Amount of ascites impacts survival in patients with hepatocellular carcinoma undergoing transarterial chemoembolization advocating for volumetric assessment.

Preliminary work has shown that portal hypertension plays a key role for the prognosis in patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). Specifically, the presence of ascites appears to be a strong negative predictor for these patients. However, it remains unclear whether different ascites volumes influence prognosis. Therefore, the aim of this work was to investigate the influence of different ascites volumes on survival for patients with HCC undergoing TACE. A total of 327 treatment-naïve patients with HCC undergoing initial TACE at our tertiary care center between 2010 and 2020 were included. In patients with ascites, the fluid was segmented, and the volume quantified by slice-wise addition using contrast-enhanced CT imaging. Median overall survival (OS) was calculated and univariate and multivariate Cox regression analysis has been performed. Ascites was present in 102 (31.9%) patients. Ascites volume as continuous variable was significantly associated with an increased hazard ratio in univariate analysis (p < 0.001) and remained an independent predictor of impaired median OS in multivariate analysis (p < 0.001). Median OS without ascites was 17.1 months, and therefore significantly longer than in patients with ascites (6.4 months, p < 0.001). When subdivided into groups of low and high ascites volume in relation to the median ascites volume, patients with low ascites volume had a significantly longer median OS (8.6 vs 3.6 months, p < 0.001). Ascites in patients with HCC undergoing TACE is strongly associated with a poor prognosis. Our results show that not only the presence but also the amount of ascites is highly relevant. Therefore, true ascites volume as opportunistic quantitative biomarker is likely to impact clinical decision-making once automated solutions become available.

Impact of test-enhanced learning as a study strategy: An exploratory study with first-year dental students.

PURPOSE: Research has demonstrated that learners who practice self-testing have superior long-term retention compared to those rereading the material alone, a phenomenon called test-enhanced learning. This testing effect can be leveraged by spacing out the testing practice over time, a technique called spaced repetition. In 2017, we provided dental students at the school with access to Osmosis, a web-based platform that supports test-enhanced learning and spaced repetition through flashcards. This exploratory study examined students' adoption of self-testing with flashcards and its impact on learning performance in basic sciences. METHODS: Participants were 143 first-year predoctoral students at a dental school in the US. The platform analytics revealed the number of flashcards students answered throughout the first academic year (2019-2020). Regression analyses examined how self-testing with flashcards impacted students' exam scores in basic sciences. Analysis of variance (ANOVA) tests examined the difference in students' exam performance among the non, minimal, occasional, and regular flashcard users who answered 0, 1-99, 100-499, and over 500 flashcards, respectively. RESULTS: Students answered 82,766 flashcards during the year. Additionally, they created 17,973 flashcards using the platform's flashcard authoring tool. Regression analyses showed that self-testing with flashcards correlated positively with students' exam performance in anatomy, biochemistry, nutrition, and physiology. ANOVA results revealed a statistically significant difference in students' exam performance in anatomy, biochemistry, and nutrition among the four groups. CONCLUSIONS: This study is the first in dental education to examine students' self-testing on the Osmosis platform. Results revealed that there was widespread adoption of self-testing with flashcards. The study provided additional evidence to support the value of self-testing for dental students. It has practical implications of how test-enhanced learning can be incorporated into dental education to support student learning. The study contributed to the test-enhanced learning literature in dental education, an area that has been underexplored.

Cln5 represents a new type of cysteine-based S-depalmitoylase linked to neurodegeneration.

Genetic CLN5 variants are associated with childhood neurodegeneration and Alzheimer's disease; however, the molecular function of ceroid lipofuscinosis neuronal protein 5 (Cln5) is unknown. We solved the Cln5 crystal structure and identified a region homologous to the catalytic domain of members of the N1pC/P60 superfamily of papain-like enzymes. However, we observed no protease activity for Cln5; and instead, we discovered that Cln5 and structurally related PPPDE1 and PPPDE2 have efficient cysteine palmitoyl thioesterase (S-depalmitoylation) activity using fluorescent substrates. Mutational analysis revealed that the predicted catalytic residues histidine-166 and cysteine-280 are critical for Cln5 thioesterase activity, uncovering a new cysteine-based catalytic mechanism for S-depalmitoylation enzymes. Last, we found that Cln5-deficient neuronal progenitor cells showed reduced thioesterase activity, confirming live cell function of Cln5 in setting S-depalmitoylation levels. Our results provide new insight into the function of Cln5, emphasize the importance of S-depalmitoylation in neuronal homeostasis, and disclose a new, unexpected enzymatic function for the N1pC/P60 superfamily of proteins.

