Multiparametric liquid biopsy analysis in metastatic prostate cancer.

Molecular profiling of prostate cancer with liquid biopsies, such as circulating tumor cells (CTCs) and cell-free nucleic acid analysis, yields informative yet distinct data sets. Additional insights may be gained by simultaneously interrogating multiple liquid biopsy components to construct a more comprehensive molecular disease profile. We conducted an initial proof-of-principle study aimed at piloting this multiparametric approach. Peripheral blood samples from men with metastatic castrate-resistant prostate cancer were analyzed simultaneously for CTC enumeration, single-cell copy number variations, CTC DNA and matched cell-free DNA mutations, and plasma cell-free RNA levels of androgen receptor (AR) and AR splice variant (ARV7). In addition, liquid biopsies were compared with matched tumor profiles when available, and a second liquid biopsy was drawn and analyzed at disease progression in a subset of patients. In this manner, multiparametric liquid biopsy profiles were successfully generated for each patient and time point, demonstrating the feasibility of this approach and highlighting shared as well as unique cancer-relevant alterations. With further refinement and validation in large cohorts, multiparametric liquid biopsies can optimally integrate disparate but clinically informative data sets and maximize their utility for molecularly directed, real-time patient management.

Reference Size Matching, Whole-Genome Amplification, and Fluorescent Labeling as a Method for Chromosomal Microarray Analysis of Clinically Actionable Copy Number Alterations in Formalin-Fixed, Paraffin-Embedded Tumor Tissue.

Cancer genome copy number alterations (CNAs) assist clinicians in selecting targeted therapeutics. Solid tumor CNAs are most commonly evaluated in formalin-fixed, paraffin-embedded (FFPE) tissue by fluorescence in situ hybridization. Although fluorescence in situ hybridization is a sensitive and specific assay for interrogating preselected genomic regions, it provides no information about coexisting clinically significant copy number changes. Chromosomal microarray analysis is an alternative DNA-based method for interrogating genome-wide CNAs in solid tumors. However, DNA extracted from FFPE tumor tissue produces an essential, yet problematic, sample type. The College of American Pathologists/American Society of Clinical Oncology guidelines for optimal tumor tissue handling, published in 2007 for breast cancer and in 2016 for gastroesophageal adenocarcinomas, are lacking for other solid tumors. Thus, cold ischemia times are seldom monitored in non-breast cancer and non-gastroesophageal adenocarcinomas, and all tumor biospecimens are affected by chemical fixation. Although intended to preserve specimens for long-term storage, formalin fixation causes loss of genetic information through DNA damage. Herein, we describe a reference size matching, whole-genome amplification, and fluorescent labeling method for FFPE-derived DNA designed to improve chromosomal microarray results from suboptimal nucleic acids and salvage highly degraded samples. With this technological advance, whole-genome copy number analysis of tumor DNA can be reliably performed in the clinical laboratory for a wide variety of tissue conditions and tumor types.

An alternative to nerve repair using an antioxidant compound: a histological study in rats.

The fascicular composition and organisation of the inferior alveolar nerve (IAN) were determined to confirm the microarchitecture of the IAN bundles into each of the mandibular teeth, including the composition of the mental nerve. The aim of this study was to evaluate peripheral nerve repair after the application of an antioxidant compound to the damaged nerve tissue to elevate the concentration and bioavailability of elements capable of favouring tissue repair. Twenty-five Wistar rats were divided into groups: The Control 1 (Ctl 1) (n = 5) animals had the ischiatic nerve exposed with no suture injury and were sacrificed at 30 days post-operatively. The Control 2 (Ctl 2) (n = 10) animals had the ischiatic nerve exposed, and the nerve was injured using suture in three distinct regions. In the experimental (Exp) animals (n = 10), an antioxidant organic compound was applied to the nerve injury site. The animals with nerve injury (Ctl2 and Exp group) were sacrificed at 15 and 30 days post-operatively. The histological analysis showed less degeneration in the Exp group at 15 and 30 days post-operatively. Nerve neoformation forming a connection between the distal and proximal suture sites was observed in the experimental group. This study presented an alternative to nerve repair using an antioxidant compound.

