Low-Titer Type O Whole Blood for Transfusing Perinatal Patients after Acute Hemorrhage: A Case Series.

Objective Acute and massive blood loss is fortunately a rare occurrence in perinatal/neonatal practice. When it occurs, typical transfusion paradigms utilize sequential administration of blood components. However, an alternative approach, transfusing type O whole blood with low anti-A and anti-B titers, (LTOWB) has recently been approved and utilized in trauma surgery. Study Design Retrospective analysis of all perinatal patients who have received LTOWB after acute massive hemorrhage at the Intermountain Medical Center. Results LTOWB was the initial transfusion product we used to resuscitate/treat 25 women with acute and massive postpartum hemorrhage and five infants with acute hemorrhage in the first hours/days after birth. We encountered no problems obtaining or transfusing this product and we recognized no adverse effects of this treatment. Conclusion Transfusing LTOWB to perinatal patients after acute blood loss is feasible and appears at least as safe a serial component transfusion. Its use has subsequently been expanded to multiple hospitals in our region as first-line transfusion treatment for acute perinatal hemorrhage. Key Points Low-titer type O whole blood (LTOWB) was our initial transfusion product for 30 perinatal patients with acute hemorrhage. Twenty-five of these were obstetrical patients and five were neonatal patients. We encountered no problems with, or adverse effects from LTOWB in any of these patients. LTOWB transfusions to women were ten days since donor draw (interquartile range, 8-13) and to neonates was six days (5-8).

Associations between blood donor sex and age, and outcomes of transfused newborn infants.

BACKGROUND: It is controversial whether the sex or age of red blood cell (RBC) donors affects mortality or morbidities of transfused newborn infants. We assessed these issues using a multi-year, multi-hospital database linking specific outcomes of neonatal transfusion recipients with RBC donor sex and age. STUDY DESIGN AND METHODS: We performed retrospective analyses of all neonates receiving ≥ one RBC transfusion during a 12-year period in all Intermountain Healthcare hospitals, matching mortality and specific morbidities of each transfusion recipient with the sex and age of each donor. RESULTS: There were 6396 RBC transfusions administered to 2086 infants in 15 hospitals. A total of 825 infants were transfused exclusively with RBC from female donors, 935 infants were transfused exclusively with RBC from male donors, and 326 infants were transfused with RBC from both female and male donors. No differences in baseline characteristics were identified among the three groups. Infants who received blood from both male and female donors had more RBC transfusions (5.3 ± 2.9 transfusions if received both male and female donor blood vs. 2.6 ± 2.2 if received blood from only one sex, mean ± SD, p < .001). We identified no significant differences in mortality or morbidities associated with the sex or the age of blood donors. Similarly, an analysis of matched vs. mismatched donor/recipient sex revealed no associations with death or neonatal morbidities. CONCLUSION: These data support the practice of transfusing newborn infants with RBC obtained from donors of either sex and regardless of donor age.

High frequency of upper aerodigestive tract manifestations in mucous membrane pemphigoid.

OBJECTIVE: The objective of this study was to evaluate the frequency of upper aerodigestive tract involvement in patients with mucous membrane pemphigoid associated with desquamative gingivitis. SUBJECTS AND METHODS: Data from 25 patients were collected by retrospective chart review. Their upper aerodigestive had been evaluated using a conventional flexible fiberscope. Oral disease activity was quantified on the basis of the Mucous Membrane Pemphigoid Disease Area Index activity score. RESULTS: Lesions of the upper aerodigestive tract were confirmed in nine symptomatic patients (9/25, 36%), of which five (5/25, 20%) had laryngeal involvement. No lesions were seen in the asymptomatic patients on fiberscope examination. There was a statistically significant difference in the symptoms, high oral disease activity score, and linear IgA deposition on direct immunofluorescence between patients with and without upper aerodigestive tract lesions (p = .001, .001, .002, respectively). CONCLUSION: The high frequency of considerable complications highlights the importance of confirming the presence of upper aerodigestive tract involvement in patients with mucous membrane pemphigoid having desquamative gingivitis. Signs including the presence of symptoms, high oral disease activity score, or linear IgA deposition on direct immunofluorescence might indicate a higher risk of upper aerodigestive tract involvement.

