Bonding Characteristics of Silane Coupling Agent and MMA-Containing Primer to Various Composite CAD/CAM Blocks.

This study evaluated the bonding characteristics of a silane coupling agent (SCA) and a methyl methacrylate (MMA)-containing primer (MCP) for 11 types of commercial composite blocks (CBs) for sandblasted and non-sandblasted surfaces. The shear bond strength (SBS) was measured according to ISO 29022: Notched-edge shear bond strength test. The SBS results demonstrated statistically significant differences between the CBs under all identical conditions. For the non-sandblasted groups, the SBSs of MCP-treated specimens were significantly higher than those of SCA-treated specimens for all but two CBs. Comparing the two treatments in sandblasted groups, the SBS was significantly higher for seven out of 11 MCP-treated RCB specimens, in contrast with three cases for the SCA-treated group. Two-way ANOVA for SBS showed the interaction effect between sandblasting and primer type for specific CBs, indicating that the sandblasting treatment improved SBS more effectively for SCA-treated specimens. Moreover, the effect of the SCA treatment was more material-dependent compared to that of the MCP treatment, which did not achieve a strong bond in all CBs but proved more effective than the SCA treatment, especially for non-sandblasted surfaces.

In Vitro Study of Zirconia Surface Modification for Dental Implants by Atomic Layer Deposition.

Zirconia is a promising material for dental implants; however, an appropriate surface modification procedure has not yet been identified. Atomic layer deposition (ALD) is a nanotechnology that deposits thin films of metal oxides or metals on materials. The aim of this study was to deposit thin films of titanium dioxide (TiO2), aluminum oxide (Al2O3), silicon dioxide (SiO2), and zinc oxide (ZnO) on zirconia disks (ZR-Ti, ZR-Al, ZR-Si, and ZR-Zn, respectively) using ALD and evaluate the cell proliferation abilities of mouse fibroblasts (L929) and mouse osteoblastic cells (MC3T3-E1) on each sample. Zirconia disks (ZR; diameter 10 mm) were fabricated using a computer-aided design/computer-aided manufacturing system. Following the ALD of TiO2, Al2O3, SiO2, or ZnO thin film, the thin-film thickness, elemental distribution, contact angle, adhesion strength, and elemental elution were determined. The L929 and MC3T3-E1 cell proliferation and morphologies on each sample were observed on days 1, 3, and 5 (L929) and days 1, 4, and 7 (MC3T3-E1). The ZR-Ti, ZR-Al, ZR-Si, and ZR-Zn thin-film thicknesses were 41.97, 42.36, 62.50, and 61.11 nm, respectively, and their average adhesion strengths were 163.5, 140.9, 157.3, and 161.6 mN, respectively. The contact angle on ZR-Si was significantly lower than that on all the other specimens. The eluted Zr, Ti, and Al amounts were below the detection limits, whereas the total Si and Zn elution amounts over two weeks were 0.019 and 0.695 ppm, respectively. For both L929 and MC3T3-E1, the cell numbers increased over time on ZR, ZR-Ti, ZR-Al, and ZR-Si. Particularly, cell proliferation in ZR-Ti exceeded that in the other samples. These results suggest that ALD application to zirconia, particularly for TiO2 deposition, could be a new surface modification procedure for zirconia dental implants.

Effect of crystal orientation on flexural strength of pressable lithium disilicate glass-ceramics.

This study examined the crystal orientation of four kinds of pressable lithium disilicate glass-ceramics and evaluated the effect of crystal orientation on flexural strength. Bar-shaped (24 mm in length, 1.2 mm in thickness, 4.0 mm in width), disk-shaped (12 mm in diameter, 0.5 mm in thickness), and crown-shaped (maxillary first molar) specimens were prepared according to the manufacturer's instructions. Three-point and biaxial flexural strengths were measured for bar- and disk-shaped specimens. Microstructure analysis was performed using X-ray diffractometry and scanning electron microscopy. Three-point flexural strength was improved by parallel crystal orientation along the longitudinal direction of the bar-shaped specimen. There was no relationship between two-dimensional crystal orientation and biaxial flexural strength. The results of this study assumed that biaxial flexural strength was improved by the crystal orientation in the cross-sectional direction. Pressed restorations are expected to possess higher strength than milled restorations due to their crystal orientation.

