Solid nanoemulsion as antigen and immunopotentiator carrier for transcutaneous immunization.

Imiquimod, a toll-like receptor 7 (TLR7) agonist, is an active pharmaceutical ingredient (API) established for the topical treatment of several dermal cancerous and precancerous skin lesions. Within this work, the immunostimulatory effect of imiquimod is further exploited in a transcutaneous immunization (TCI) approach based on a solid nanoemulsion (SN) formulation. SN contains a combination of imiquimod with the model peptide antigen SIINFEKL as a novel approach to omit needle and syringe and optimize dermal antigen administration. Excipients including sucrose fatty acid esters and the pharmaceutically acceptable oils MCT (middle chain triglycerides), avocado oil, jojoba wax and squalene are high pressure homogenized together with the antigen SIINFEKL. Freeze drying was performed to eliminate water and to achieve spreadable properties of the formulation for dermal administration. The influence of the different oil components was assessed regarding in vitro drug permeation in a Franz diffusion cell model using a murine skin setup. In vivo performance in terms of cytotoxic T-cell response was assessed in a C57BL/6 mouse model. Whereas Aldara® cream contains imiquimod in a dissolved state, the SN formulations carry the active in a suspended state. This resulted in a reduction of imiquimod permeation across murine skin from the SN when compared to Aldara® cream. In spite of this permeation rate reduction, each SN induced an in vivo immune response by specific T-cell lysis. A stabilized solid nanosuspension containing squalene/tocopherol exhibited a significantly higher performance (p⩽0.05) in comparison with Aldara® cream. MCT based SN exerted an in vivo effect comparable to Aldara®. In conclusion, anhydrous highly dispersed vehicles containing imiquimod in a submicron particle size distribution can represent promising formulations for TCI. The choice of the oil component has a strong influence on SN performance, independent of in vitro drug permeation.

Donor and host B cell-derived IL-10 contributes to suppression of graft-versus-host disease.

Graft-versus-host disease (GvHD) is a frequent life-threatening complication following allogeneic HSC transplantation (HSCT). IL-10 is a regulatory cytokine with important roles during GvHD, yet its relevant sources, and mode of action, remain incompletely defined in this disease. Using IL-10-deficient donor or host mice (BALB/c or C57BL/6, respectively) in a MHC-mismatched model for acute GvHD, we found a strongly aggravated course of the disease with increased mortality when either donor or host cells could not produce this cytokine. A lack of IL-10 resulted in increased allogeneic T-cell responses and enhanced activation of host DCs in spleen and MLNs. Remarkably, IL-10 was prominently produced by host- and donor-derived CD5(int) CD1d(int) TIM-1(int) B cells in this disease, and consistent with this, allogeneic HSCT resulted in exacerbated GvHD when mice lacking IL-10 expression in B cells were used as donor or host, compared with controls. Taken together, this study demonstrates that host and donor B cell-derived IL-10 provides a unique mechanism of suppression of acute GvHD, and suggests that DCs are the targets of this B cell-mediated suppressive effect. These findings open novel therapeutic possibilities based on the use of B cells to increase the feasibility of allogeneic HSCT.

Steady-state neutrophil homeostasis is dependent on TLR4/TRIF signaling.

UNLABELLED: Polymorphonuclear neutrophil granulocytes (neutrophils) are tightly controlled by an incompletely understood homeostatic feedback loop adjusting the marrow's supply to peripheral needs. Although it has long been known that marrow cellularity is inversely correlated with G-CSF levels, the mechanism linking peripheral clearance to production remains unknown. Herein, the feedback response to antibody induced neutropenia is characterized to consist of G-CSF­dependent shifts of marrow hematopoietic progenitor populations including expansion of the lin-/Sca-1/c-kit (LSK) and granulocyte macrophage progenitor (GMP) compartments at the expense of thrombopoietic and red cell precursors. Evidence is provided that positive feedback regulation is independent from commensal germs as well as T, B, and NK cells. However, in vivo feedback is impaired in TLR4-/- and TRIF-/-, but not MyD88-/- animals. In conclusion, steady-state neutrophil homeostasis is G-CSF­dependent and regulated through pattern-recognition receptors,thereby directly linking TLR-triggering to granulopoiesis. KEY POINTS: Steady-state and emergency granulopoiesis are both dependent on TLR signaling.

Perceptions of oral health in Appalachian Kentucky: implications for message design.

