Hemogram parameters can predict in-hospital mortality of patients with Myasthenic crisis.

BACKGROUND: Myasthenia gravis (MG) is an autoimmune disease involving the neuromuscular junction. Myasthenic crisis (MC), which is characterized by respiratory failure and the requirement of mechanical ventilation in patients with MG, is still a medical emergency despite the decrease in mortality with the advances in acute management. Hemogram is a cost-effective test for evaluating hematological complications and systemic inflammation, and hemogram data have been used to predict various clinical outcomes of several diseases. The relationship between hemogram and MG has been discussed, but the role of hemogram data in predicting the prognosis of MC patients has not been established. METHODS: To identify whether hemogram data can predict in-hospital mortality in patients with MC, we retrospectively investigated 188 myasthenic crisis events from the Chang Gung Research Database between April 2001 and March 2019. Demographic and clinical characteristics were collected, as well as hemogram data before intubation and extubation. The endpoints were mortality during mechanical ventilation and mortality after extubation. RESULTS: The overall in-hospital mortality rate was 22%. Multivariate logistic regression analysis for predicting mortality during mechanical ventilation showed that old age at MC onset (OR = 1.039, p = 0.022), moderate-to-severe anemia (OR = 5.851, p = 0.001), and extreme leukocytosis (OR = 5.659, p = 0.022) before intubation were strong predictors of mortality, while acute management with plasma exchange or double-filtration plasmapheresis (PE/DFPP) significantly decreased mortality (OR = 0.236, p = 0.012). For predicting mortality after extubation, moderate-to-severe anemia before extubation (OR = 8.452, p = 0.017) and non-treated with disease-modifying therapy before MC (OR = 5.459, p = 0.031) were crucial predictive factors. CONCLUSION: This study demonstrated that both old age at MC onset and moderate-to-severe anemia are important predictors of in-hospital mortality in patients with MC, and extreme leukocytosis is another crucial predictor of mortality during mechanical ventilation. The suggested mechanism is that anemia-induced hypoxia may enhance the release of proinflammatory cytokines, exacerbate systemic inflammation, and lead to multiple organ dysfunction syndrome and, finally, mortality.

Investigation of Bone Growth in Additive-Manufactured Pedicle Screw Implant by Using Ti-6Al-4V and Bioactive Glass Powder Composite.

In this study, we optimized the geometry and composition of additive-manufactured pedicle screws. Metal powders of titanium-aluminum-vanadium (Ti-6Al-4V) were mixed with reactive glass-ceramic biomaterials of bioactive glass (BG) powders. To optimize the geometry of pedicle screws, we applied a novel numerical approach to proposing the optimal shape of the healing chamber to promote biological healing. We examined the geometry and composition effects of pedicle screw implants on the interfacial autologous bone attachment and bone graft incorporation through in vivo studies. The addition of an optimal amount of BG to Ti-6Al-4V leads to a lower elastic modulus of the ceramic-metal composite material, effectively reducing the stress-shielding effects. Pedicle screw implants with optimal shape design and made of the composite material of Ti-6Al-4V doped with BG fabricated through additive manufacturing exhibit greater osseointegration and a more rapid bone volume fraction during the fracture healing process 120 days after implantation, per in vivo studies.

Use of customized 3-dimensional printed mandibular prostheses with a dental implant pressure-reducing device in mandibular body defect: A finite element study performing multiresponse surface methodology.