An initial assessment of haptics in preclinical operative dentistry training.

AIM: The purpose of this study was to assess novice student perception of haptic-based manual dexterity training. The short-term impact of haptic training in the early phase of preclinical operative dentistry education was also investigated. METHODS: Dental students performed a class II amalgam and a class III resin tooth preparation in a typodont model at baseline. The experimental group performed exercises on the manual dexterity module of the IDEA™ software using a haptic device. The exercises required removing the maximum amount of three-dimensional geometric shapes within a predetermined width and depth. Tooth preparations were repeated 2 weeks later. A questionnaire survey was given to assess the subjective evaluation of the haptic simulation exercise. RESULTS: Tooth preparations were scored regarding external outline, internal form, and integrity of adjacent tooth. Improvement of overall tooth preparation scores post-haptic use was not statistically significant compared to controls (P > 0.05). However, students found the game-feature of the haptic device made the learning experience more fun and interesting. CONCLUSION: The haptic exercises with the manual dexterity module software were not superior in improving the dexterity of students for tooth cavity preparations in short-term. Benefits of ease of use and fun learning experience can be further investigated in future studies.

Human histologic assessment of a platform-switched osseointegrated dental implant.

This case report examined crestal bone level maintenance surrounding a platform-switched implant that was retrieved due to prosthetic difficulty. The retrieved platform-switched implant threads demonstrated tight contact with the surrounding bone and demonstrated both radiographic and histologic features that were indicative of successful osseointegration. Very high bone-to-implant contact (BIC) without epithelial downgrowth to the implant thread was noted. The BIC consisted of a combination of newly formed bone and native bone. The buccal and lingual bone levels coincided with the original platform position noted at the time of the surgery, and did not appear to resorb at all. The result of the present investigation confirms the maintenance of the crestal bone level for platform-switched implants.

Performance of dental students versus prosthodontics residents on a 3D immersive haptic simulator.

This study evaluated the performance of dental students versus prosthodontics residents on a simulated caries removal exercise using a newly designed, 3D immersive haptic simulator. The intent of this study was to provide an initial assessment of the simulator's construct validity, which in the context of this experiment was defined as its ability to detect a statistically significant performance difference between novice dental students (n=12) and experienced prosthodontics residents (n=14). Both groups received equivalent calibration training on the simulator and repeated the same caries removal exercise three times. Novice and experienced subjects' average performance differed significantly on the caries removal exercise with respect to the percentage of carious lesion removed and volume of surrounding sound tooth structure removed (p<0.05). Experienced subjects removed a greater portion of the carious lesion, but also a greater volume of the surrounding tooth structure. Efficiency, defined as percentage of carious lesion removed over drilling time, improved significantly over the course of the experiment for both novice and experienced subjects (p<0.001). Within the limitations of this study, experienced subjects removed a greater portion of carious lesion on a 3D immersive haptic simulator. These results are a first step in establishing the validity of this device.

Negotiating the severely resorbed extraction site: a clinical case report with histologic sample.

The treatment of an infected socket with a severe facial dehiscence/ fenestration defect presents a therapeutic dilemma to the dental team. Both implant-supported restoration and fixed partial denture are viable options to restore function and occlusion, each with its benefits and disadvantages. In the present case report, a multi-stage regenerative approach was selected to enable implant-supported single crown. The first phase of the treatment after extraction of the maxillary central incisor was the stabilization of the blood clot with a collagen plug. Six weeks later, the surgical site was re-entered and the socket was grafted with biphasic calcium sulfate (BCS). Six months later, a dental implant was placed and a core biopsy taken. However, the central portion of the facial defect demonstrated only partial regeneration resulting in exposure of six implant threads. Freeze-dried bone allograft (FDBA) and a collagen membrane were utilized to augment the ridge and cover the exposed threads. The histology of the bone core showed a complete resorption of the grafted material with the presence of new woven bone throughout the specimen. Clinically, complete defect regeneration and augmentation of the alveolar ridge were attained after 4 months. Thus, the clinician should consider the pros and cons of this regenerative approach along with other more conservative treatment alternatives when dealing with similar cases.