Evaluating emergency-release blood transfusion of newborn infants at the Intermountain Healthcare hospitals.

BACKGROUND: An emergency-release blood transfusion (ERBT) protocol (uncrossmatched type O-negative red blood cells, AB plasma, AB platelets) is critical for neonatology practice. However, few reports of emergency transfusions are available. We conducted an ERBT quality improvement project as a basis for progress. STUDY DESIGN AND METHODS: For each ERBT in the past 8 years, we logged indications, products, locations and timing of the transfusions, and outcomes. RESULTS: One hundred forty-nine ERBTs were administered; 42% involved a single blood product, and 58% involved two or more. The incidence was 6.25 ERBT per 10,000 live births, with a higher rate (9.52 ERBT/10,000) in hospitals with a Level 3 neonatal intensive care unit (NICU) (p < 0.001). Seventy percent of ERBTs were administered in a NICU and 30% in a delivery room, operating room, or emergency department. Indications were abruption/previa (32.2%), congenital anemia (i.e., fetomaternal hemorrhage; 15.4%), umbilical cord accident (i.e., velamentous insertion; 15.0%), and bleeding/coagulopathy (12.8%). Fifty-eight percent of those with hemorrhage before birth did not have a hemoglobin value reported on the umbilical cord gas; thus, anemia was not recognized initially. None of the 149 ERBTs were administered using a blood warmer. The mortality rate of recipients was 35%. CONCLUSION: Based on our findings, we recommend including a hemoglobin value with every cord blood gas after emergency delivery to rapidly identify fetal anemia. We also discuss two potential improvements for future testing: 1) the use of a warming device for massive transfusion of neonates and 2) the use of low-titer group O cold-stored whole blood for massive hemorrhage in neonates.

Acantholysis may precede elevation of circulating anti-desmoglein 3 antibody levels in pemphigus vulgaris presenting with desquamative gingivitis.

Pemphigus vulgaris (PV) is an autoimmune, blistering disease that affects the mucosa and skin. The current theory favors the concept that anti-desmoglein (Dsg) 3 autoimmunity is the only pathogenic event needed to induce acantholysis. However, a few cases of active PV in the oral cavity had no detectable anti-Dsg 3 antibody. The aim of this study was to evaluate the differences in clinical and laboratory findings, whether or not the anti-Dsg 3 antibodies were present. This study was based on a retrospective review of 10 PV cases. The evaluation of the circulating autoantibody titers to Dsg 3 was conducted by using enzyme-linked immunosorbent assay (ELISA). An index value of 20 or more was used as the cutoff for a positive reaction. Only five of the 10 PV cases had a positive Dsg 3 ELISA. There were no differences in clinical, cytological, histopathological, and direct immunofluorescence findings, whether or not the anti-Dsg 3 antibodies were present. Of the five patients with a negative reaction at the time of diagnosis, the Dsg 3 ELISA became positive in the follow-up period in three cases. In the remaining two cases, the Dsg 3 ELISA was consistently negative for 18 months. Dsg 3 ELISA was negative early in some PV cases. Therefore, PV acantholysis may precede the elevation of circulating anti-Dsg 3 antibody levels. The diagnosis of PV should be considered based on comprehensive clinical, histopathological, and immunofluorescent criteria.

Handheld tunable focus confocal microscope utilizing a double-clad fiber coupler for in vivo imaging of oral epithelium.

A reflectance confocal endomicroscope with double-clad fiber coupler and electrically tunable focus lens is applied to imaging of the oral mucosa. The instrument is designed to be lightweight and robust for clinical use. The tunable lens allows axial scanning through > 250 ?? ? m in the epithelium when the probe tip is placed in contact with tissue. Images are acquired at 6.6 frames per second with a field of view diameter up to 850 ?? ? m . In vivo imaging of a wide range of normal sites in the oral cavity demonstrates the accessibility of the handheld probe. In vivo imaging of clinical lesions diagnosed as inflammation and dysplasia illustrates the ability of reflectance confocal endomicroscopy to image cellular changes associated with pathology.

A randomized controlled trial evaluating antioxidant-essential oil gel as a treatment for gingivitis in orthodontic patients.