Characterization of the amidoxime reducing components ARC1 and ARC2 from Arabidopsis thaliana.

Five molybdenum-dependent enzymes are known in eukaryotes. While four of them are under investigation since decades, the most recently discovered, (mitochondrial) amidoxime reducing component ((m)ARC), has only been characterized in mammals and the green algae Chlamydomonas reinhardtii. While mammalian mARCs have been shown to be involved in various signalling pathways, Chlamydomonas ARC was shown to be a nitric oxide (NO)-forming nitrite reductase. Similar to mammals, higher plants possess two ARC proteins. To test whether plant ARCs have a similar function in NO production to the function they have in C. reinhardtii, we analysed the enzymes from the model plant Arabidopsis thaliana. Both ARC1 and ARC2 from Arabidopsis could reduce N-hydroxylated compounds, while nitrite reduction to form NO could only be demonstrated for ARC2. Searching for physiological electron donors, we found that both ARC enzymes accept electrons from NADH via cytochrome b5 reductase and cytochrome b5 , but only ARC2 is able to accept electrons from nitrate reductase at all. Furthermore, arc-deficient mutant plants were similar to wildtype plants regarding growth and also nitrite-dependent NO-formation. Altogether, our results did not confirm the hypothesis that either ARC1 or ARC2 from Arabidopsis are involved in physiologically relevant nitrite-dependent NO-formation. In contrast, our data suggest that ARC1 and ARC2 have distinct, yet unknown physiological roles in higher plants.

Molecular mechanism of intramolecular electron transfer in dimeric sulfite oxidase.

Sulfite oxidase (SOX) is a homodimeric molybdoheme enzyme that oxidizes sulfite to sulfate at the molybdenum center. Following substrate oxidation, molybdenum is reduced and subsequently regenerated by two sequential electron transfers (ETs) via heme to cytochrome c. SOX harbors both metals in spatially separated domains within each subunit, suggesting that domain movement is necessary to allow intramolecular ET. To address whether one subunit in a SOX dimer is sufficient for catalysis, we produced heterodimeric SOX variants with abolished sulfite oxidation by replacing the molybdenum-coordinating and essential cysteine in the active site. To further elucidate whether electrons can bifurcate between subunits, we truncated one or both subunits by deleting the heme domain. We generated three SOX heterodimers: (i) SOX/Mo with two active molybdenum centers but one deleted heme domain, (ii) SOX/Mo_C264S with one unmodified and one inactive subunit, and (iii) SOX_C264S/Mo harboring a functional molybdenum center on one subunit and a heme domain on the other subunit. Steady-state kinetics showed 50% SOX activity for the SOX/Mo and SOX/Mo_C264S heterodimers, whereas SOX_C264S/Mo activity was reduced by two orders of magnitude. Rapid reaction kinetics monitoring revealed comparable ET rates in SOX/Mo, SOX/Mo_C264S, and SOX/SOX, whereas in SOX_C264S/Mo, ET was strongly compromised. We also combined a functional SOX Mo domain with an inactive full-length SOX R217W variant and demonstrated interdimer ET that resembled SOX_C264S/Mo activity. Collectively, our results indicate that one functional subunit in SOX is sufficient for catalysis and that electrons derived from either Mo(IV) or Mo(V) follow this path.

A defect in molybdenum cofactor binding causes an attenuated form of sulfite oxidase deficiency.