Associated lesions requiring additional surgical treatment in grade 3 acromioclavicular joint dislocations.

PURPOSE: To evaluate the incidence of associated pathologic shoulder lesions that were addressed surgically in grade 3 acromioclavicular joint (ACJ) dislocations, as well as to compare this incidence between younger and older patients and between acute and chronic cases. METHODS: In this multicenter nonrandomized retrospective study, 98 patients operated on for grade 3 ACJ dislocation underwent concomitant arthroscopic evaluation for the identification and treatment of any associated lesions. The type and treatment of associated lesions were collected in a central database and analyzed. We classified patients according to age (<45 years and ≥ 45 years) and according to the length of time between trauma and surgical treatment (≤ 30 days and ≥ 120 days), obtaining the following stratification: younger acute, older acute, younger chronic, and older chronic. RESULTS: Of the patients, 42 (42.8%) were diagnosed with at least 1 additional pathologic lesion, and 29 (29.5%) required a dedicated additional treatment. Rates of treatment on associated lesions were analyzed: younger versus older groups presented a significant difference, as did younger acute versus older acute groups; SLAP and posterior rotator cuff tear treatments represented 24 of the 35 additional surgeries (68.5%). CONCLUSIONS: The overall rate of associated pathologic lesions requiring additional surgical treatment in patients with ACJ dislocation was 29.5%. Patients aged 45 years or older had a greater risk of presenting with associated lesions that needed to be surgically addressed (odds ratio, 3.01). The overall rates of associated surgical lesions in acute versus chronic cases were not shown to be significantly different. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Popularity of suture materials among residents and faculty members of a postdoctoral periodontology program.

AIM: The aim of the present study was to determine the favoritism of suture materials among a group of clinicians at a teaching institution. METHODS: The surveys included 11 absorbable and nine non-absorbable sutures. The surveyor was asked to select his or her suture preferences when it comes to using it in 13 different, commonly-performed surgical procedures. RESULTS: The surveys showed overall preferences for non-absorbable versus absorbable sutures. Chromic Gut with a 4-0 diameter thread reverse cutting FS2 needle was the most favored suture. For periodontal bone grafts and hard tissue ridge augmentation, polytetrafluoroethylene with a 4-0 thread and FS2 needle was preferred. For autogenous gingival grafts, gingival allografts, connective tissue grafts, frenectomy and frenoplasty, Chromic Gut with 5-0 diameter thread reverse cutting P3 needle was favored. For extraction socket preservation, soft tissue canine exposure, ridge augmentation, and dental implants, Chromic Gut with 4-0 diameter thread reverse cutting FS2 needle was preferred, and for sinus augmentation, Vicryl with a 4-0 diameter thread reverse cutting FS2 needle was favored. CONCLUSION: Absorbable sutures were preferred in the majority of periodontal procedures; however, non-absorbable sutures were favored in procedures that required longer healing or better stability of the flap edges in cases of periodontal and ridge augmentation.

Recombinant human bone morphogenetic protein 2 in lateral ridge augmentation.

This case report describes the augmentation of severe lateral ridge defects in the maxilla and mandible using recombinant human bone morphogenetic protein 2 (rhBMP-2) on an absorbable collagen sponge (ACS). The surgical technique used tenting screws and a membrane to maintain space for the ACS. After 7 months of healing, the ridge width increased from 1 to 2 mm to 6 to 9 mm, thus allowing successful placement of dental implants. De novo bone formation through use of the surgical technique for space maintenance of rhBMP-2/ACS was demonstrated without the need for additional particulate bone grafting.