OBJECTIVE: To evaluate the treatment effect of an antioxidant-essential oil gel on orthodontic patients with generalized gingivitis. The gel contains the essential oils menthol and thymol and the antioxidants ferulic acid and phloretin. MATERIALS AND METHODS: Thirty patients from the university's orthodontic clinic were screened for gingivitis and randomly allocated into treatment and placebo-control groups. Each patient was evaluated at three orthodontic treatment visits (T1, T2, and T3). A periodontal examination, including probing depth (PD), bleeding on probing (BOP), gingival index (GI), and plaque index (PI) was performed at each visit. Between T1 and T2, patients were instructed to apply a topical gel (active or placebo) to their gingiva twice daily after brushing. From T2 to T3, patients were instructed to discontinue use of the gel. RESULTS: The treatment group showed statistically significant (P < .05) reductions of BOP (-13.6 percentage points) and GI (-0.14) between T1 and T2, and significant increases in BOP (13.3 percentage points) and GI (0.14) between T2 and T3. Except for an increase in the GI between T2 and T3, the control group showed no significant changes in BOP or GI over time. The only other significant changes that occurred pertained to the treatment group, which showed significant increases in PD (0.08 mm) and PI (0.18) between T2 and T3. CONCLUSION: Application of a topical antioxidant-essential oil gel is an effective means of reducing inflammation in orthodontic patients with gingivitis.

Updates Regarding Diagnostic Adjuncts for Oral Squamous Cell Carcinoma.

The 5-year survival rate for oral cancer (66%) is still one of the lowest among major human cancers, and delayed diagnosis until an advanced stage is thought to be the main factor contributing to this low survival rate. The detection and diagnosis of oral cancer is currently based on clinical visual examination and histopathological evaluation of a biopsy specimen. In response to the need for early detection of oral cancer, several diagnostic adjuncts have been developed and sold commercially over the years, including vital tissue staining, brush cytology, light-based visualization adjuncts, and the most recently developed test for salivary biomarkers for oral cancer. The purpose of this article is to review the current knowledge and research regarding these diagnostic adjuncts developed for early detection of oral cancer. Clinicians are best served by an awareness of the advantages and disadvantages of each adjunct, and to always consider and correlate with the clinical findings when interpreting the test results from these adjuncts.

The diagnostic challenges of separating chronic ulcerative stomatitis from oral lichen planus.

OBJECTIVE: To attempt to establish criteria to differentiate between chronic ulcerative stomatitis (CUS) and oral lichen planus (OLP) with hematoxylin and eosin (H&E) staining alone. STUDY DESIGN: Ten confirmed cases of CUS were reviewed from the Stomatology Clinic at the Texas A&M University Baylor College of Dentistry. RESULTS: The original diagnosis on H&E evaluation was OLP, chronic mucositis, or mucositis with lichenoid features, but subsequent direct immunofluorescence (DIF) revealed a positive speckled intranuclear deposition of immunoglobulin G (IgG) in the basal and parabasal layers of the epithelium, confirming a diagnosis of CUS. CONCLUSIONS: No consistent histopathologic features were present that would allow recognition of CUS from H&E analysis alone. DIF remains the gold standard for diagnosis.

A stab-and-roll biopsy technique to maintain gingival epithelium for desquamative gingivitis.

BACKGROUND: Desquamative gingivitis (DG) is a clinical manifestation common to several diseases. It is known that most cases of DG are caused by mucous membrane pemphigoid (MMP), oral lichen planus (OLP), or pemphigus vulgaris (PV). Early recognition and treatment of these diseases can improve the prognosis, but diagnostic delays are common in patients with DG because obtaining a diagnostic biopsy is technically challenging. A biopsy technique designed to maintain the gingival epithelium for patients with DG was developed. The usefulness of this technique is discussed. METHODS: This study is based on a retrospective review of 27 DG cases. A stab-and-roll technique was used to obtain gingival tissue. This technique is designed to reduce lateral forces on the epithelium during the procedure and to thereby prevent the inadvertent removal of the epithelium from the biopsy specimen. A total of 52 biopsies comprising 27 for hematoxylin and eosin (H&E)-stained samples and 25 for direct immunofluorescence (DIF) testing were reviewed. RESULTS: Fifty-one of the 52 biopsies (98.1%) maintained the epithelium. Only one biopsy (1.9%) showed that the epithelium was totally absent. Therefore, H&E and DIF features of 51 biopsies were analyzed. Definitive diagnoses of the diseases causing DG included MMP (13 cases), PV (eight cases), and OLP (six cases). CONCLUSIONS: A diagnostic biopsy was obtained from the gingiva of patients with DG using the stab-and-roll technique. The gingival epithelium was well maintained, and the relationship with the underlying connective tissue was diagnostic. In the future, this stab-and-roll biopsy technique may facilitate early diagnosis and treatment of diseases causing DG.