Isolated sulfite oxidase deficiency (ISOD) is a rare recessive and infantile lethal metabolic disorder, which is caused by functional loss of sulfite oxidase (SO) due to mutations of the SUOX gene. SO is a mitochondrially localized molybdenum cofactor (Moco)- and heme-dependent enzyme, which catalyzes the vital oxidation of toxic sulfite to sulfate. Accumulation of sulfite and sulfite-related metabolites such as S-sulfocysteine (SSC) are drivers of severe neurodegeneration leading to early childhood death in the majority of ISOD patients. Full functionality of SO is dependent on correct insertion of the heme cofactor and Moco, which is controlled by a highly orchestrated maturation process. This maturation involves the translation in the cytosol, import into the intermembrane space (IMS) of mitochondria, cleavage of the mitochondrial targeting sequence, and insertion of both cofactors. Moco insertion has proven as the crucial step in this maturation process, which enables the correct folding of the homodimer and traps SO in the IMS. Here, we report on a novel ISOD patient presented at 17 months of age carrying the homozygous mutation NM_001032386.2 (SUOX):c.1097G > A, which results in the expression of SO variant R366H. Our studies show that histidine substitution of Arg366, which is involved in coordination of the Moco-phosphate, causes a severe reduction in Moco insertion efficacy in vitro and in vivo. Expression of R366H in HEK SUOX-/- cells mimics the phenotype of patient's fibroblasts, representing a loss of SO expression and specific activity. Our studies disclose a general paradigm for a kinetic defect in Moco insertion into SO caused by residues involved in Moco coordination resulting in the case of R366H in an attenuated form of ISOD.

Online learning during COVID-19 produced equivalent or better student course performance as compared with pre-pandemic: empirical evidence from a school-wide comparative study.

BACKGROUND: The COVID-19 pandemic forced dental schools to close their campuses and move didactic instruction online. The abrupt transition to online learning, however, has raised several issues that have not been resolved. While several studies have investigated dental students' attitude towards online learning during the pandemic, mixed results have been reported. Additionally, little research has been conducted to identify and understand factors, especially pedagogical factors, that impacted students' acceptance of online learning during campus closure. Furthermore, how online learning during the pandemic impacted students' learning performance has not been empirically investigated. In March 2020, the dental school studied here moved didactic instruction online in response to government issued stay-at-home orders. This first-of-its-kind comparative study examined students' perceived effectiveness of online courses during summer quarter 2020, explored pedagogical factors impacting their acceptance of online courses, and empirically evaluated the impact of online learning on students' course performance, during the pandemic. METHOD: The study employed a quasi-experimental design. Participants were 482 pre-doctoral students in a U.S dental school. Students' perceived effectiveness of online courses during the pandemic was assessed with a survey. Students' course grades for online courses during summer quarter 2020 were compared with that of a control group who received face-to-face instruction for the same courses before the pandemic in summer quarter 2019. RESULTS: Survey results revealed that most online courses were well accepted by the students, and 80 % of them wanted to continue with some online instruction post pandemic. Regression analyses revealed that students' perceived engagement with faculty and classmates predicted their perceived effectiveness of the online course. More notably, Chi Square tests demonstrated that in 16 out of the 17 courses compared, the online cohort during summer quarter 2020 was equally or more likely to get an A course grade than the analogous face-to-face cohort during summer quarter 2019. CONCLUSIONS: This is the first empirical study in dental education to demonstrate that online courses during the pandemic could achieve equivalent or better student course performance than the same pre-pandemic in-person courses. The findings fill in gaps in literature and may inform online learning design moving forward.

Oxygen and nitrite reduction by heme-deficient sulphite oxidase in a patient with mild sulphite oxidase deficiency.