Bone Tissue Engineering in Rat Calvarial Defects Using Induced Bone-like Tissue by rhBMPs from Immature Muscular Tissues In Vitro.

This study aimed to induce bone-like tissue from immature muscular tissue (IMT) in vitro using commercially available recombinant human bone morphogenetic protein (rhBMP)-2, rhBMP-4, and rhBMP-7, and then implanting this tissue into a calvarial defect in rats to assess healing. IMTs were extracted from 20-day-old Sprague-Dawley (SD) fetal rats, placed on expanded polytetrafluoroethylene (ePTFE) with 10 ng/µL each of rhBMP-2, BMP-4, and BMP-7, and cultured for two weeks. The specimens were implanted into calvarial defects in 3-week-old SD rats for up to three weeks. Relatively strong radiopacity was observed on micro-CT two weeks after culture, and bone-like tissue, comprising osteoblastic cells and osteoids, was partially observed by H&E staining. Calcium, phosphorus, and oxygen were detected in the extracellular matrix using an electron probe micro analyzer, and X-ray diffraction patterns and Fourier transform infrared spectroscopy spectra of the specimen were found to have typical apatite crystal peaks and spectra, respectively. Furthermore, partial strong radiopacity and ossification were confirmed one week after implantation, and a dominant novel bone was observed after two weeks in the defect site. Thus, rhBMP-2, BMP-4, and BMP-7 differentiated IMT into bone-like tissue in vitro, and this induced bone-like tissue has ossification potential and promotes the healing of calvarial defects. Our results suggest that IMT is an effective tissue source for bone tissue engineering.

Accuracy of a titanium maxillary complete denture baseplate fabricated by using the electron beam melting technique: An in vitro study.

STATEMENT OF PROBLEM: Electron beam melting (EBM) is a promising additive manufacturing technique for fabricating denture baseplates; however, studies evaluating its accuracy are sparse. PURPOSE: The purpose of this in vitro study was to compare the fit accuracy of titanium maxillary complete denture baseplates fabricated by using the EBM technique with those fabricated by using the conventional casting technique and to evaluate the dimensional accuracy of the EBM baseplate by using a 3-dimensional inspection software program. MATERIAL AND METHODS: Definitive casts of an edentulous maxilla were prepared. After the casts were optically scanned, computer-aided designs for the EBM baseplate were created by using a software program for standard tessellation language file editing. The EBM baseplates were fabricated with an EBM machine by using a Grade II titanium powder as the raw material. The cast baseplates were fabricated with a lost-wax casting technique by using refractory casts duplicated from the definitive casts. After fitting the EBM and cast baseplates to their corresponding definitive cast, they were embedded in a Type IV stone. The embedded baseplates on the casts were sectioned at 3 regions: posterior palatal seal, molar, and premolar. The maximum gaps between the baseplate and definitive cast were measured in these 3 regions. The virtual casts obtained by scanning the EBM baseplate were superimposed on the computer-aided design to evaluate the dimensional accuracy. Distribution color maps were then generated, and the mean absolute deviations and root mean square deviations were calculated. One-way analysis of variance and t tests were used for statistical analysis (α=.05). RESULTS: No significant differences in the maximum gaps among the 3 regions were found in the cast or EBM baseplate groups (P>.05). The EBM baseplate group showed significantly lower values than the cast baseplate group in all regions (premolar: P=.008; molar: P=.003; posterior palatal seal: P=.004). The mean maximum gap for the 3 regions in the cast baseplates was 168.0 µm and that in the EBM baseplates was 60.7 µm. The distribution color map of the EBM baseplate showed a favorable dimensional accuracy. The mean absolute deviation value was 19.7 µm, and the root mean square deviation value was 25.1 µm. CONCLUSIONS: The EBM baseplates had a significantly higher fit accuracy than the cast baseplates. Thus, the fit accuracy of the EBM technique is suitable for fabricating metal baseplates.

Effect of degradation of filler elements on flexural strength for dental CAD/CAM resin composite materials in water.