Pseudoparalysis: the importance of rotator cable integrity.

The purpose of this study was to clinically examine the relationship between rotator cable integrity and the presence of pseudoparalysis. A retrospective review was performed of a consecutive series of arthroscopic repairs of massive rotator cuff tears performed between January 2007 and June 2009. A total of 127 massive tears were identified. Group 1 comprised 24 patients with preoperative pseudoparalysis. Group 2 comprised 97 patients (103 repairs) with active forward flexion more than 90°. In group I, no patient maintained integrity of both rotator cable attachments; 1 rotator cable attachment was disrupted in 45.8% of cases; and both rotator cable attachments were disrupted in 54.2% of cases. In group II, both rotator cable attachments were intact in 22.3% of cases; 1 rotator cable attachment was disrupted in 62.1% of cases; and both rotator cable attachments were disrupted in 15.5% of cases. The difference in the distribution of cable attachments between the 2 groups was statistically significant (P<.001). Overall, preoperative pseudoparalysis predicted a disruption of both rotator cables with 88.8% specificity, 44.8% sensitivity, and 77.8% accuracy. Pseudoparalysis requires the disruption of at least 1 rotator cable attachment. This study reinforces the concept of rotator cable integrity and the ability of patients to maintain forward flexion above shoulder level and highlights the importance of reinforcing the rotator cable attachments in the repair of massive rotator cuff tears.

A systematic approach for diagnosing subscapularis tendon tears with preoperative magnetic resonance imaging scans.

PURPOSE: To determine and propose a systematic approach to evaluating magnetic resonance imaging (MRI) scans for subscapularis tears and compares preoperative MRI interpretations with findings of the same shoulders at arthroscopy. METHODS: The study was composed of 202 patients who underwent shoulder arthroscopy by 1 of 5 orthopaedic surgeons during a 3-month period. All patients had MRI scans performed within 6 months before arthroscopy. RESULTS: Of the 202 patients, 82 had subscapularis tendon tears confirmed at the time of arthroscopy. The orthopaedic surgeons correctly diagnosed 60 of 82 patients (73%) with subscapularis tendon tears on preoperative MRI that were subsequently identified by arthroscopy. The orthopaedic surgeons correctly diagnosed 113 of 120 patients (94%) as not having subscapularis tendon tears. This resulted in an overall sensitivity of 73%, specificity of 94%, positive predictive value of 90%, negative predictive value of 84%, and accuracy of 86%. The frequency of subscapularis tears was highest when the long head of the biceps was displaced from the groove (88%), a combined supraspinatus/infraspinatus tear existed (71%), or the long head of the biceps tendon was torn (69%). CONCLUSIONS: Preoperative MRI scans of the shoulder interpreted by orthopaedic surgeons with the described systematic approach resulted in improved accuracy in diagnosing subscapularis tendon tears compared with previous studies. A consistent finding is that larger subscapularis tendon tears are more easily detected using MRI scans whereas smaller tears are more frequently missed. LEVEL OF EVIDENCE: Level III, development of diagnostic criteria with universally applied reference (nonconsecutive patients).

A Wnt-bmp feedback circuit controls intertissue signaling dynamics in tooth organogenesis.

Many vertebrate organs form through the sequential and reciprocal exchange of signaling molecules between juxtaposed epithelial and mesenchymal tissues. We undertook a systems biology approach that combined the generation and analysis of large-scale spatiotemporal gene expression data with mouse genetic experiments to gain insight into the mechanisms that control epithelial-mesenchymal signaling interactions in the developing mouse molar tooth. We showed that the shift in instructive signaling potential from dental epithelium to dental mesenchyme was accompanied by temporally coordinated genome-wide changes in gene expression in both compartments. To identify the mechanism responsible, we developed a probabilistic technique that integrates regulatory evidence from gene expression data and from the literature to reconstruct a gene regulatory network for the epithelial and mesenchymal compartments in early tooth development. By integrating these epithelial and mesenchymal gene regulatory networks through the action of diffusible extracellular signaling molecules, we identified a key epithelial-mesenchymal intertissue Wnt-Bmp (bone morphogenetic protein) feedback circuit. We then validated this circuit in vivo with compound genetic mutations in mice that disrupted this circuit. Moreover, mathematical modeling demonstrated that the structure of the circuit accounted for the observed reciprocal signaling dynamics. Thus, we have identified a critical signaling circuit that controls the coordinated genome-wide expression changes and reciprocal signaling molecule dynamics that occur in interacting epithelial and mesenchymal compartments during organogenesis.

