip created surfaces showed lower microhardness values than polished surfaces. Different polishing procedures did not effect the microhardness of nanocomposites. One-step polishing systems may be a good choice for polishing nanocomposites, resulting in reduced chair time.

NO-cGMP signaling molecules in cells of the rat molar dentin-pulp complex

By the formation of cyclic guanosine 3',5'-monophosphate (cGMP), nitric oxide (NO)-sensitive enzyme-soluble guanylate cyclase (sGC) plays a receptor role for NO within the NO-cGMP signaling cascade, which is involved in vasodilatation and neurotransmission. The hypothesis that NO-cGMP signaling molecules modulate cells of the dentin-pulp complex was investigated in rat molars by histochemical, immunohistochemical, immuno-ultrastructural, and organ bath techniques. NO synthase (NOS) I-III, the sGC alpha(2)-subunit/beta(1)-subunit, and cGMP were detected in odontoblasts and blood vessels. NOS I, sGC alpha(2), and cGMP were identified in nerve fibers. Treatment of rat molars with the NO donor NONOate (10(-5) M) increased cGMP staining intensities in blood vessels and odontoblasts, while NO synthase inhibitor L-NAME (10(-4) M) attenuated intensity of the reaction products for cGMP, suggesting an effect of endogenous NO on sGC. These correlations of patterns and alterations of cGMP staining intensities after treatment with the NO donor or NO inhibitor might represent an NO-sGC-cGMP signaling-dependent modulation of odontoblasts, blood vessels, and nerve fibers in the dentin-pulp complex.

Sealant and composite bond strength to enamel with antibacterial/self-etching adhesives

INTRODUCTION

The enamel in pits and fissures undergoing preventive or ultraconservative resin restorations may be affected by secondary caries. An antibacterial adhesive bond may be a useful choice to prevent and reduce demineralization.

OBJECTIVES

The purpose of this study was to determine the shear bond strength of an experimental antibacterial bond, a self-etch bond, and an ormocer-based adhesive bond using an ormocer-based fissure sealant and a composite resin on intact enamel.

METHODS

Twenty-four extracted human molars were sectioned bucco-lingually to obtain two flat and sound enamel surfaces. Forty-eight specimens were randomly assigned into four groups. The groups were prepared to receive the following treatments: (1) Admira Bond + Admira Seal (n = 10); (2) ABF Bond + Admira Seal (n = 11); (3) Clearfil SE Bond + Clearfil AP-X (n = 12); and (4) ABF Bond + Clearfil AP-X (n = 11). A cylindrical mould was placed over the bonded surface, and both materials were applied according to the instructions. The teeth were thermocycled 500 cycles between 5 and 55 degrees with a dwell time of 30 s. For shear bond strength testing, the load was applied vertically to the base of the mould. The cross-head speed was 5 mm min(-1).

RESULTS

The maximum load that a specimen can withstand until failure was determined and shear bond strength was calculated by dividing the load at failure by the surface area of the mould. The results (median, minimum and maximum, respectively) for the four groups were: (1) 7.9, 4.2 and 13.6 MPa; (2) 8.6, 2.6 and 15.9 MPa; (3) 5.9, 5.3 and 8.2 MPa; and (4) 8.8, 3.0 and 19.2 MPa. Kruskal-Wallis and Mann-Whitney U-tests were performed for the statistical analysis. Groups 3 and 4 were statistically significantly different (P = 0.005; P < 0.05). There was no statistically significant difference between the sealant and composite groups for ABF (P = 0.375). Fracture sites were viewed by microscope under x 16 magnification to determine if the mode of failure was adhesive or cohesive. The results (number of adhesive failed specimens and number of cohesive failed specimens, respectively) for the four groups were: (1) 7 and 3; (2) 3 and 8; (3) 2 and 9; and (4) 8 and 3.

CONCLUSION

The ABF bond has sufficiently physical qualities to be used under fissure sealant and composite resin on uncut enamel, its antibacterial efficiency notwithstanding.