Purpose This study aimed to evaluate the effects of degradation on the strength of computer-aided design/computer-aided manufacturing (CAD/CAM) resin composite blocks (RCBs) by subjecting them to accelerated degradation in water and conducting biaxial flexural strength tests.Methods Six commercial RCBs were tested. The RCBs were cut into disks, after which the disks were immersed in purified water. For the aging experiment, the samples were subjected to heat treatment at 37, 60, 70, and 80 °C, in a constant temperature oven and stored statically for 30 d. After the aging experiment, the elements released from the RCB fillers were measured by inductively coupled plasma atomic emission spectroscopy. In addition, the biaxial flexural strength of the RCB fillers was measured after accelerated degradation at 70 °C.Results Si (the main component of the filler) was detected in all the RCB solutions after the aging experiment; however, the type and amount of other elements differed considerably among the RCBs. The flexural strength of some of the RCBs decreased by approximately 20-40% after the accelerated degradation. For most materials, the Weibull coefficient decreased or remained unchanged after the test, whereas it increased in some materials.Conclusions The strength of all the RCBs decreased after the accelerated degradation tests; however, this behavior differed among the materials. In addition, the release of elements from the filler of some of the materials into the water correlated with the decrease in the strength of these materials. These findings indicate that the evaluation of the degradation behavior of RCBs in water is essential for their long-term usage.

Gelatin Methacryloyl-Riboflavin (GelMA-RF) Hydrogels for Bone Regeneration.

Gelatin methacryloyl (GelMA) is a versatile biomaterial that has been used in various biomedical fields. UV light is commonly used to photocrosslink such materials; however, its use has raised several biosafety concerns. We investigated the mechanical and biological properties of a visible-wavelength (VW)-light-crosslinked gelatin-based hydrogel to evaluate its viability as a scaffold for bone regeneration in bone-destructive disease treatment. Irgacure2959 or riboflavin was added as a photoinitiator to create GelMA solutions. GelMA solutions were poured into a mold and exposed to either UV or VW light. KUSA-A1 cell-laden GelMA hydrogels were crosslinked and then cultured. Mechanical characterization revealed that the stiffness range of GelMA-RF hydrogel was suitable for osteoblast differentiation. KUSA-A1 cells encapsulated in GelMA hydrogels photopolymerized with VW light displayed significantly higher cell viability than cells encapsulated in hydrogels photopolymerized with UV light. We also show that the expression of osteogenesis-related genes at a late stage of osteoblast differentiation in osteoblasts encapsulated in GelMA-RF hydrogel was markedly increased under osteoblast differentiation-inducing conditions. The GelMA-RF hydrogel served as an excellent scaffold for the encapsulation of osteoblasts. GelMA-RF hydrogel-encapsulated osteoblasts have the potential not only to help regenerate bone mass but also to treat complex bone defects associated with bone-destructive diseases such as periodontitis.

Measurement of exothermic heat released during polymerization of a lightcuring composite resin: Comparison of light irradiation modes.

High-power light-curing units have emerged that reduce the time of procedures in dental clinical work. However, patients sometimes complain of pain during the polymerization of composite resin. In this experiment, we investigated how differences in light-curing mode affect the temperature rise during composite resin polymerization in vitro. Light-curing mode conditions were divided into four groups: 3 s in plasma mode (Plm3) and 5, 10, and 20 s in standard mode. The temperature curve under Plm3 exhibited a rapid increase during the first 3 s of light curing before reaching a maximum of around 55°C. In contrast, the temperature rose rapidly but less sharply for irradiation in each standard mode compared with Plm3. These results suggest that irradiation using a high-power mode increases the temperature at an excessively high rate, and this may raise concern about side effects on the pulp.

Leaching behaviors of computer-aided design/computer-aided manufacturing composite resin component elements immersed in water.

PURPOSE: Immersion tests in purified water were conducted to evaluate the leaching behaviors of filler elements contained in computer-aided design/computer-aided manufacturing (CAD/CAM) composite resin. METHODS: Four commercial CAD/CAM resin composite blanks were tested: Shofu block HC 2 layer, Cerasmart, Katana Avencia block, and KZR-CAD HR Block 2. The specimens in the size of 10.0×12.0×2.0mm were immersed in a 50-mL conical tube containing 40mL of purified water, and then placed in a constant-temperature oven set at a temperature of 37, 60, 70, or 80°C and stored statically for 30 days. After storage, the concentrations of leached elements in the immersion solution were measured with an inductively coupled plasma atomic emission spectrometer. To characterize the surface of the specimen after the immersion test, secondary electron images were obtained. RESULTS: The immersion test resulted in the leaching of Si, the main component, from all materials tested. Some materials were found to have leached high amount of Ba or Sr in addition to Si, and remarkable surface degradation was observed. The amount of leached elements increased with increased immersion temperatures. CONCLUSIONS: Filler elements in CAD/CAM composite resins used in this study leached into purified water. The leached elements and its quantities greatly differed among materials and depend on the types of the oxides composing the filler. The amounts of leached elements varied in a temperature-dependent manner.