We conducted three studies to investigate Appalachian college students' perceptions and behavior concerning oral health for the purpose of identifying salient factors to consider in designing persuasive messages to promote oral health. In Study 1, we conducted seven focus groups with 67 college students at a state university in Appalachian Kentucky. Using thematic analysis, we found that students based their oral health behavior on the perception that people living in Appalachia have poor oral health and that students denied, confirmed, reframed, or fulfilled this "misconception." In Study 2, quantitative results from a representative survey of students (N = 587) at the same university indicated that the barriers to enacting good oral health behavior were primarily logistical in nature, whereas the facilitators of good oral health behavior were largely social. In Study 3, results from dental screenings (N = 364) of students at the university demonstrated that about one in five students presented with active, visible decay. We discuss how these results inform our understanding of oral health behavior in Appalachia and the implications of these results for designing messages to promote oral health in the region.

Dental Care in the Frail Older Adult: Special Considerations and Recommendations.

Frail older adults disproportionately suffer from untreated dental problems. Age-related biological changes to hard and soft dental tissues, existing medical conditions, polypharmacy, diet and uncontrolled plaque exacerbate the problem. All of these factors increase the complexity of treatment and will differ greatly from standard treatment of younger adults. This article discusses the key considerations and suggestions for risk assessment, disease management, treatment planning and palliative care to maintain the patient's comfort and quality of life.

Host-derived CD8⁺ dendritic cells protect against acute graft-versus-host disease after experimental allogeneic bone marrow transplantation.

Graft-versus-host disease (GVHD) is a frequent life-threatening complication after allogeneic hematopoietic stem cell transplantation (HSCT) and induced by donor-derived T cells that become activated by host antigen-presenting cells. To address the relevance of host dendritic cell (DC) populations in this disease, we used mouse strains deficient in CD11c(+) or CD8α(+) DC populations in a model of acute GVHD where bone marrow and T cells from BALB/c donors were transplanted into C57BL/6 hosts. Surprisingly, a strong increase in GVHD-related mortality was observed in the absence of CD11c(+) cells. Likewise, Batf3-deficient (Batf3(-/-)) mice that lack CD8α(+) DCs also displayed a strongly increased GVHD-related mortality. In the absence of CD8α(+) DCs, we detected an increased activation of the remaining DC populations after HSCT, leading to an enhanced priming of allogeneic T cells. Importantly, this was associated with reduced numbers of regulatory T cells and transforming growth factor-ß levels, indicating an aggravated failure of peripheral tolerance mechanisms after HSCT in the absence of CD8α(+) DCs. In summary, our results indicate a critical role of CD8α(+) DCs as important inducers of regulatory T cell-mediated tolerance to control DC activation and T cell priming in the initiation phase of GVHD.

Dental pain in the ED: costs that hurt patients and EDs.

BACKGROUND AND OBJECTIVES: The objective of this retrospective study was to determine if the collection rates for dental related visits to the emergency department (ED) are less than collection rates for ED visits for other problems. METHODS: Data were analyzed from one Kentucky hospital's electronic health record system from April 2010 to April 2012. Collection rates for patients who received care in the ED for uncomplicated dental problems were compared to collection rates for all patients who received care in the ED for any reason. RESULTS: Each month during the study period, an average of 77 patients presented to the ED for dental problems. Compensation rates for physician fees were 9.8% for dental related care and 39% for all patients who received care for any reason. Compensation rates for hospital fees were 16% for dental related care and 20.1% for all patients who received care for any reason. Uninsured patients accounted for 68.8% of physician fees and 62.4% of hospital fees for dental related care. CONCLUSIONS: Using the ED as a dental safety net is costly to the patient because the underlying problem is typically not resolved and costly to the hospital because of very low collection rates. In addition, other patients who present to the ED for non-dental, high acuity problems may have delayed care or no care because of the number of patients using the ED for dental pain.

Antiphospholipid antibodies induce translocation of TLR7 and TLR8 to the endosome in human monocytes and plasmacytoid dendritic cells.

