Aggregated neutrophil extracellular traps resolve inflammation by proteolysis of cytokines and chemokines and protection from antiproteases.

Papillon-Lefèvre syndrome (PLS) is characterized by nonfunctional neutrophil serine proteases (NSPs) and fulminant periodontal inflammation of unknown cause. Here we investigated neutrophil extracellular trap (NET)-associated aggregation and cytokine/chemokine-release/degradation by normal and NSP-deficient human and mouse granulocytes. Stimulated with solid or soluble NET inducers, normal neutrophils formed aggregates and both released and degraded cytokines/chemokines. With increasing cell density, proteolytic degradation outweighed release. Maximum output of cytokines/chemokines occurred mostly at densities between 2 × 107 and 4 × 107 neutrophils/cm3. Assessment of neutrophil density in vivo showed that these concentrations are surpassed during inflammation. Association with aggregated NETs conferred protection of neutrophil elastase against α1-antitrypsin. In contrast, eosinophils did not influence cytokine/chemokine concentrations. The proteolytic degradation of inflammatory mediators seen in NETs was abrogated in Papillon-Lefèvre syndrome (PLS) neutrophils. In summary, neutrophil-driven proteolysis of inflammatory mediators works as a built-in safeguard for inflammation. The absence of this negative feedback mechanism might be responsible for the nonresolving periodontitis seen in PLS.-Hahn, J., Schauer, C., Czegley, C., Kling, L., Petru, L., Schmid, B., Weidner, D., Reinwald, C., Biermann, M. H. C., Blunder, S., Ernst, J., Lesner, A., Bäuerle, T., Palmisano, R., Christiansen, S., Herrmann, M., Bozec, A., Gruber, R., Schett, G., Hoffmann, M. H. Aggregated neutrophil extracellular traps resolve inflammation by proteolysis of cytokines and chemokines and protection from antiproteases.

High-resolution MR imaging for dental impressions: a feasibility study.

OBJECTIVES: Magnetic resonance imaging is an emerging technology in dental medicine. While low-resolution MRI has especially provided means to examine the temporomandibular joint due to its anatomic inaccessibility, it was the goal of this study to assess whether high-resolution MRI is capable of delivering a dataset sufficiently precise enough to serve as digital impression of human teeth. MATERIALS AND METHODS: An informed and consenting patient in need of dental restoration with fixed partial dentures was chosen as subject. Two prepared teeth were measured using MRI and the dataset subjected to mathematical processing before Fourier transformation. After reconstruction, a 3D file was generated which was fed into an existing industry standard CAD/CAM process. RESULTS: A framework for a fixed dental prosthesis was digitally modeled and manufactured by laser-sintering. The fit in situ was found to be acceptable by current clinical standards, which allowed permanent placement of the fixed prosthesis. CONCLUSIONS: Using a clinical whole-body MR scanner with the addition of custom add-on hardware, contrast enhancement, and data post-processing, resolution and signal-to-noise ratio were sufficiently achieved to allow fabrication of a dental restoration in an acquisition time comparable to the setting time of common dental impression materials. Furthermore, the measurement was well tolerated. CLINICAL RELEVANCE: The herein described method can be regarded as proof of principle that MRI is a promising option for digital impressions when fixed partial dentures are required.

Analysis of Escherichia Coli O104:H4 Outbreak in Germany in 2011 Using Differentiation Method for Unusual Epidemiological Events.

AIM: The aim of the study was to further clarify the origin of Escherichia coli O104:H4 outbreak in Germany in 2011 (German Ec) as the likelihood of a deliberate act has not been excluded in previous analyses. METHODS: We use an original and the most detailed scoring method so far, with 33 parameters pertaining to the source of infection/reservoir or possible perpetrator, pathogen or biological agent, transmission mechanism/factors or means/media of delivery, and population at risk or target. RESULTS: Total scores for a deliberate or accidental epidemic indicate that the outbreak was more probably caused unintentionally, presumably due to technical accidents or hygienic shortcomings in the food chain. CONCLUSIONS: The validity of the present assessment is limited by the lack of data on the reservoir of the pathogen, the source of infection, and the mode of food contamination. Conclusive evidences on these parameters are essential for the final clarification of the outbreak origin.

Escherichia coli O104:H4 outbreak in Germany--clarification of the origin of the epidemic.