Fracture strength testing of crowns made of CAD/CAM composite resins.

PURPOSE: The purpose of this study was to ascertain whether computer aided design/computer aided manufacturing (CAD/CAM) composite resin crowns have sufficient strength to withstand the bite force of the molar teeth. The null hypothesis was that the fracture strength of CAD/CAM composite resin crowns is lower than the average maximum bite force of the molar tooth. METHODS: The crowns, which shape is the right maxillary first molar, were fabricated using four CAD/CAM blanks made of composite resins (Block HC: HC, KZR-CAD HR: HR, KZR-CAD HR2: HR2, Avencia Block: AVE) and one CAD/CAM blank made of lithium disilicate glass-ceramic (IPS e.max CAD: IPS), which was used as a control. Fracture strength of fabricated crowns bonded to metal abutment and biaxial flexural strength of the materials were evaluated. RESULTS: The results of fracture strength test and biaxial flexural strength test showed different tendencies. The fracture strength of CAD/CAM composite resin crowns except HC ranged from 3.3kN to 3.9kN, and was similar to that of IPS (3.3kN). In contrast, biaxial flexural strength of CAD/CAM composite resins ranged from 175MPa to 247MPa, and was significantly lower than that of IPS (360MPa). CONCLUSIONS: All CAD/CAM composite resin crowns studied presented about 3-4 times higher fracture strength than the average maximum bite force of the molar tooth (700-900N), which result leads to the conclusion that CAD/CAM composite resin crowns would have sufficient strength to withstand the bite force of the molar teeth.

Rheological approach for determining yield stresses in flowable resin composites prior to setting.

The purpose of this study is to develop a method for quantifying the fluidity of flowable resin composites using determinations of yield stress. Five commercially available composites (AliteFlo LV, Flow-it ALC, Venus flow, Tetric N-flow, Revolution Formula2) were investigated. Yield stress values were obtained by plotting shear stresses for a range of shear rates, followed by fitting of Casson fluid models to flow curve data and extrapolation to the stress axis. To confirm that yield stress reflected fluidity, apparent viscosity at the lower shear rate (0.2 s-1) was calculated from flow curves. Yield stresses ranged from 5.4 to 43.1 Pa, and were found to capture differences in the fluidity of composites that were not captured by viscosity measurement at the low shear rate. Yield stress is directly proportional to fluidity, and could serve as a simple and precise indicator for selecting flowable resin composites for use in various clinical applications.

Physical Characteristics and Performance of Japanese Top-Level American Football Players.

Yamashita, D, Asakura, M, Ito, Y, Yamada, S, and Yamada, Y. Physical characteristics and performance of Japanese top-level American football players. J Strength Cond Res 31(9): 2455-2461, 2017-This study aimed to compare the physical characteristics and performance between top-level nonprofessional football players in Japan and National Football League (NFL) Combine invited players and between top-level and middle-level players in Japan to determine the factors that enhance performance in international and national competitions. A total of 168 American football players (>20 years) in Japan participated in an anthropometric (height and weight) and physical (vertical jump, long jump, 40-yard dash, pro-agility shuttle, 3-cone drill, and bench press repetition test) measurement program based on the NFL Combine program to compete in the selection of candidates for the Senior World Championship. All players were categorized into 1 of the 3 position groups based on playing position: skill players, big skill players, and linemen. Japanese players were additionally categorized into selected and nonselected players for the second tryout. The NFL Combine candidates had significantly better performance than selected Japanese players on all variables except on performance related to quickness among the 3 position groups. Compared with nonselected players, selected Japanese skill players had better performance in the 40-yard dash and bench press test and big skill players had better performance in the vertical jump, broad jump, and 40-yard dash. Selected and nonselected Japanese linemen were not different in any measurements. These results showed the challenges in American football in Japan, which include not only improving physical performance of top-level players, but also increasing the number of football players with good physical performance.