The antiphospholipid syndrome (APS) is an autoimmune disease characterized by thromboembolic events and/or fetal loss in the presence of antiphospholipid antibodies (aPLs). The mechanisms underlying the pathogenicity of aPLs are still poorly understood. Here we show that 3 human monoclonal aPLs as well as IgG fractions from patients with the APS increase mRNA expression of the intracellular toll-like receptor (TLR) 7 in plasmacytoid dendritic cells and TLR8 in monocytes. Simultaneously they induce the translocation of TLR7 or TLR8 from the endoplasmic reticulum to the endosome. These effects depend on the uptake of aPLs into the endosome, subsequent activation of endosomal NADPH oxidase, and generation of superoxide. As a consequence cells are dramatically sensitized to ligands for TLR7 and TLR8. This observation delineates a novel signal transduction pathway in innate immunity originating from the endosome. Because the overexpression of TLR7 can also be detected in plasmacytoid dendritic cells from patients with the APS ex vivo, our results provide an explanation for proinflammatory and procoagulant effects of aPLs. Because inappropriate expression of TLR7 has been implicated in the development of systemic autoimmunity, these findings may also be relevant for the understanding of autoimmunity.

Comparative transcutaneous immunization with imiquimod-containing ointments and potential of in vitro methods to predict effects.

This work evaluates the transcutaneous in vitro and in vivo immunization efficacy of five commercially available 5% imiquimod containing formulations. The parameters included microscopic analysis, rheological properties, drug permeation across synthetic membranes of molecular weight cutoff 10 kDa and ablated murine skin with both 0.1 m HCl and a phthalate buffer pH 3.6 Ph.Eur./methanol 3/7 (v/v) as receiver solutions in a Franz-diffusion cell model. For in vivo formulation characterization, the cytotoxic T-cell activity and interferon-γ production in C57BL/6 mice was determined ex vivo 24 h after transcutaneous administration. OVA(257-264) (SIINFEKL) from chicken albumin served as a target antigen. Microscopic images demonstrated differences with respect to the presence or absence of crystalline API. Rheological properties point to a roughly ten-fold difference between the products at low shear rates. With regard to drug permeation across synthetic membranes, only 'Nan Bo' demonstrated equality compared with Aldara™, resulting in f1 and f2 values of 5.25 and 59.58, respectively. The drug permeation rates were maximum from Aldara™ across ablated murine skin. Furthermore, differentiation between the formulations containing crystalline and dissolved states of active imiquimod was possible using this model. The in vivo results yielded significant immunomodulating activities (p < 0.05) of multisource formulations compared with the untreated control group, however, the significance of differences between the formulations was dependent on the parameter of interest. A correlation plot of skin permeation versus in vivo immunostimulating activity yielded a slope significantly different from zero only in the case of the murine skin setup (r between 0.421 and 0.669). Yet this correlation is deemed not satisfactory for formulation optimization.

Serum antibodies to periodontal pathogens are a risk factor for Alzheimer's disease.

BACKGROUND: Chronic inflammation in periodontal disease has been suggested as a potential risk factor in Alzheimer's disease (AD). The purpose of this study was to examine serum antibody levels to bacteria of periodontal disease in participants who eventually converted to AD compared with the antibody levels in control subjects. METHODS: Serum samples from 158 participants in the Biologically Resilient Adults in Neurological Studies research program at the University of Kentucky were analyzed for immunoglobulin G antibody levels to seven oral bacteria associated with periodontitis, including Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Campylobacter rectus, Treponema denticola, Fusobacterium nucleatum, Tannerella forsythia, and Prevotella intermedia. All 158 participants were cognitively intact at baseline venous blood draw. In all, 81 of the participants developed either mild cognitive impairment (MCI) or AD or both, and 77 controls remained cognitively intact in the years of follow-up. Antibody levels were compared between controls and subjects with AD at baseline draw and after conversion and controls and subjects with MCI at baseline draw and after conversion using the Wilcoxon rank-sum test. AD and MCI participants were not directly compared. Linear regression models were used to adjust for potential confounding. RESULTS: Antibody levels to F nucleatum and P intermedia were significantly increased (α = 0.05) at baseline serum draw in the patients with AD compared with controls. These results remained significant when controlling for baseline age, Mini-Mental State Examination score, and apolipoprotein epsilon 4 status. CONCLUSIONS: This study provides initial data that demonstrate elevated antibodies to periodontal disease bacteria in subjects years before cognitive impairment and suggests that periodontal disease could potentially contribute to the risk of AD onset/progression. Additional cohort studies profiling oral clinical presentation with systemic response and AD and prospective studies to evaluate any cause-and-effect association are warranted.

Using text messaging in an undergraduate nursing course.