BACKGROUND: In 2011, Germany was hit by one of its largest outbreaks of acute gastroenteritis and haemolytic uraemic syndrome caused by a new emerging enterohaemorrhagic Escherichia coli O104:H4 strain. The German Haemolytic Uraemic Syndrome/Enterohaemorrhagic E. coli (GHUSEC) outbreak had unusual microbiological, infectiological and epidemiological features and its origin is still only partially solved. The aim of this article is to contribute to the clarification of the origin of the epidemic. METHODS: To retrospectively assess whether the GHUSEC outbreak was natural, accidental or a deliberate one, we analysed it according to three published scoring and differentiation models. Data for application of these models were obtained by literature review in the database Medline for the period 2011-13. RESULTS: The analysis of the unusual GHUSEC outbreak shows that the present official assumption of its natural origin is questionable and pointed out to a probability that the pathogen could have also been introduced accidentally or intentionally in the food chain. CONCLUSION: The possibility of an accidental or deliberate epidemic should not be discarded. Further epidemiological, microbiological and forensic analyses are needed to clarify the GHUSEC outbreak.

Prophylaxis of intra- and postoperative nausea and vomiting in patients during cesarean section in spinal anesthesia.

BACKGROUND: This paper describes a randomized prospective study conducted in 308 patients undergoing caesarean section in spinal anaesthesia at a single hospital between 2010 and 2012 to find a suitable anti-emetic strategy for these patients. MATERIAL AND METHODS: Spinal anesthesia was performed in left prone position, at L3/L4 with hyperbaric 0.5% Bupivacaine according to a cc/cm body height ratio. There were no opioids given peri-operatively. The patients received either no prophylaxis (Group I) or tropisetron and metoclopramide (Group II) or dimenhydrinate and dexamethasone (Group III), or tropisetron as a single medication (Group IV). The primary outcome was nausea and/or vomiting (NV) in the intraoperative, early (0-2 h) or late (2-24 h) postoperative period. Multivariate statistical analysis was conducted with a regression analysis and a backward elimination of factors without significant correlation. RESULTS: All prophylactic agents significantly reduced NV incidence intraoperatively. Relative risk reduction for NV by prophylaxis was most effective (59.5%) in Group II (tropisetron and metoclopramide). In Group III (dimenhydrinate and dexamethasone), NV risk was reduced by 29.9% and by 28.7% in Group IV (tropisetron mono-therapy). The incidence of NV in the early (0?2 h) and the late (2?24 h) postoperative period was low all over (7.8%), but the relative risk reduction of NV in the early postoperative period was 54.1% (Group IV), 45.1% (Group III), and 34.8% (Group II), respectively. In the late postoperative period, there was no significant difference between the 4 groups. CONCLUSIONS: We recommend a prophylactic medication with tropisetron 2 mg and metoclopramide 20 mg for patients during caesarean section. These agents are safe, reasonably priced, and highly efficient in preventing nausea and vomiting.

Diagnosis of dental abnormalities in children using 3-dimensional magnetic resonance imaging.

PURPOSE: To assess the feasibility of magnetic resonance imaging (MRI) of dental abnormalities in children. MATERIALS AND METHODS: The study included 16 patients (mean age, 10.8 yr) prospectively selected from 1,500 orthodontic patients. The selected patients included 3 with a mesiodens, 9 with supernumerary teeth other than a mesiodens, 1 with gemination, 1 with dilacerations, 1 with transmigration, and 1 with transposition. Three-dimensional (3D) images were acquired on a 1.5-T MRI scanner using a 3D turbo spin echo pulse sequence with a voxel size of 0.8 × 0.8 × 1 mm. The measurement time was 4 to 5 minutes. RESULTS: Using natural MRI contrast, the teeth, dental pulp, mandibular canal, and cortical bone could be clearly delineated. The position and shape of malformed teeth could be assessed in all 3 spatial dimensions. CONCLUSION: MRI was found to be a well-tolerated imaging modality for the diagnosis of dental abnormalities in children and for orthodontic treatment and surgical planning. Compared with conventional radiography, dental MRI provides the advantage of 3-dimensionality and complete elimination of ionizing radiation, which is particularly relevant for repeated examinations in children.

Economic Impact of COVID-19 Pandemic on Dental Practices in Germany: A Cross-Sectional Survey.