Background/purpose: Segmental body defects of the mandible result in the complete loss of the affected region. In our previous study, we investigated the clinical applicability of a customized mandible prosthesis (CMP) with a pressure-reducing device (PRD) in an animal study. In this study, we further incorporated dental implants into the CMP and explored the use of dental implant PRD (iPRD) designs. Materials and methods: By employing a finite element analysis approach, we created 4 types of CMP: CMP, CMP with iPRD, CMP-PRD, and CMP-PRD with iPRD. We developed 2 parameters for the iPRD: cone length (CL) in the upper part and spring pitch (SP) in the lower part. Using the response surface methodology (RSM), we determined the most suitable structural assignment for the iPRD. Results: Our results indicate that CMP-PRD had the highest von Mises stress value for the entire assembly (1076.26 MPa). For retentive screws and abutments, CMP with iPRD had the highest von Mises stress value (319.97 and 452.78 MPa, respectively). CMP-PRD had the highest principal stress (131.66 MPa) in the anterior mandible. The iPRD reduced principal stress in both the anterior and posterior mandible. Using the RSM, we generated 25 groups for comparison to achieve the most favorable results for the iPRD and we might suggest the CL to 12 mm and the SP to 0.4 mm in the further clinical trials. Conclusion: Use of the PRD and iPRD in CMP may resolve the challenges associated with CMP, thereby promoting its usage in clinical practice.

The use of customized 3D-printed mandibular prostheses with pressure-reducing device: A clinical trial.

BACKGROUND: Segmental bone defects of the mandible result in the complete loss of the affected region. We had incorporated the pressure-reducing device (PRD) designs into the customized mandible prostheses (CMP) and conducted a clinical trial to evaluate this approach. METHODS: Seven patients were enrolled in this study. We examined the association among the history of radiotherapy, the number of CMP regions, the number of chin regions involved, and CMP exposure. RESULTS: We included five men and two women with an average age of 55 years. We excised tumors with an average weight of 147.8 g and the average weight of the CMP was 68.5 g. No significant difference between the two weights was noted (p = 0.3882). Three patients received temporary dentures and the CMP remained stable in all patients. CONCLUSION: The use of PRD in CMP may address the previous challenges associated with CMP, but further research is necessary.

Additive Manufacturing of Honeycomb Lattice Structure-From Theoretical Models to Polymer and Metal Products.

The study aims to compare mechanical properties of polymer and metal honeycomb lattice structures between a computational model and an experiment. Specimens with regular honeycomb lattice structures made of Stratasys Vero PureWhite polymer were produced using PolyJet technology while identical specimens from stainless steel 316L and titanium alloy Ti6Al4V were produced by laser powder bed fusion. These structures were tested in tension at quasi-static rates of strain, and their effective Young's modulus was determined. Analytical models and finite element models were used to predict effective Young's modulus of the honeycomb structure from the properties of bulk materials. It was shown, that the stiffness of metal honeycomb lattice structure produced by laser powder bed fusion could be predicted with high accuracy by the finite element model. Analytical models slightly overestimate global stiffness but may be used as the first approximation. However, in the case of polymer material, both analytical and FEM modeling significantly overestimate material stiffness. The results indicate that computer modeling could be used with high accuracy to predict the mechanical properties of lattice structures produced from metal powder by laser melting.

Neutrophil-to-lymphocyte ratio and monocyte-to-lymphocyte ratio are associated with a 2-year relapse in patients with multiple sclerosis.

BACKGROUND: The association between increased neutrophil-to-lymphocyte ratio (NLR) and multiple sclerosis has been demonstrated in several studies. The monocyte-to-lymphocyte ratio (MLR) is an emerging biomarker for disease monitoring. Moreover, there has not been a published Taiwanese study to date. AIM: To investigate the correlation of NLR, MLR and white blood cell (WBC) count as possible biomarkers for predicting a 2-year relapse in patients with multiple sclerosis (MS). MATERIALS AND METHODS: A total of 641 Taiwanese patients with MS were enrolled in the present study between January 1, 2001, and December 31, 2018. We collected data on NLR, MLR, WBC count, disease-modifying therapy (DMT) use, and the time between first diagnosis and first relapse in all patients within a 2-year duration. RESULTS: In the relapse group, there were significantly more patients with NLR >median or MLR >median (p = 0.006 and p = 0.020, respectively). There were also more patients with WBC count >median, although the difference was not statically significant (p = 0.069). The adjusted hazard ratio for relapse and NLR >median was 1.61(p = 0.008). The adjusted hazard ratio for relapse and MLR >median was 1.43 (p = 0.044). Patients with NLR >median or MLR >median had a significantly (p = 0.008 and p = 0.039, respectively) increased risk of MS relapse in the 2 years, compared with those who had NLR

The Use of Customized Three-Dimensionally Printed Mandible Prostheses with a Pressure-Reducing Device: A Finite Element Analysis in Different Chewing Positions, Biomechanical Testing, and In Vivo Animal Study Using Lanyu Pigs.