Text messaging is a popular means of communication among young adults. Consequently, this mode of communication may be used to positively influence students in their academic studies. In this study, students were given the opportunity to receive text or e-mail messages regarding lecture content. Short message reminders, in the form of texts or e-mails, were used to send bite-sized course content to undergraduate nursing students. Messages included questions that would be answered in the next day's lecture or reiterated a main point presented in the previous day's lecture. Following a survey at the end of the course, text users responded positively toward this pedagogical approach and felt the use of text messaging enhanced their learning experience. E-mail users reported a short message reminder was moderately useful to their study of anatomy. These results suggest text messaging may be a valuable tool for educators as they seek to incorporate technology into the classroom.

Opiate overdose in an adolescent after a dental procedure: a case report.

Oxycodone/acetaminophen is a combination of acetaminophen and the opiate oxycodone. It is an effective analgesic that is commonly prescribed postoperatively. The potential for misuse, diversion, abuse, and overdose with opiates in general is an area of increasing concern to all prescribing clinicians. This case report illustrates the possibility of a severe or potentially fatal outcome to a common prescribing practice. Caution is emphasized when prescribing opiates, and screening for substance misuse and suicide risk factors is recommended.

Employee relations.

This review highlights some of the more important employee relation aspects involved in starting, establishing, or expanding an existing dental practice. Despite a competitive compensation package, staff-related conflicts can sometimes hamper the progress of a dental practice. Such conflicts can be reduced by having policies and procedures in place for each employee that set expectations concerning the hours of operation, professional manner, dress code, job tasks, performance evaluations, disciplinary actions, and termination if violations occur. Understanding the legal requirements set by various governmental agencies such as OSHA can help ensure that the rights and well-being of every employee are protected.

Tooth loss, dementia and neuropathology in the Nun study.

BACKGROUND: Numerous studies have linked dementia to the subsequent deterioration of oral health. Few investigators, however, have examined oral disease as a potential risk factor in the development of dementia. The authors conducted a study to investigate a potential association between a history of oral disease and the development of dementia. METHODS: Longitudinal dental records supplemented data collected from 10 annual cognitive assessments of 144 Milwaukee participants in the Nun Study, a longitudinal study of aging and Alzheimer disease, who were 75 to 98 years old. Neuropathologic findings at autopsy were available for 118 participants who died. RESULTS: A low number of teeth increased the risk of higher prevalence and incidence of dementia. CONCLUSION: Participants with the fewest teeth had the highest risk of prevalence and incidence of dementia. CLINICAL IMPLICATIONS: Edentulism or very few (one to nine) teeth may be predictors of dementia late in life.

Using audience response technology for pretest reviews in an undergraduate nursing course.

Implementing strategies to promote classroom interaction has been shown to enhance learning. In this study, we used an audience response system (ARS), an emerging technology, to actively engage students in examination reviews in an undergraduate nursing anatomy and physiology course. The reviews, set up as a pre-test of 25 questions in a format similar to that of the game Jeopardy!, were used before six of the eight examinations. Average scores of the class on examinations preceded by the interactive ARS review were compared with those on examinations preceded by the more traditional, lecture-style review; no significant improvement due to ARS use was found. However, results from a student satisfaction survey about ARS use demonstrated positive attitudes and perceived benefit from this interactive technology.

Composite resin in medicine and dentistry.

Composite resin has been used for nearly 50 years as a restorative material in dentistry. Use of this material has recently increased as a result of consumer demands for esthetic restorations, coupled with the public's concern with mercury-containing dental amalgam. Composite is now used in over 95% of all anterior teeth direct restorations and in 50% of all posterior teeth direct restorations. Carbon fiber reinforced composites have been developed for use as dental implants. In medicine, fiber-reinforced composites have been used in orthopedics as implants, osseous screws, and bearing surfaces. In addition, hydroxyapatite composite resin has become a promising alternative to acrylic cement in stabilizing fractures and cancellous screw fixation in elderly and osteoporotic patients. The use of composite resin in dentistry and medicine will be the focus of this review, with particular attention paid to its physical properties, chemical composition, clinical applications, and biocompatibility.

Gold as an implant in medicine and dentistry.