An observational cross-sectional survey was planned and carried out to evaluate the economic impact of the SARS-CoV-2/COVID-19 pandemic on dental practices in Germany. An online-questionnaire was developed and previously calibrated by a group consisting of experts from dentists, lawyers, and business economists (n = 21; Intra-Class-Coefficient > 0.8). It consisted of four main categories: vital statistics, professional activity and practice structure, economic impact of the COVID-19 pandemic and validation and contextualization to avoid automated filling in. The questionnaire was administered anonymously to 9732 dentists in Germany, 4434 of whom opened it and 1496 of whom fully completed it. These results were evaluated and summarized. Respondents were divided into seven German economic macro areas. Difference in proportion among questionnaire items was evaluated with χ2 test or Fisher exact test appropriately. Linear trend analysis was performed among German macro areas. Ordinal multinomial linear regression analysis was run to evaluate the association with questionnaire items with respect to a collapse and/or quarantine measures due to a positive test/infection/disease of dental personnel or an increase in average monthly costs due to the pandemic. One-third experienced a collapse or quarantine measures of the predominantly self-employed participating dentists (92%). Small practices were less affected than larger ones. Average monthly costs increased sharply in all practice structures. The findings shall help to better manage future pandemics and provide information to policy makers. As the pandemic situation is still ongoing, the medium- and long-term economic impact should be further evaluated.

Vitamin C promotes widespread yet specific DNA demethylation of the epigenome in human embryonic stem cells.

Vitamin C (ascorbate) is a widely used medium supplement in embryonic stem cell culture. Here, we show that ascorbate causes widespread, consistent, and remarkably specific DNA demethylation of 1,847 genes in human embryonic stem cells (hESCs), including important stem cell genes, with a clear bias toward demethylation at CpG island boundaries. We show that a subset of these DNA demethylated genes displays concomitant gene expression changes and that the position of the demethylated CpGs relative to the transcription start site is correlated to such changes. We further show that the ascorbate-demethylated gene set not only overlaps with gene sets that have bivalent marks, but also with the gene sets that are demethylated during differentiation of hESCs and during reprogramming of fibroblasts to induced pluritotent stem cells (iPSCs). Our data thus identify a novel link between ascorbate-mediated signaling and specific epigenetic changes in hESCs that might impact on pluripotency and reprogramming pathways.

Influence of Oral Health Care Systems on Future Career Environment of Dental Students in Europe.

Oral healthcare is organized subsidiarily and independently by nation states in Europe and also within the EU and consequently, major differences between the nation states and the various oral healthcare systems in Europe are present. The socialization in the respective catchment area can have an impact on the job choice and the perception of employment opportunities of different professional groups. Therefore, the purpose of this survey was to elucidate the influence of different oral healthcare systems on students living or studying in the respective catchment area. A questionnaire (in English, French, German, Italian, and Spanish) with 18 different components was administered. Data on gender, age, country of origin, university, semester, nationality, expected time of graduation, and forecast for future professional practices were gathered. In addition, 3851 students participated (2863 f/988 m). The sample distribution was uneven with predominantly Bismarckian and Southern European System participants. The National oral health care system was statistically significantly linked (p < 0.01) to the ownership period of a dental practice. Students in Bismarckian and Nordic systems tended to find their own practice earlier than in the Beverdigian system or Southern European and Transitional-East European systems. An association between the oral health care system and vocational training was inhomogeneous, but also significantly different (p < 0.01). The majority (47.51%, n = 1555) would like to work in their own practice, 18.95% (n = 621) want to establish a practice with two or more owners. It was striking that no student would like to work in the investor practice/practice chain of both Nordic, Beveridgian and Transitional-East European countries systems (p < 0.01). The oral health care system in which a dental student grows up/resides/studies influences the career choice/perception of future professional practice.

Review: The risk of contracting anthrax from spore-contaminated soil - A military medical perspective.