Segmental bony defects of the mandible constitute a complete loss of the regional part of the mandible. Although several types of customized three-dimension-printed mandible prostheses (CMPs) have been developed, this technique has yet to be widely used. We used CMP with a pressure-reducing device (PRD) to investigate its clinical applicability. First, we used the finite element analysis (FEA). We designed four models of CMP (P1 to P4), and the result showed that CMP with posterior PRD deployment (P4 group) had the maximum total deformation in the protrusion and right excursion positions, and in clenching and left excursion positions, posterior screws had the minimum von Mises stress. Second, the P4 CMP-PRD was produced using LaserCUSING from titanium alloy (Ti-6Al-4V). The fracture test result revealed that the maximum static pressure that could be withstood was 189 N, and a fatigue test was conducted for 5,000,000 cycles. Third, animal study was conducted on five male 4-month-old Lanyu pigs. Four animals completed the experiment. Two animals had CMP exposure in the oral cavity, but there was no significant inflammation, and one animal had a rear wing fracture. According to a CT scan, the lingual cortex of the mandible crawled along the CMP surface, and a bony front-to-back connection was noted in one animal. A histological examination indicated that CMP was significantly less reactive than control materials (p = 0.0170). Adequate PRD deployment in CMP may solve a challenge associated with CMP, thus promoting its use in clinical practice.

Depth-sensing nano-indentation on a myelinated axon at various stages.

A nano-mechanical characterization of a multi-layered myelin sheath structure, which enfolds an axon and plays a critical role in the transmission of nerve impulses, is conducted. Schwann cells co-cultured in vitro with PC12 cells for various co-culture times are differentiated to form a myelinated axon, which is then observed using a transmission electron microscope. Three major myelination stages, with distinct structural characteristics and thicknesses around the axon, can be produced by varying the co-culture time. A dynamic contact module and continuous depth-sensing nano-indentation are used on the myelinated structure to obtain the load-on-sample versus measured displacement curve of a multi-layered myelin sheath, which is used to determine the work required for the nano-indentation tip to penetrate the myelin sheath. By analyzing the harmonic contact stiffness versus the measured displacement profile, the results can be used to estimate the three stages of the multi-layered structure on a myelinated axon. The method can also be used to evaluate the development stages of myelination or demyelination during nerve regeneration.

Tailoring grain sizes of the biodegradable iron-based alloys by pre-additive manufacturing microalloying.

We demonstrated the design of pre-additive manufacturing microalloying elements in tuning the microstructure of iron (Fe)-based alloys for their tunable mechanical properties. We tailored the microalloying stoichiometry of the feedstock to control the grain sizes of the metallic alloy systems. Two specific microalloying stoichiometries were reported, namely biodegradable iron powder with 99.5% purity (BDFe) and that with 98.5% (BDFe-Mo). Compared with the BDFe, the BDFe-Mo powder was found to have lower coefficient of thermal expansion (CTE) value and better oxidation resistance during consecutive heating and cooling cycles. The selective laser melting (SLM)-built BDFe-Mo exhibited high ultimate tensile strength (UTS) of 1200 MPa and fair elongation of 13.5%, while the SLM-built BDFe alloy revealed a much lower UTS of 495 MPa and a relatively better elongation of 17.5%, indicating the strength enhancement compared with the other biodegradable systems. Such an enhanced mechanical behavior in the BDFe-Mo was assigned to the dominant mechanism of ferrite grain refinement coupled with precipitate strengthening. Our findings suggest the tunability of outstanding strength-ductility combination by tailoring the pre-additive manufacturing microalloying elements with their proper concentrations.