A review of research on salivary biomarkers for oral cancer detection.

Using saliva for disease diagnostics and health surveillance is a promising approach as collecting saliva is relatively easy and non-invasive. Over the past two decades, using salivary biomarkers specifically for early cancer detection has attracted much research interest, especially for cancers occurring in the oral cavity and oropharynx, for which the five-year survival rate (62%) is still one of the lowest among all major human cancers. More than 90% of oral cancers are oral squamous cell carcinoma (OSCC) and the standard method for detection is through a comprehensive clinical examination by oral healthcare professionals. Despite the fact that the oral cavity is easily accessible, most OSCCs are not diagnosed until an advanced stage, which is believed to be the major reason for the low survival rate, and points to the urgent need for clinical diagnostic aids for early detection of OSCC. Thus, much research effort has been dedicated to investigating potential salivary biomarkers for OSCC, and more than 100 such biomarkers have been reported in the literature. However, some important issues and challenges have emerged that require solutions and further research in order to find reliable OSCC salivary biomarkers for clinical use. This review article provides an up-to-date list of potential OSCC salivary biomarkers reported as of the fall of 2013, and discusses those emerging issues. By raising the awareness of these issues on the part of both researchers and clinicians, it is hoped that reliable, specific and sensitive salivary biomarkers may be found soon-and not only biomarkers for early OSCC detection but also for detecting other types of cancers or even for monitoring non-cancerous disease activity.

Levels of potential oral cancer salivary mRNA biomarkers in oral cancer patients in remission and oral lichen planus patients.

OBJECTIVES: To gather preliminary data concerning the feasibility of using seven salivary mRNAs-IL-8; IL-1ß; dual specificity phosphatase 1 (DUSP1); H3 histone family 3A (H3F3A); ornithin decarboxylase antizyme 1 (OAZ1); S100 calcium-binding protein P (S100P); and spermidine/spermine N1-acetyltransferase 1 (SAT1)-for detecting development of oral squamous cell carcinoma (OSCC) in oral lichen planus (OLP) patients and OSCC patients whose disease was in remission. MATERIALS AND METHODS: Saliva samples were collected from five study groups (25 subjects/group): newly diagnosed OSCC, OSCC-in-remission, disease-active OLP, disease-inactive OLP, and normal controls. The salivary mRNA levels were determined by a pre-amplification RT-qPCR approach with nested gene-specific primers. Mean fold changes between each pair of study groups were analyzed by the Mann-Whitney U test. RESULTS: Salivary levels of OAZ1, S100P, and DUSP1 mRNAs were significantly higher in newly diagnosed OSCC patients, compared to: (1) normal controls (p = 0.003; p = 0.003; and p < 0.001, respectively); (2) OSCC-in-remission (p < 0.001; p = 0.001; and p < 0.001, respectively); (3) disease-active OLP (p < 0.001; p = 0.016; and p < 0.001, respectively); and (4) disease-inactive OLP (p = 0.043; p < 0.001; and p < 0.001, respectively). No significant differences were found in the levels of salivary IL-8, IL-1ß, H3F3A, and SAT1 mRNAs between newly diagnosed OSCC patients and the normal controls (p = 0.093, 0.327, 0.764, and 0.560, respectively). CONCLUSION: Salivary OAZ1, S100P, and DUSP1 mRNAs are candidate biomarkers for detecting OSCC development in OSCC patients in remission and in OLP patients. CLINICAL RELEVANCE: The results of this study serve as the basis for a further large-scale study which may lead to a non-invasive screening method for early detection of OSCC.

Salivary interleukin-6 and -8 in patients with oral cancer and patients with chronic oral inflammatory diseases.