Anthrax is an infectious disease of relevance for military forces. Although spores of Bacillus anthracis obiquitously occur in soil, reports on soil-borne transmission to humans are scarce. In this narrative review, the potential of soil-borne transmission of anthrax to humans is discussed based on pathogen-specific characteristics and reports on anthrax in the course of several centuries of warfare. In theory, anthrax foci can pose a potential risk of infection to animals and humans if sufficient amounts of virulent spores are present in the soil even after an extended period of time. In praxis, however, transmissions are usually due to contacts with animal products and reported events of soil-based transmissions are scarce. In the history of warfare, even in the trenches of World War I, reported anthrax cases due to soil-contaminated wounds are virtually absent. Both the perspectives and the experience of the Western hemisphere and of former Soviet Republics are presented. Based on the accessible data as provided in the review, the transmission risk of anthrax by infections of wounds due to spore-contaminated soil is considered as very low under the most circumstance. Active historic anthrax foci may, however, still pose a risk to the health of deployed soldiers.

Expectations Regarding Dental Practice: A Cross-Sectional Survey of European Dental Students.

Obtaining information on expectations among dental students regarding their career planning was the main purpose of this observational online survey. The questionnaire was designed with 18 items in five different languages: English, French, German, Italian and Spanish. Data were collected on nationality, age, sex, country of residence, university attended, semester, expected year of graduation and expectations about future career. More than 3000 participants (n = 3851, 2863 females 74.34% and 988 males 25.66% with a sex ratio of 0.35) participated in the survey. Almost one-third (31.29%) of the participants plan to start their own practice at least three years after vocational training, a quarter (25.76%) after three, and only 12.59% after one year. A positive influence of the family in the decision to start a practice was observed in 50.07% of the sample with a statistically significant difference regarding sex (p < 0.01). Almost one-third of the participants did not wish to work in an institution run by private equity or insurance companies, while 21.79% would work in that environment (p < 0.01). European dental students desire mainly to become self-employed and start their own practice. New professional practices also offer them options for their future career that they have not yet decided on or thought about.

The effects of recombinant human growth/differentiation factor-5 (rhGDF-5) on bone regeneration around titanium dental implants in barrier membrane-protected defects: a pilot study in the mandible of beagle dogs.

PURPOSE: This dog study sought to evaluate guided bone regeneration (GBR) in peri-implant defects following implantation of beta-tricalcium phosphate (beta-TCP) with and without osteoinductive recombinant human growth/differentiation factor-5 (rhGDF-5). MATERIALS AND METHODS: In five beagle dogs, all mandibular premolars and the first molar were extracted. After 2 months, six buccolingual critical-size defects were created, and an implant was inserted into the center of each defect. One defect was filled with beta-TCP coated with rhGDF-5 (600 microg/g beta-TCP) and covered with a titanium-reinforced e-PTFE membrane (GDF group). A second defect received the same treatment, but pure uncoated beta-TCP was used (TCP group). A third defect was filled with beta-TCP mixed with autograft and not protected with a membrane (control group). The remaining three defects were filled with other biomaterials. After 2 months, total new bone area, regenerated bone height, and residual amount of beta-TCP were determined histomorphometrically. RESULTS: All implants osseointegrated. One membrane in each group became exposed. Mean new bone area for GDF, TCP, and control sites was 43.9 +/- 18.7 mm2, 32.3 +/- 16.1 mm2, and 13.1 +/- 4.0 mm2, respectively, with a significant difference between GDF and control groups. Mean regenerated bone height was 103.8 +/- 29.7%, 75.4 +/- 36.6%, and 67.2 +/- 19.1% for the GDF, TCP, and control groups, respectively. Mean residual matrix volumes were 25.9 +/- 13.6%, 30.0 +/- 13.0%, and 13.4 +/- 6.5%, respectively. Membrane protection of peri-implant defects filled with beta-TCP resulted in a stronger effect on bone regeneration, although this was not statistically significant. The most pronounced regenerative results were achieved in rhGDF-5/beta-TCP filled membrane-protected defects. CONCLUSION: Delivery of rhGDF-5 on beta-TCP might have the potential to enhance the results of GBR in peri-implant defects.

Fracture characteristics of anterior resin-bonded zirconia-fixed partial dentures.