Deformations of Ti-6Al-4V additive-manufacturing-induced isotropic and anisotropic columnar structures: Insitu measurements and underlying mechanisms.

The deformations of isotropic and anisotropic Ti-6Al-4V columnar structures fabricated by additive manufacturing were extensively examined. The distinct texture and microstructure distributions were characterised. In situ X-ray diffraction measurements show different lattice activities resulting from the different microstructure distributions. Spatially resolved mapping revealed manufacturing-induced crystallite-orientation distributions that determine the deformation mechanisms. We propose a self-consistent model to correlate the multi-scale characteristics, from the anisotropic-texture-distribution microstructure to the bulk mechanical properties. We determined that basal and pyramidal slip activities were activated by tension deformation. The underlying additive-manufacturing-induced crystal plasticity plays a major role. We find that the texture development of the columnar structures and the distribution of crystallite orientation achieved by different processing conditions during additive manufacturing have important effects on the mechanical properties. The dominant deformation mode for the anisotropic Ti-6Al-4V columnar structure is basal slip, and that for the isotropic Ti-6Al-4V columnar structure is pyramidal slip. The difference may be important for determining the fatigue behaviour.

Determination and controlling of grain structure of metals after laser incidence: Theoretical approach.

There are serious questions about the grain structure of metals after laser melting and the ways that it can be controlled. In this regard, the current paper explains the grain structure of metals after laser melting using a new model based on combination of 3D finite element (FE) and cellular automaton (CA) models validated by experimental observation. Competitive grain growth, relation between heat flows and grain orientation and the effect of laser scanning speed on final micro structure are discussed with details. Grains structure after laser melting is founded to be columnar with a tilt angle toward the direction of the laser movement. Furthermore, this investigation shows that the grain orientation is a function of conduction heat flux at molten pool boundary. Moreover, using the secondary laser heat source (SLHS) as a new approach to control the grain structure during the laser melting is presented. The results proved that the grain structure can be controlled and improved significantly using SLHS. Using SLHS, the grain orientation and uniformity can be change easily. In fact, this method can help us to produce materials with different local mechanical properties during laser processing according to their application requirements.

Myelinated nerve bundles developed on the plano-concave fibers containing nerve conduit.

Morphologically and chemically modified plano-concave fibers (PCFs) are designed as a unit of guided channels for supporting Schwann cells to facilitate mass transport and promote nerve regeneration. The surface-modified PCFs are imprinted with linearly patterned grooves (LPGs) to guide adherent Schwann cell elongation and axon extension. After being cocultured with PC12 neuron-like cells, Schwann cells differentiate into the myelinated type and interact with PC12 axons. The myelinated axons aggregate as a linear bundle and extend along the direction of LPGs on a PCF. The cross section of a myelin structure is examined using a transmission electron microscope. The PCFs can potentially bridge gaps in injured nerves, improving the therapeutic efficacy of nerve regeneration.

Enhanced Schwann cell adhesion and elongation on a topographically and chemically modified poly(L-lactic acid) film surface.

A dense poly-L-lactic acid (PLLA) film was employed as the primary material and hot-embossed with the formation of microgrooves (g-PLLA). A thin layer of Au was then deposited on the film to obtain a morphologically modified substrate (Au/g-PLLA). The Au/g-PLLA film surface was then chemically modified by imprinting octadecanethiolate (ODT) self-assembled monolayers on the upper surface (ODT/Au/g-PLLA), followed by Arg-Gly-Asp (RGD) peptide sequences on the microgrooves (RGD_ODT/Au/g-PLLA). The surface chemistry of the as-prepared RGD_ODT/Au/g-PLLA samples was examined. The bioactivity and spreading function of Schwann cells cultured on the morphologically and chemically modified surfaces were assessed. The results demonstrate that Schwann cells adhered to the RGD/Au/g-PLLA surface and proliferated along the microgrooves without crossing over the ODT/Au/PLLA surface. The proposed film surface can be used for manipulating the outgrowth of axons by modifying and arranging a selected region to induce cell growth and to prevent cells from spreading out nondirectionally.