Isolated sulphite oxidase deficiency (iSOD) is an autosomal recessive inborn error in metabolism characterised by accumulation of sulphite, which leads to death in early infancy. Sulphite oxidase (SO) is encoded by the SUOX gene and forms a heme- and molybdenum-cofactor-dependent enzyme localised in the intermembrane space of mitochondria. Within SO, both cofactors are embedded in two separated domains, which are linked via a flexible 11 residue tether. The two-electron oxidation of sulphite to sulphate occurs at the molybdenum active site. From there, electrons are transferred via two intramolecular electron transfer steps (IETs) via the heme cofactor and to the physiologic electron acceptor cytochrome c. Previously, we reported nitrite and oxygen to serve as alternative electron acceptors at the Moco active site, thereby overcoming IET within SO. Here, we present evidence for these reactions to occur in an iSOD patient with an unusual mild disease representation. In the patient, a homozygous c.427C>A mutation within the SUOX gene leads to replacement of the highly conserved His143 to Asn. The affected His143 is one of two heme-iron-coordinating residues within SO. We demonstrate, that the H143N SO variant fails to bind heme in vivo leading to the elimination of SO-dependent cytochrome c reduction in mitochondria. We show, that sulphite oxidation at the Moco domain is unaffected in His143Asn SO variant and demonstrate that nitrite and oxygen are able to serve as electron acceptors for sulphite-derived electrons in cellulo. As result, the patient H143N SO variant retains residual sulphite oxidising activity thus ameliorating iSOD progression.

Role of Ceramidases in Sphingolipid Metabolism and Human Diseases.

Human pathologies such as Alzheimer's disease, type 2 diabetes-induced insulin resistance, cancer, and cardiovascular diseases have altered lipid homeostasis. Among these imbalanced lipids, the bioactive sphingolipids ceramide and sphingosine-1 phosphate (S1P) are pivotal in the pathophysiology of these diseases. Several enzymes within the sphingolipid pathway contribute to the homeostasis of ceramide and S1P. Ceramidase is key in the degradation of ceramide into sphingosine and free fatty acids. In humans, five different ceramidases are known-acid ceramidase, neutral ceramidase, and alkaline ceramidase 1, 2, and 3-which are encoded by five different genes (ASAH1, ASAH2, ACER1, ACER2, and ACER3, respectively). Notably, the neutral ceramidase N-acylsphingosine amidohydrolase 2 (ASAH2) shows considerable differences between humans and animals in terms of tissue expression levels. Besides, the subcellular localization of ASAH2 remains controversial. In this review, we sum up the results obtained for identifying gene divergence, structure, subcellular localization, and manipulating factors and address the role of ASAH2 along with other ceramidases in human diseases.

Mechanism of nitrite-dependent NO synthesis by human sulfite oxidase.

In addition to nitric oxide (NO) synthases, molybdenum-dependent enzymes have been reported to reduce nitrite to produce NO. Here, we report the stoichiometric reduction in nitrite to NO by human sulfite oxidase (SO), a mitochondrial intermembrane space enzyme primarily involved in cysteine catabolism. Kinetic and spectroscopic studies provide evidence for direct nitrite coordination at the molybdenum center followed by an inner shell electron transfer mechanism. In the presence of the physiological electron acceptor cytochrome c, we were able to close the catalytic cycle of sulfite-dependent nitrite reduction thus leading to steady-state NO synthesis, a finding that strongly supports a physiological relevance of SO-dependent NO formation. By engineering SO variants with reduced intramolecular electron transfer rate, we were able to increase NO generation efficacy by one order of magnitude, providing a mechanistic tool to tune NO synthesis by SO.

Impaired mitochondrial maturation of sulfite oxidase in a patient with severe sulfite oxidase deficiency.

Sulfite oxidase (SO) is encoded by the nuclear SUOX gene and catalyzes the final step in cysteine catabolism thereby oxidizing sulfite to sulfate. Oxidation of sulfite is dependent on two cofactors within SO, a heme and the molybdenum cofactor (Moco), the latter forming the catalytic site of sulfite oxidation. SO localizes to the intermembrane space of mitochondria where both-pre-SO processing and cofactor insertion-are essential steps during SO maturation. Isolated SO deficiency (iSOD) is a rare inborn error of metabolism caused by mutations in the SUOX gene that lead to non-functional SO. ISOD is characterized by rapidly progressive neurodegeneration and death in early infancy. We diagnosed an iSOD patient with homozygous mutation of SUOX at c.1084G>A replacing Gly362 to serine. To understand the mechanism of disease, we expressed patient-derived G362S SO in Escherichia coli and surprisingly found full catalytic activity, while in patient fibroblasts no SO activity was detected, suggesting differences between bacterial and human expression. Moco reconstitution of apo-G362S SO was found to be approximately 90-fold reduced in comparison to apo-WT SO in vitro. In line, levels of SO-bound Moco in cells overexpressing G362S SO were significantly reduced compared to cells expressing WT SO providing evidence for compromised maturation of G362S SO in cellulo. Addition of molybdate to culture medium partially rescued impaired Moco binding of G362S SO and restored SO activity in patient fibroblasts. Thus, this study demonstrates the importance of the orchestrated maturation of SO and provides a first case of Moco-responsive iSOD.