Proliferation of mouse fibroblast-like and osteoblast-like cells on pure titanium films manufactured by electron beam melting.

The physical characteristics and biological compatibility of surfaces produced by electron beam melting (EBM) are not well known. In particular, there are not many reports on biocompatibility qualities. In this study, pure Ti films were manufactured using EBM. While it is reported that moderately hydrophilic biomaterial surfaces display improved cell growth and biocompatibility, contact angle measurements on the EBM-produced pure Ti films showed slight hydrophobicity. Nonetheless, we found the cell count of both fibroblast-like cells (L929) and osteoblast-like cells (MC3T3-E1) increased on pure Ti films, especially the MC3T3-E1, which increased more than that of the control. In addition, the morphology of L929 and MC3T3-E1 was polygonal and spindle-shaped and the cytoskeleton was well developed in the pure Ti surface groups. Upon staining with Alizarin red S, a slight calcium deposition was observed and this level gradually rose to a remarkable level. These results indicate that pure Ti films manufactured by EBM have good biocompatibility and could be widely applied as biomedical materials in the near future.

Improving biocompatibility of zirconia surface by incorporating Ca ions.

Though zirconia has been used in dental implant fixtures, the biocompatibility of the zirconia surface is not optimal for the surrounding tissue, and many surface modifications have been attempted. We have developed a novel method for improving the biocompatibility of zirconia by incorporating Ca ions. Elemental analysis showed that calcium ions become thoroughly incorporated into the zirconia surface after firing with calcium acetate. Mechanical tests indicated that the Ca ions had little effect on the flexural strength and hardness. Moreover, incorporating Ca ions also dramatically improved the water wettability of specimens that had been soaked in a simulated body fluid. The surface of the Ca-modified zirconia demonstrated good initial cell attachment.

Enhanced bioactivity of polyvinylidene chloride films using argon ion bombardment for guided bone regeneration.

Polyvinylidene chloride (PVDC) is a long chain carbon synthetic polymer. The objective of this study was to improve the bioactivity of PVDC films through surface modification using argon (Ar) ion bombardment to create Ar-modified PVDC films (Ar-PVDC) to address the clinical problems of guided bone regeneration (GBR), which is technique-sensitive, and low bone regenerative ability. First, the effects of Ar ion bombardment, a low temperature plasma etching technique widely used in industry, on PVDC film wettability, surface chemistry, and morphology were confirmed. Next, fibroblast-like and osteoblast-like cell attachment and proliferation on Ar-PVDC were assessed. As a preclinical in vivo study, Ar-PVDC was used to cover a critical-sized bone defect on rat calvaria and osteoconductivity was evaluated by micro-computed tomography analysis and histological examinations. We found that the contact angle of PVDC film decreased by 50° because of the production of -OH groups on the PVDC film surface, though surface morphological was unchanged at 30 min after Ar ion bombardment. We demonstrated that cell attachment increased by about 40% and proliferation by more than 140% because of increased wettability, and 2.4 times greater bone regeneration was observed at week 3 with Ar-PVDC compared with untreated PVDC films. These results suggest that Ar ion bombardment modification of PVDC surfaces improves osteoconductivity, indicating its potential to increase bone deposition during GBR.

Immature muscular tissue differentiation into bone-like tissue by bone morphogenetic proteins in vitro, with ossification potential in vivo.

The objective of this study was to induce bone formation from immature muscular tissue (IMT) in vitro, using bone morphogenetic proteins (BMPs) as a cytokine source and an expanded polytetrafluoroethylene (ePTFE) scaffold. In addition, cultured IMTs were implanted subcutaneously into Sprague-Dawley (SD) rats to determine their in vivo ossification potential. BMPs, extracted from bovine cortical bones, were applied to embryonic SD rat IMT cultures, before 2 weeks culture on ePTFE scaffolds. Osteoblast-like cells and osteoid tissues were partially identified by hematoxylin-eosin staining 2 weeks after culture. Collagen type I (Col-I), osteopontin (OP), and osteocalcin (OC) were detected in the osteoid tissues by immunohistochemical staining. OC gene expression remained low, but OP and Col-I were upregulated during the culture period. In vivo implanted IMTs showed slight radiopacity 1 week after implantation and strong radiopacity 2 and 3 weeks after implantation. One week after implantation, migration of numerous capillaries was observed and ossification was detected after 2 weeks by histological observation. These results suggest that IMTs are able to differentiate into bone-like tissue in vitro, with an ossification potential after implantation in vivo.