BACKGROUND: Previous research has indicated that salivary interleukin (IL)-6 and IL-8 are potential biomarkers for oral squamous cell carcinoma (OSCC). However, their levels have been found to be significantly elevated in patients with chronic periodontitis (CP) or oral lichen planus (OLP). The data also showed wide variations in levels among the different studies, and no standardization procedure was ever performed. Therefore, the objective of this study is to determine whether CP or OLP confounds the use of IL-6 or IL-8 for OSCC detection. METHODS: Saliva samples were collected from five groups: OSCC before treatment (n = 18); CP (n = 21); disease-active OLP (n = 21); disease-inactive OLP (n = 20); and healthy controls (n = 21). IL-6 and IL-8 concentrations (determined by enzyme-linked immunosorbent assays) were compared, using total salivary protein-standardized levels to validate the data. The Kruskal-Wallis test (α = 0.05) followed by pairwise Mann-Whitney U (post hoc) tests with Bonferroni adjustments (α = 0.00625) were used for statistical analysis. RESULTS: Salivary IL-6 levels were significantly higher in patients with OSCC than in patients with CP (P <0.001), disease-active OLP (P = 0.001), disease-inactive OLP (P <0.001), and healthy controls (P <0.001). Salivary IL-8 levels were significantly higher in patients with OSCC than in patients with CP (P <0.001), but only marginally significantly higher than in healthy controls (P = 0.014). Statistical results of standardized IL-6 and IL-8 levels were consistent with the non-standardized levels in all pairs except one. CONCLUSION: Salivary IL-6 may be a useful biomarker in the detection of OSCC, unconfounded by CP or OLP.

Salivary basic fibroblast growth factor in patients with oral squamous cell carcinoma or oral lichen planus.

OBJECTIVE: The objective of this study was to gather preliminary data concerning the feasibility of using salivary basic fibroblast growth factor (bFGF) for detecting development of oral squamous cell carcinoma (OSCC) in patients with oral lichen planus (OLP), and in patients with OSCC whose disease was in remission. STUDY DESIGN: Saliva samples were collected from 5 patient groups: patients with newly diagnosed OSCC, patients with OSCC whose disease was in remission, patients with OLP in disease-active state, patients with OLP in disease-inactive state, and healthy controls. Salivary bFGF levels were determined by enzyme-linked immunosorbent assay, and data were analyzed using the Mann-Whitney U test. RESULTS: Salivary bFGF levels were significantly elevated in patients with newly diagnosed OSCC compared with patients with OSCC in remission, patients with disease-active OLP, and healthy controls. No significant difference was found between patients with newly diagnosed OSCC and patients with disease-inactive OLP. CONCLUSIONS: Our results suggested that salivary bFGF might be a potential biomarker for detecting OSCC development in patients with OSCC in remission, but not in patients with OLP.

A comparative study of root defect coverage using an acellular dermal matrix with and without a recombinant human platelet-derived growth factor.

BACKGROUND: The objective of this case series is to compare root defect coverage results and healing responses of bilateral recession defects treated with acellular dermal matrix (ADM) with and without recombinant human platelet-derived growth factor (rhPDGF). METHODS: Seventeen patients with 40 bilateral gingival recession defects were compared. Each defect was ≥2 mm and treated with ADM and a coronally advanced flap. Using split-mouth design, the control-side ADM was hydrated in sterile saline, whereas the test-side ADM was hydrated in rhPDGF. The patients were evaluated at 1 week, 1 month, 3 months, and 6 months. Standardized measurements were taken preoperatively at 3 and 6 months. Healing was clinically assessed at 1 week and 1 month post-surgically. RESULTS: Both test and control groups showed significant gain in root defect coverage over the 6-month period for all individuals, with the test group showing a 69.0% gain and the control group showing a 76.7% gain. Patients divided into Miller Class I and Class III defects were also found to have a significant gain in root defect coverage over 6 months. The test group showed 84.1% gain, and the control group showed 84.7% gain for Miller Class I defects. For Miller Class III defects, the test group showed 51.5% gain, and the control group showed a 60.8% gain. One week after surgery, 35% of the test group showed better healing, whereas 15% of the control group showed better healing. One month after surgery, 20% of the test group showed better healing, whereas 15% of the control group showed better healing. CONCLUSION: Based on the results of this case series, there were no statistically or clinically significant differences in root defect coverage, keratinized tissue, clinical attachment level, or clinical healing for treatment of root recession with a coronally advanced flap and ADM with and without rhPDGF.