Evaluating outcomes of computer-based classroom testing: Student acceptance and impact on learning and exam performance.

Computer-based testing (CBT) has made progress in health sciences education. In 2015, the authors led implementation of a CBT system (ExamSoft) at a dental school in the U.S. Guided by the Technology Acceptance Model (TAM), the purposes of this study were to (a) examine dental students' acceptance of ExamSoft; (b) understand factors impacting acceptance; and (c) evaluate the impact of ExamSoft on students' learning and exam performance. Survey and focus group data revealed that ExamSoft was well accepted by students as a testing tool and acknowledged by most for its potential to support learning. Regression analyses showed that perceived ease of use and perceived usefulness of ExamSoft significantly predicted student acceptance. Prior CBT experience and computer skills did not significantly predict acceptance of ExamSoft. Students reported that ExamSoft promoted learning in the first program year, primarily through timely and rich feedback on examination performance. t-Tests yielded mixed results on whether students performed better on computerized or paper examinations. The study contributes to the literature on CBT and the application of the TAM model in health sciences education. Findings also suggest ways in which health sciences institutions can implement CBT to maximize its potential as an assessment and learning tool.

Nitrite-dependent nitric oxide synthesis by molybdenum enzymes.

Nitric oxide (NO) is an important gasotransmitter involved in numerous intra- and intercellular signaling events. In addition to the oxidative pathway of NO generation, which includes three NO synthase (NOS) isoforms in mammals, a reductive pathway contributes to NO generation. In this pathway, nitrite is reduced to NO by various metal-containing proteins. Among these, all members of the eukaryotic molybdenum (Mo)-dependent enzyme family were found to be able to reduce nitrite to NO. This Review focuses on the current state of research in the field of Mo-dependent nitrite reduction in eukaryotes. An overview on the five eukaryotic Mo-enzymes is given, and similarities as well as differences in their nitrite reduction mechanisms are presented and discussed in the context of physiological relevance.

Multicenter clinical assessment of improved wearable multimodal convulsive seizure detectors.

OBJECTIVE: New devices are needed for monitoring seizures, especially those associated with sudden unexpected death in epilepsy (SUDEP). They must be unobtrusive and automated, and provide false alarm rates (FARs) bearable in everyday life. This study quantifies the performance of new multimodal wrist-worn convulsive seizure detectors. METHODS: Hand-annotated video-electroencephalographic seizure events were collected from 69 patients at six clinical sites. Three different wristbands were used to record electrodermal activity (EDA) and accelerometer (ACM) signals, obtaining 5,928 h of data, including 55 convulsive epileptic seizures (six focal tonic-clonic seizures and 49 focal to bilateral tonic-clonic seizures) from 22 patients. Recordings were analyzed offline to train and test two new machine learning classifiers and a published classifier based on EDA and ACM. Moreover, wristband data were analyzed to estimate seizure-motion duration and autonomic responses. RESULTS: The two novel classifiers consistently outperformed the previous detector. The most efficient (Classifier III) yielded sensitivity of 94.55%, and an FAR of 0.2 events/day. No nocturnal seizures were missed. Most patients had <1 false alarm every 4 days, with an FAR below their seizure frequency. When increasing the sensitivity to 100% (no missed seizures), the FAR is up to 13 times lower than with the previous detector. Furthermore, all detections occurred before the seizure ended, providing reasonable latency (median = 29.3 s, range = 14.8-151 s). Automatically estimated seizure durations were correlated with true durations, enabling reliable annotations. Finally, EDA measurements confirmed the presence of postictal autonomic dysfunction, exhibiting a significant rise in 73% of the convulsive seizures. SIGNIFICANCE: The proposed multimodal wrist-worn convulsive seizure detectors provide seizure counts that are more accurate than previous automated detectors and typical patient self-reports, while maintaining a tolerable FAR for ambulatory monitoring. Furthermore, the multimodal system provides an objective description of motor behavior and autonomic dysfunction, aimed at enriching seizure characterization, with potential utility for SUDEP warning.