Antibacterial properties of a self-cured acrylic resin composed of a polymer coated with a silver-containing organic composite antibacterial agent.

A novel antibacterial polymer, coated with a silver-containing organic composite antibacterial agent, was dispersed in a self-cured acrylic resin. Residual viable cell count of each oral bacterial and fungal species cultivated on acrylic resin specimens containing the antibacterial polymer was significantly decreased when compared to those cultivated on specimens prepared from untreated polymer. A strong inverse correlation was found between the amount of eluted silver ions and the residual viable cell count of all species grown on the antibacterial polymer: the lower the viable cell count, the higher the amount of eluted silver ions. This clearly indicated the antibacterial activity of silver ions. As the content of organic composite antibacterial agent added to the polymer increased from 0.5% to 1.5% in 0.5% increments, amount of eluted silver ions significantly increased with each 0.5% increment to exert greater antibacterial effect.

The effect of zinc levels in a gold-based alloy on porcelain-metal bonding.

OBJECTIVES: The purpose of this study was to ascertain whether the amount of Zn in gold alloys contributes to porcelain-metal bonding. METHODS: Experiments were carried out using a commercial Pd-free gold alloy with a nominal composition of 88.7 wt% Au, 9.49 wt% Pt, 1.5 wt% Zn, 0.1 wt% Mn, 0.2 wt% Rh, and 0.1 wt% Ir, which contains Zn and no other elements (In, Sn, Fe) known to affect porcelain-metal bond strength. To establish the effect of oxidation of the metal surface, porcelain was applied both to preoxidized and to non-preoxidized metal specimens. The bond strength was evaluated by means of the ISO 9693: 1999 crack initiation test. A conventional gold alloy was used as a control. The elemental distributions at the porcelain/alloy interfaces were analyzed in cross section by electron probe microanalysis. Additionally, after the bond strength test, cross-sections of the interfaces of the debonded specimens were microscopically analyzed to characterize the fracture mode. RESULTS: The Pd-free gold alloy joints showed significantly higher bond strength values than joints made with conventional gold alloy. Preoxidation treatment significantly increases the bond strength, in the preoxidized joints Zn was highly localized at the interface and diffused into the porcelain up to about 10 µm from the interface, and the joint failed by cohesive fracture in the porcelain. In contrast, the non-preoxidized joint showed mainly adhesive fracture at the porcelain/alloy interface. SIGNIFICANCE: The presence of Zn in gold alloys plays a part in establishing chemical bonding thus improving the bond strength between porcelain and alloy.

Cumulative episodes of rejection altered myocardial sarcoplasmic reticulum Ca(2+)-ATPase and ryanodine receptor-2 mRNA expression in heart transplant recipients.

The aim of the present study was to investigate the relationship between rejections and gene expression of Ca(2+)-handling proteins in heart transplant recipients. Thirty-seven heart transplant recipients underwent routine endomyocardial biopsy. Levels of sarcoplasmic reticulum Ca(2+)-ATPase (SERCA2) and ryanodine receptor-2 mRNAs in endomyocardial tissue were quantified by a real-time quantitative reverse transcription polymerase chain reaction (RT-PCR) method. Rejections were diagnosed according to the conventional International Society for Heart and Lung Transplantation criteria. Patients were classified as follows; group AR(+) (n = 9) with rejection grade of 2 or higher versus group AR(-) (n = 28) with rejection grade of 0, 1a or 1b at the time of biopsy, and group Rec-AR(+) (n = 6) with a history of more than 4 episodes of treatment required rejection versus group Rec-AR(-) (n = 31) without history of recurrent rejection. The mRNA levels of the SERCA2/GAPDH ratio and ryanodine receptor-2/GAPDH ratio were not different between group AR(+) and group AR(-); however, they were reduced in group Rec-AR(+) more than in group Rec-AR(-) (0.83 +/- 0.07 versus 0.90 +/- 0.07, P = 0.034, 0.74 +/- 0.06 versus 0.84 +/- 0.10, P = 0.027, respectively). A single episode of on-going rejection would not affect myocardial Ca(2+)-handling proteins; however, cumulative rejection episodes might alter the gene expression of myocardial Ca(2+)-handling proteins in heart transplant recipients.