The purpose of this collective review is to study the history, physical and chemical properties, application, and clinical consequences of gold implants in the dental and medical fields. Gold implants are used in various medical procedures, including reconstructive surgery of the middle ear, upper lid closure in facial nerve paresis-induced lagophthalmos, drug delivery microchips, antitumor treatment, treatment of rheumatoid arthritis, use on the surface of voice prostheses, and endovascular stents, with sound clinical results. However, in order to achieve better therapeutic benefits, clinical reports have documented that the surface of gold implants have been modified or encased in biocompatible alloplastic materials, or they have been replaced by cheaper and more biocompatible materials. Gold is also applied to a long list of dental prostheses, including inlays, onlays, crowns, bridges, periodontal splints, and post and cores. It has sufficient strength and corrosion resistance, and it is relatively biocompatible. In addition, gold dental prostheses have a long life cycle. However, esthetic concerns and cost make it a less desirable prosthesis today than in the past.

Surgical endodontic retrograde root-end filling materials.

The treatment of diseased and necrotic pulpal tissue in teeth spans has been well known throughout history. Root canal treatment in the twentieth century has included complete removal of pulpal remnants to remove the failing tissue and then obturating the canal space with biocompatible material. This treatment preserves individual teeth to further function as part of a whole dentition for the patient's well-being. Failed root canal treatment, however, sometimes requires surgical intervention to treat the teeth from the root end. This article reviews the materials placed in intimate contact with tissues in this surgical procedure. The implications of these various materials within the tissues are discussed, along with clinical signs and symptoms a healthcare provider might encounter when examining these patients. There is no clear-cut "best" material for root-end surgical obturation at this time. Therefore, major materials that might be used are included in this discussion.

Evaluation and Validation of the Detection of soluble Triggering Receptor Expressed on Myeloid Cells 1 by Enzyme-linked immunosorbent Assay.

Triggering receptor expressed on myeloid cells (TREM)-1 plays an important role in innate immune responses and is upregulated under infectious as well as non-infectious conditions. In addition, a soluble TREM-1 variant (sTREM-1) is detectable in sera or bronchoalveolar-lavage fluids from patients. Currently, various studies are difficult to compare, since the methods of detection by enzyme-linked immunosorbent assays (ELISA) vary among different research groups. In this study, we compared three different s-TREM-1 specific ELISAs and identified individual assay characteristics finding notable differences in sTREM-1 concentrations in part depending on the employed buffers. Investigating potential confounding factors for sTREM-1 detection, serum heat-inactivation (HI) showed improved recovery compared to non-HI (NHI) serum, reproducible by addition of complement and re-heat-inactivation. Hence we identified complement as a heat-sensitive confounder in some sTREM-1 ELISAs. We conclude that it is difficult to directly compare data of several studies, in particular if different ELISAs are engaged. Immunoassays for research use only are in general hampered by lack of standardization. Further standardization is needed until sTREM-1 ELISA is capable for better reproducibility of studies and clinical application.

Cofactor-independent antiphospholipid antibodies activate the NLRP3-inflammasome via endosomal NADPH-oxidase: implications for the antiphospholipid syndrome.

The antiphospholipid syndrome (APS) is an autoimmune disease characterised by thromboembolic events and/or pregnancy morbidity in the presence of antiphospholipid antibodies (aPL). Here we show that three cofactor independent human monoclonal aPL can induce transcription of NLRP3 and caspase-1 resulting in inflammasome activation specific for NLRP3. This depends fully on activation of endosomal NADPH-oxidase-2 (NOX2) by aPL. Activation of NOX2 and subsequent inflammasome activation by aPL are independent from TLR2 or TLR4. While endosomal superoxide production induces caspase-1 and NLRP3 transcription, it does not affect prae-IL-1ß transcription. Therefore, release of IL-1ß occurs only after activation of additional pathways like TLR7/8 or TLR2. All effects exerted by the monoclonal aPL can be reproduced with IgG fractions of APS patients proving that the monoclonal aPL are representative for the APS. IgG fractions of healthy controls or patients suffering from systemic lupus erythematosus have no effect. In a mouse model of the APS we can show inflammasome activation in vivo. Furthermore, mononuclear cells isolated from patients with the APS show an increased expression of caspase-1 and NLRP3 which is accompanied by a three-fold increased serum concentration of IL-1ß suggesting chronic inflammasome activation in APS patients. In summary, we provide further evidence that endosomal NOX2 can be activated by cofactor independent aPL. This leads to induction of the NLRP3 inflammasome. Our data indicate that cofactor independent aPL might contribute significantly to the pathogenesis of the APS.