An Interactive Online Approach to Teaching Evidence-Based Dentistry with Web 2.0 Technology.

At many dental schools, evidence-based dentistry (EBD) is taught in a traditional lecture format. To avoid the constraints of lectures, in 2012 the EBD unit was redesigned for online delivery at the Arthur A. Dugoni School of Dentistry at the University of the Pacific with a Web 2.0 tool called Voicethread. The aim of this study was to assess the impact of Voicethread-based online learning on students' perceptions of learning EBD, their participation and engagement, and their acceptance of this new online delivery approach. Students' perceptions were collected from two sources: a self-assessment quiz and a question on their self-reported preparedness in EBD from the 2014 American Dental Education Association (ADEA) Survey of Dental School Seniors. The Voicethread analytics tool provided data on students' participation and engagement. Students' responses to the survey questions on the self-assessment quiz provided data on their acceptance of Voicethread-based learning. The average score of the 124 students (91% of total) taking the quiz was 7.3 out of 8. The percentage of students who reported in the 2014 ADEA survey that they were "well prepared" in EBD was 45.2%, compared with the national average of 31.2%. Responses to this question for the Classes of 2013 and 2015, who received instruction in the traditional lecture format, were 35.2% and 34.6%, respectively. With Voicethread, students actively participated and interacted with their peers through questions and answers. They perceived Voicethread to be more effective than other delivery approaches and reported that it made learning more active and engaging. These findings suggest that Voicethread may be an effective tool for students to learn EBD since it adds interactivity to online learning.

Non-unions treated with bone morphogenic protein 7: introducing the quantitative measurement of human serum cytokine levels as promising tool in evaluation of adjunct non-union therapy.

BACKGROUND: In this study we sought to determine if application of bone morphogenic protein 7 (BMP-7) promotes physiological bone healing of non-unions and to investigate if serum cytokine analysis may serve as a promising tool in the analysis of adjunct non-union therapy. Therefore we analyzed the influence of BMP-7 application on the serum cytokine expression patterns on patients with impaired bone healing compared to patients that showed proper bone healing. METHODS: Our study involved analyzing blood samples from 208 patients with long bone fractures together with patients that subsequently developed non-unions. From this large pool, 15 patients with atrophic non-union were matched to 15 patients with atrophic non-union treated with local application of BMP-7 as well as normal bone healing. Changes in the cytokine expression patterns were monitored during the 1st, 2nd, 4th, 8th, 12th and 52nd week. The patients were followed both clinically and radiologically for the entire duration of the study. Serum cytokine expression levels of transforming growth factor beta (TGF-ß), platelet-derived growth factor (PDGF) and basic fibroblast growth factor (bFGF) were analyzed and compared. RESULTS: Serum expression of TGF-ß were nearly parallel in all three groups, however serum concentrations were significantly higher in patients with proper bone healing and those treated with BMP-7 than in patients with non-unions (p < 0.05). bFGF serum concentrations increased initially in patients with proper bone healing and in those treated with BMP-7. Afterwards, values decreased; bFGF serum concentrations in the BMP-7 group were significantly higher than in the other groups (p < 0.05). PDGF serum concentration levels were nearly parallel in all groups, serum concentrations were significantly higher in patients with proper bone healing and those treated with BMP-7 than in patients with non-unions (p < 0.05). CONCLUSION: Treatment with BMP-7 in patients with former non-unions led to similar cytokine expression patterns after treatment as those found in patients with proper bone healing. Our results suggest that treatment with BMP-7 promote healing of non-unions. Furthermore, quantitative measurement of serum cytokine expression is a promising tool for evaluating the effectiveness of additional non-union therapies such as adjunct application of growth factors.