Cellular Allograft in the Treatment of a Severe Periodontal Intrabony Defect: A Case Report.

INTRODUCTION: This report describes the use of allograft cellular bone matrix containing mesenchymal stem cells in the treatment of a severe periodontal defect. To our knowledge, this regenerative technique has not been reported in the periodontal literature in the past, and it offers an alternative to the commonly used regenerative techniques. CASE PRESENTATION: The patient presented with generalized severe periodontitis with a severe radiographic defect on the distal aspect of tooth #9 extending to the apex of the tooth. Despite the depth of the defect, the tooth was vital. After thorough debridement, the defect was grafted with cellular allograft and covered with resorbable membrane. Nine months after grafting, the periapical radiograph demonstrated bone fill of the defect. The postoperative clinical examination revealed gain in the clinical attachment level and reduction in the probing depth. In addition, the tooth maintained its vitality. CONCLUSION: This case report shows that a severe periodontal intrabony defect of single-rooted tooth can be treated using cellular allograft with improvement of periodontal parameters and radiographic bone fill.

Reduction of postoperative stiffness after arthroscopic rotator cuff repair: results of a customized physical therapy regimen based on risk factors for stiffness.

PURPOSE: The purpose of this study was to determine the benefits of a modified rehabilitation protocol (incorporating early closed-chain overhead stretching) in reducing the risk of postoperative stiffness after arthroscopic rotator cuff repair. METHODS: During a 17-month period, we performed primary arthroscopic rotator cuff repairs in 152 patients. After surgery, patients with risk factors identified in the previous study (calcific tendonitis, adhesive capsulitis, PASTA [partial articular surface tendon avulsion]-type rotator cuff repair, concomitant labral repair, or single-tendon cuff repair) were enrolled in a modified rehabilitation protocol that added early overhead closed-chain passive motion exercises to our standard protocol; alternatively, patients without risk factors received a standard conservative rehabilitation program. Historical controls were used and comprised patients in the senior author's practice who all received the conservative rehabilitation protocol. The prevalence of postoperative stiffness was compared between the historical cohort and current study patients by use of Fisher exact tests. RESULTS: Among the 152 patients studied, 79 were positive for at least 1 of the specified risk factors and received the modified protocol. Postoperative stiffness developed in none of the 79 patients enrolled in the modified program. This finding represented a significant improvement (Fisher exact test, P = .004) over the historical controls, in which 18 of the 231 at-risk patients had significant postoperative stiffness develop. CONCLUSIONS: In at-risk patients (with calcific tendonitis, adhesive capsulitis, PASTA repair, concomitant labral repair, and single-tendon repair), a postoperative rehabilitation regimen that incorporates early closed-chain passive overhead motion can reduce the incidence of postoperative stiffness after arthroscopic rotator cuff repair.

Subscapularis tendon tears: identifying mid to distal footprint disruptions.

We present an arthroscopic technique used to identify mid to distal subscapularis tendon disruptions. These tears can be easy to miss and require a thorough arthroscopic evaluation of the medial biceps sling and the medial side wall of the bicipital groove to detect. The arthroscopic procedure is performed with the patient in the lateral decubitus position, and the same portals used for standard subscapularis repair are used for this technique. If a high degree of clinical suspicion exists for subscapularis pathology and no tendon disruption is initially identified, an inspection of the medial biceps sling and medial side wall of the bicipital groove may show mid to distal subscapularis tendon disruptions. A 70 degrees arthroscope is essential in visualizing the medial sling, the subscapularis tendon, the biceps tendon, and the proximal 2 cm of the bicipital groove. Any disruptions or rents in the medial sling or medial side wall are suggestive of a subscapularis tear. Once a tear is identified, we proceed with a biceps tenodesis and then take down the medial sling from the lesser tuberosity to better delineate the subscapularis footprint. The subscapularis may then be repaired in standard fashion.