Salivary endothelin-1 potential for detecting oral cancer in patients with oral lichen planus or oral cancer in remission.

Endothelin-1 (ET-1) is a potent vasoconstrictor involved not only in vascular biology but also in carcinogenesis. Results of a study in 2007 suggested salivary ET-1 as a potential biomarker for oral squamous cell carcinoma (OSCC), but a later study showed conflicting results. The purpose of our pilot study was to investigate feasibility of using salivary ET-1 as a biomarker for OSCC in two groups: oral lichen planus (OLP) patients and patients with OSCC in remission. Saliva samples were collected from five groups of subjects: patients with newly diagnosed, active OSCC (Group A); patients with OSCC in remission (Group B); patients with active OLP lesions (Group C); patients with OLP in remission (Group D); and normal controls (Group E). Salivary ET-1 levels were determined by enzyme-linked immunosorbent assay, and the results were analyzed by the Mann-Whitney U test. The mean salivary ET-1 level in Group A was significantly higher than that found in Group C (p=0.001), Group D (p=0.015) or Group E (p=0.004). There were no significant differences (p>0.05) in the mean salivary ET-1 levels between Groups A and B; Groups B and C; Groups B and D; Groups B and E; Groups C and D; Groups C and E; or Groups D and E. Salivary ET-1 could be a good biomarker for OSCC development in OLP patients regardless of the degree of OLP disease activity. However, it appeared not to be a good biomarker for detecting recurrence of OSCC in patients in remission.

Oral mucosal findings related to tobacco use and alcohol consumption: a study on Swiss army recruits involving self-reported and clinical data.

PURPOSE: The aim of the present study was to assess the oral mucosal health status of young male adults (aged 18 to 24 years) in Switzerland and to correlate their clinical findings with self-reported risk factors such as tobacco use and alcohol consumption. MATERIALS AND METHODS: Data on the oral health status of 615 Swiss Army recruits were collected using a standardised self-reported questionnaire, followed by an intraoral examination. Positive clinical findings were classified as (1) common conditions and anatomical variants, (2) reactive lesions, (3) benign tumour lesions and (4) premalignant lesions. The main locations of the oral mucosal findings were recorded on a topographical classification chart. Using correlational statistics, the findings were further associated with the known risk factors such as tobacco use and alcohol consumption. RESULTS: A total of 468 findings were diagnosed in 327 (53.17%) of the 615 subjects. In total, 445 findings (95.09%) were classified as common conditions, anatomical variants and reactive soft-tissue lesions. In the group of reactive soft-tissue lesions, there was a significantly higher percentage of smokers (P < 0.001) and subjects with a combination of smoking and alcohol consumption (P < 0.001). Eight lesions were clinically diagnosed as oral leukoplakias associated with smokeless tobacco. The prevalence of precursor lesions in the population examined was over 1%. CONCLUSIONS: Among young male adults in Switzerland, a significant number of oral mucosal lesions can be identified, which strongly correlate with tobacco use. To improve primary and secondary prevention, young adults should therefore be informed more extensively about the negative effects of tobacco use on oral health.

Surgical considerations and management of patients with mucocutaneous disorders.

Surgeons may be confronted with providing periodontal plastic or implant therapy for patients with gingival manifestations of systemic conditions. These conditions (often referred to as mucocutaneous disorders) commonly present with features of desquamative gingivitis, which was once believed to represent a disease entity. However, today, the term desquamative gingivitis is used to describe clinical features of various local or systemic diseases or disorders that result in chronic gingival lesions characterized by epithelial desquamation, erythema, ulceration, and/or vesiculobullous lesions of the gingiva. Often, other oral tissues also are involved. Mucocutaneous disorders include such disease entities as lichen planus, graft-versus-host disease, pemphigoid, pemphigus vulgaris, lupus erythematosus, erythema multiforme, and linear IgA disease. Surgeons should be able to recognize these disorders and have the tools necessary to treat these conditions so that they can render the appropriate surgical care. This article describes the diagnosis, etiology, and clinical manifestation of these disease entities, as well as the surgical considerations and management in providing care to these patients.