Resin-bonded fixed partial dentures (RBFPD) are used as a minimal invasive, tooth-preventing alternative for replacing anterior teeth. Zirconia cantilever restorations were supposed to show sufficient strength for a clinical application. The aim of this investigation was to determine the fracture characteristics of cantilever and two-retainer RBFPD, which are fabricated by computer-manufactured high-strength zirconia. Human incisors and canines were used to form three groups of 14 RBFPDs with different types of preparation: group 1, an invasive cantilever; group 2, a minimal-invasive cantilever and group 3, a two-retainer RBFPD control. After thermal cycling and mechanical loading, which was performed to simulate oral service, all restorations were loaded to fracture in a universal testing machine. One half of the specimens were investigated as a control without simulated service. Mode of failure was determined for the three designs. Both cantilever groups showed comparable fracture resistance of 227 N (no. 1) and 210 N (no. 2) before thermal cycling and mechanical loading. The resistance after aging was reduced to 210 N for the invasive cantilever RBFPD and to 179 N for the minimal invasive group. Three-unit RBFPDs showed a significantly higher (p < 0.02) fracture resistance than cantilever bridges before (426 N) as well as after aging (360 N). Predominant failure was FPD and retainer fracture for the invasive cantilever design, debonding for the minimal cantilever design and RBFPD fracture for the two-retainer design. The present study revealed a significantly higher fracture resistance for two-retainer RBFPDs than for cantilever RBFPDs. The frequency of adhesive debonding increased for non-retentive prepared cantilever RBFPDs.

Influence of microgap location and configuration on the periimplant bone morphology in submerged implants. An experimental study in dogs.

OBJECTIVES: The vertical location of the implant-abutment connection influences the periimplant bone morphology. It is unknown, however, whether different microgap configurations cause different bone reactions. Therefore, in this study the bone morphologies of two different implant systems were compared. MATERIAL AND METHODS: Three months after tooth extraction in eight mongrel dogs, two grit-blasted screw implants with internal Morse taper connection (ANK group) were placed on one side whereas the contralateral side received two oxidized screw implants with external hex (TIU group). One implant on each side was placed level with the bone (equicrestal), the second implant was inserted 1.5 mm below bone level (subcrestal). After 3 months the implants were uncovered. Three months after stage two surgery, histometrical evaluations were performed in order to assess the periimplant bone levels (PBL), the first bone-to-implant contact points (BICP), the width (HBD) and the steepness (SLO) of the bone defect. RESULTS: All implants osseointegrated clinically and histologically. Bone overgrowth of the microgap was seen in ANK implants only. No significant differences between ANK and TIU could be detected in neither vertical position for PBL and BICP. However, a tendency in favor of ANK was visible when the implants were placed subcrestally. In the parameters HBD (ANK equicrestal -0.23 mm; TIU equicrestal -0.51 mm; ANK subcrestal +0.19 mm; TIU subcrestal -0.57 mm) and SLO (ANK equicrestal 35.36 degrees; TIU equicrestal 63.22 degrees; ANK subcrestal 20.40 degrees; TIU subcrestal 44.43 degrees) more pronounced and significant differences were noted. CONCLUSIONS: Within the limits of this study, it is concluded that different microgap designs cause different shapes and sizes of the periimplant ('dish-shaped') bone defect in submerged implants both in equicrestal and subcrestal positions.

Off-rate and concentration diversity in multidonor-derived dimers of immunoglobulin G.

IgG-dimers in multidonor-derived preparations of IgG antibodies represent not only agents of therapeutic potential, but also molecules of basic immunological interest since their composition mirrors the currently unknown range of clonal concentrations and affinities. To analyze this fundamental type of diversity, a computational model is developed in agreement with a density functional theory and used to simulate the dissociation kinetics of dimers separated from a 5000 donor-derived IgG preparation (protein concentration: 0.74 mg/mL) via superimposition of 8100 arbitrary combinations of off-rates and initial concentrations. The Greedy algorithm-like procedure described requires iterative and consecutive changes of 8 from a total of 11 fitting parameters and allows to approximate the probability density distributions of either quantities within defined limits (apparent off-rates: approximately 4 x 10(-4) to 9 x 10(-17)s(-1); concentrations: approximately 3 x 10(-20) to 1 x 10(-11)M) by lognormal distributions of log-log(10)-type, each of them adapted with four particular parameters, as well as the number of different dimer populations ( approximately 2 x 10(13)). Moreover, reasonably dimensioned equilibrium constants involved in monovalent and bivalent random IgG dimerization are estimated by using a mean on-rate of 2.5 x 10(5)M(-1)s(-1) and interrelationships of molecular parameters derived from known models for antibody-antigen interaction.

A new design for post and core restorations implementing positive locking.