Rehabilitation following arthroscopic rotator cuff repair.

The postoperative rehabilitation program is critical for the successful arthroscopic treatment of rotator cuff injury. The authors' experience has confirmed that the best clinical results (restoration of strength, motion, and relief of pain) following rotator cuff repair are achieved after a durable repair of tendon to bone that heals in its entirety. Therefore, the senior author (SSB) has adopted a customized rehabilitation protocol to optimize postoperative range of motion while maintaining rotator cuff integrity. A customized rehabilitation program that begins closed-chained overhead stretches (table slides) early for groups at risk for developing stiffness and delays overhead stretches for the remaining patients until 6 weeks is best to avoid stiffness without potentially increasing the risk of rerupture in the early postoperative period.

Arthroscopic double-pulley remplissage technique for engaging Hill-Sachs lesions in anterior shoulder instability repairs.

We present a modified arthroscopic technique used to treat anterior shoulder instability associated with mild glenoid bone loss and a large Hill-Sachs lesion. The procedure aims to convert a bony intra-articular defect into an extra-articular defect by insetting the infraspinatus into the Hill-Sachs lesion. The arthroscopic procedure is performed with the patient in the lateral decubitus position, and the same portals used for anterior instability repair are used for this technique. The sequence of steps involves placing and passing the glenoid anchors and sutures and then waiting to tie the anterior sutures until after the humeral suture anchors have been placed. The subacromial bursa is cleared; then 2 transtendon suture anchors are placed in the Hill-Sachs lesion. Next, the previously placed Bankart repair sutures are tied, and finally, the remplissage sutures are tied in the subacromial space over the infraspinatus by use of the transtendon double-pulley technique. This technique uses the eyelets of the 2 suture anchors as pulleys and creates a double-mattress suture.

Radiographic and navigation measurements of TKA limb alignment do not correlate.

UNLABELLED: Precise pre- and postoperative anatomic measurements are necessary to plan, perform, and evaluate total knee arthroplasty (TKA). We evaluated the relationship between radiographic and navigation alignment measurements, identified sources of error in radiographic and navigated alignment assessment, and determined the differences between desired and clinically accepted alignment. Fifty-eight computer-assisted TKAs were performed and limb alignment measurements were recorded both pre- and postoperatively with standard radiographs and with an intraoperative navigation system. Intraoperative navigation produced consistent navigation-generated alignment results that were within 1 degrees of the desired alignment. The difference between preoperative radiographic and navigation measurements varied by as much as 12 degrees and the difference between postoperative radiographic and navigation measurements varied by as much as 8 degrees. This discrepancy depended on the degree of limb deformity. Postoperative radiographic measurements have inherent limitations. Navigation can generate precise, accurate, and reproducible alignment measurements. This technology can function as an effective tool for assessing pre- and postoperative limb alignment and relating intraoperative alignment measurements to clinical and functional outcomes. LEVEL OF EVIDENCE: Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Ridge-splitting technique with simultaneous implant placement.

Bone augmentation procedures are routinely required before dental implant placement. Several techniques for this procedure may be considered, such as guided bone regeneration, bone block grafting, and ridge splitting for bone expansion. These case reports describe the technique for ridge splitting and gradual expansion in the maxilla and the mandible. Simultaneously, dental implants were placed within the split ridge, surrounded by the particulate bone graft and covered by a resorbable membrane. Six months later, the implants were uncovered followed by impression and final restoration with implant-supported porcelain-fused-to-metal crowns.