Validity of subjective smoking status in orthopedic patients.

PURPOSE: In this level 1 diagnostic study, we analyzed the validity of subjective smoking status and, as secondary research question, the smoking cessation adherence in orthopedic patients during a routine hospital stay of nonunion patients by measuring serum cotinine. METHODS: We included patients undergoing revision surgery due to nonunion of long bones. Patients were interviewed about their smoking status. Blood samples were taken from all the patients prior to surgery and for an additional 6 weeks following surgery. Serum levels of cotinine were measured, and coherence between subjective smoking status and objective cotinine analysis was evaluated. RESULTS: Between March 2012 and August 2014, we enrolled 136 patients. Six of the 26 "previous smokers" (23%) and four of the 65 "nonsmokers" (6%) had serum cotinine above cutoff levels. In self-labeled smokers, serum cotinine levels averaged at 2,367.4±14,885.9 ng/mL (with a median of 100 ng/mL), whereas in previous smokers the levels averaged at 4,270±19,619.4 ng/mL (with a median of 0 ng/mL) and in the nonsmokers group the levels averaged at 12±53.9 ng/mL (with a median of 0.03 ng/mL). Overall, the subjective smoking status matched serum cotinine testing in 88% of the cases. Sensitivity was 79.6% and specificity was 93.1%. Ninety-one percent of the patients with preoperative positive serum values were still positive at follow-up. CONCLUSION: In this study, we could show that subjective smoking status in orthopedic patients is predominantly reliable as validated by objective cotinine measurements; however, patients who declare themselves as "previous smokers" are at elevated risk for underreporting continued smoking and patients who smoked preoperatively are at high risk for continuing their habit. In the future, caregivers should consider introducing effective treatments for smoking cessation to smokers and furthermore offer effective treatments to maintain smoking cessation in previous smokers during their routine consultation prior to orthopedic and trauma surgery.

Dynamic contrast-enhanced magnetic resonance imaging can assess vascularity within fracture non-unions and predicts good outcome.

OBJECTIVES: To prospectively evaluate whether dynamic contrast-enhanced (DCE) MRI can assess vascularity within non-unions and predicts clinical outcome in combination with the clinical Non-Union Scoring System (NUSS). METHODS: Fifty-eight patients with non-unions of extremities on CT underwent 3-T DCE MRI. Signal intensity curves obtained from a region-of-interest analysis were subdivided into those with more intense contrast agent uptake within the non-union than in adjacent muscle (vascularised non-union) and those with similar or less contrast uptake. The pharmacokinetic parameters of the Tofts model K trans, K ep, iAUC and V e were correlated with union at CT 1 year later (n = 49). RESULTS: Despite inserted osteosynthetic material, DCE parameters could be evaluated in 57 fractures. The sensitivity/specificity of vascularised non-unions as an indicator of good outcome was 83.9%/50.0 % compared to 96.8%/33.3% using NUSS (n = 49). Logistic regression revealed a significant impact of NUSS on outcome (P = 0.04, odds ratio = 0.93). At first examination, median iAUC (initial area under the enhancement curve) for the ratio non-union/muscle was 10.28 in patients with good outcome compared with 3.77 in non-responders (P = 0.023). K trans, K ep and Ve within the non-union were not significantly different initially (n = 57) or 1 year later (n = 19). CONCLUSIONS: DCE MRI can assess vascularity in fracture non-unions. A vascularised non-union correlates with good outcome. KEY POINTS: • Dynamic contrast-enhanced magnetic resonance imaging can assess vascularity within bony non-unions. • Vascularised ununited fractures appear better at 1-year CT than poorly vascularised fractures. • Non-union healing after osteosynthesis or osteoinductive drugs fundamentally requires vascularity. • DCE MRI predicts treatment outcome better than the clinical Non-Union Scoring System. • DCE MRI is clinically feasible to predict treatment outcome in bony non-unions.