The design of a post and core restoration is a trade-off between a series of requirements to achieve stability of the post itself, the surrounding root dentine and the joint between tooth and post, while maintaining a sufficient apical seal of the remaining root canal filling. Post and core restoration systems come in a variety of different designs and dimensions, where each has its specific strength and weakness. With the exception of threaded versions, posts normally rely on either chemical and/or frictional locking between the post and the remaining root. Failure due to fatigue of the joint or root fracture due to overloading of the dentine is a frequent failure mode, especially for posts anchoring removable prostheses. Perforation of the root in an attempt to maximize the post length is a main cause for failure, too. A new design is proposed which uses a short but large diameter post. The risk of decementation is reduced by positive locking. A cavity with an undercut is prepared into the root, into which the post is fitted. Once joined, the post cannot be separated from the tooth without destruction of either the root or the post. The principle of the new design uses preparation tools and a post which is spread at the bottom. A cylindrically prepared hole is re-shaped to a defined inverse taper with the wider diameter at the bottom of the hole. A cylindrical post is inserted and spread at the bottom to a matching shape after placement. A first in vitro test of the stability showed that the positive locking provides at least as good extraction resistance as conventional post without the critical reliance on the luting/bonding agent.

Effect of load angulation and crown shape on forces acting on post and core restored teeth: an in vitro study.

To assess the usefulness of different post and core materials and systems, in vitro testing of fracture strength and fatigue resistance is a useful tool. However, the literature does not present coherent results as to which system can withstand the highest loads. With a geometrical model, the effects of load angulation and contact point location on the generated forces were calculated. To validate the mathematical model, a set of measurements was performed with a set-up that made it possible to measure the critical forces on a post and core restoration. A high level of correlation between the predictions of the model and the measurements was found. It was shown that the resulting forces are strongly dependent on the precise design of the test set-up and results from different geometries cannot be compared directly. Very strong sensitivity to small misalignment was found, all of which serves to explain the large differences in the literature.

Failure analysis of a new post-and-core restoration system using the finite element method.

Human teeth with substantial coronal defects are subject to reconstruction by means of post-and-core restorations. Typically, such a restoration comprises a slightly cylindrical post onto which an abutment of varying shape, depending on the designated restoration, is attached. As clinical results are not satisfactory to date, a new post-and-core design which makes use of positive locking (rather than relying on chemical bonding agents for retention in the residual root) was proposed. Using proprietary burs, an inversely conical hole is machined into the root, into which the prefabricated post-and-core restoration is inserted. This part can be spread at the bottom to match the cavity's undercut form, resulting in a positive lock which can only be separated by destruction of root, restoration or both. Another key feature of this system is a ring/groove geometry which is able to absorb the wedging forces created by said spreading and the stress of loading of the restoration which arises from mascatory forces. To assess the properties, especially in terms of the stress imposed on the remaining tooth at highest possible loading, both finite element simulations and in vitro failure tests were performed and the findings compared. The results suggest that the parameters of the finite element simulations are in good agreement with reality. As calculated and measured force levels immediately before failure of the restoration are high, the introduced new geometry has significant advantages over the classical restoration.

The influence of the root cross-section on the stress distribution in teeth restored with a positive-locking post and core design: a finite element study.

Human teeth with substantial coronal defects are subject to reconstruction by means of post and core restorations. Typically, such a restoration comprises a slightly cylindrical post onto which an abutment of varying shape, depending on the designated restoration, is attached. As clinical results are not satisfactory to date, we proposed a new proprietary post and core design which makes use of positive locking. As this prefabricated system is not customised to an individual root's cross-sectional geometry (usually oval), a varying amount of radicular dentin is left in periphery of the core's outer edge. The aim of this study was to assess the implications of this fact, i.e., whether the root has to endure higher overall stress levels which ultimately may lead to failure of one of the components involved. A series of finite element simulations were performed to evaluate stress and strain on the system, in which the proposed post and core was embedded into a virtual dentin cylinder of different diameters, ranging from flush mounting of the restoration to a dentin excess of 4 mm, and subsequently loaded with forces with two angles of attack (90 degrees and 130 degrees ). The results show that flush mounting yields an agreeable stress and strain distribution within the radicular dentin, but overall stress levels drop significantly with an excess of 0.5 mm of surrounding dentin. More than 1 mm excess was not found to have profound positive effects.