New valproate regulations, informed choice and seizure risk.

Valproate is the most effective medication for generalised epilepsies, and several specific epilepsy syndromes. For some people, it will be the only medication to establish seizure remission, and withdrawing it carries risks of seizure recurrence and Sudden Unexpected Death in Epilepsy (SUDEP). It is also of proven efficacy for bipolar disorder and migraine prevention. Guidelines based on observational and epidemiological studies stress that maternal valproate related teratogenicity and neurodevelopmental effects are significantly higher than for other antiseizure medications (ASMs). It should, therefore, only be used if other medications are ineffective and after balancing the teratogenicity risk. Regulatory restrictions have changed prescribing practices and reduced valproate use. The number of other medications that must be trialled in the different conditions for which valproate has effectiveness and the consequences of the lack of efficacy of those drugs leading to significant harm including death remains unexplored. Risk minimisation measures (RMMs) for valproate, chiefly Pregnancy Prevention practices (PPP), consider foetal risk and not risk to people living with epilepsy. In the United Kingdom (UK), limitations relating to valproate use in all people < 55 years commenced in January 2024. While the evidence in child-bearing women is not disputed, the data in males are based on animal models, case reports, and one commissioned, unpublished, non-peer reviewed report unavailable to the UK public, stakeholder charities or professionals. Evidence suggests that 30-40% of people switching from valproate have breakthrough seizures. Thus, an estimated 21,000-28000 people in the UK will imminently be exposed to the potential hazards of breakthrough seizures, including death. There is little government investment in monitoring the effects of these changes to valproate prescribing on patient health and quality of life. This review summarises the history of valproate regulation, evidence underpinning it and argues how the latest regulations in the UK do not align with the country's medical regulatory bodies ethical principles nor with the Montgomery principles of informed patient choice and autonomy. It dissects how such regulations infringe Common Law principles, nor give due regard for patient outcomes beyond reproduction. The paper looks to provide recommendations to redress these concerns while appreciating the core need for such governance to emerge in the first place.

Harnessing the Regenerative Potential of Purified Bovine Dental Pulp and Dentin Extracellular Matrices in a Chitosan/Alginate Hydrogel.

When a tooth is diseased or damaged through caries, bioactive molecules are liberated from the pulp and dentin as part of the natural response to injury and these are key molecules for stimulating stem cell responses for tissue repair. Incorporation of these extracellular-matrix (ECM)-derived molecules into a hydrogel model can mimic in vivo conditions to enable dentin-pulp complex regeneration. Here, a chitosan/alginate (C/A) hydrogel is developed to sequester bovine ECM extracts. Human dental pulp cells (hDPCs) are cultured with these constructs and proliferation and cytotoxicity assays confirm that these C/A hydrogels are bioactive. Sequential z-axis fluorescent imaging visualizes hDPCs protruding into the hydrogel as it degraded. Alizarin red S staining shows that hDPCs cultured with the hydrogels display increased calcium-ion deposition, with dentin ECM stimulating the highest levels. Alkaline phosphatase activity is increased, as is expression of transforming growth factor-beta as demonstrated using immunocytochemistry. Directional analysis following phase contrast kinetic image capture demonstrates that both dentin and pulp ECM molecules act as chemoattractants for hDPCs. Data from this study demonstrate that purified ECM from dental pulp and dentin when delivered in a C/A hydrogel stimulates dental tissue repair processes in vitro.

A scoping review of the influence of clinical contaminants on bond strength in direct adhesive restorative procedures.

OBJECTIVE: Clinical contamination during direct adhesive restorative procedures can affect various adhesive interfaces differently and contribute to bulk failure of the restorations. This review aims to summarise the current knowledge on the influence of a variety of clinical contaminants on the bond strength at various adhesive interfaces during adhesive restorative procedures and identify gaps in the literature for future research. DATA AND SOURCES: An electronic database search was performed in PubMed and EMBASE to identify articles that investigated the influence of contaminants on direct restorative bonding procedures. A data-charting form was developed by two researchers to capture the key characteristics of each eligible study. STUDY SELECTION: The initial search yielded 1,428 articles. Fifty-seven articles published between 1 Jan 2007 and 25 Oct 2023 were included in the final review. Thirty-three of the articles examined the influence of saliva contamination, twelve articles examined the influence of blood contamination, and twenty-five articles examined the influence of other contaminants. CONCLUSION: Saliva contamination exerted less influence on the decrease in bond strength when self-etch systems were used, compared to when etch-and-rinse systems were used. Blood contamination adversely affected the bond strength at the interface between resin composite and dentine, and resin composite and resin-modified glass ionomer cement. Treating contaminated surfaces with water spray for 10-30 s followed by air drying could be effective in recovering bond strength following saliva and blood contamination. CLINICAL SIGNIFICANCE: This scoping review provides a valuable overview of the range of potential clinical contaminants that can influence the bond strength between different interfaces in direct adhesive restorative procedures. Additionally, it identifies potential decontamination protocols that can be followed to restore and enhance bond strength.

Food insecurity in children with heart disease.

PURPOSE OF REVIEW: This review discusses the epidemiology of food insecurity (FI) and its consequences in children with congenital heart disease. We aimed to highlight current interventions to screen and address food insecurity in the context of pediatric cardiology and to offer strategies for providers to engage in this meaningful work. RECENT FINDINGS: Food insecurity is consistently associated with poor health outcomes in children. In the United States, 17.3% of households with children experience FI. Nonwhite and single-parent families are disproportionately affected. Interestingly, because of a low-quality diet, FI is associated with childhood obesity, putting affected children at increased risk for cardiovascular morbidity and mortality over time. Children with congenital heart disease are susceptible to poor outcomes due to unique altered metabolic demands, increased risk for growth impairment, frequent need for specialized feeding regimens, and additional morbidity associated with heart surgery in underweight children. SUMMARY: Today, the burden of screening for FI is most commonly placed on general pediatricians. Considering the importance of nutrition to cardiovascular health and general wellbeing, and the ease with which screening can be performed, pediatric cardiologists and other subspecialists should take a more active role in FI screening.

Early results of combined total ankle total talus replacement in the revision setting.

BACKGROUND: Revision of failed total ankle replacement (TAR) is challenging and associated with increased morbidity. Given the increased popularity of TAR in treating end-stage ankle arthritis (ESAA), viable revision options are needed. The objective of this case series is to present a minimum 2-year clinical and radiographic outcomes of patient-specific custom 3D-printed total ankle total talus (TATR) prostheses in this unique subset of patients. METHODS: 19 participants with ESAA and failed primary TAR who underwent TATR by a single surgeon at our institution from 2019 to 2021 were retrospectively identified. All participants were indicated for revision of primary STAR implant (Stryker, Kalamazoo, MI) and underwent replacement with 3D-printed titanium implants based on preoperative CT analysis (Additive Orthopaedics, Little Silver, NJ). Custom components included a mobile-bearing total talus and stemmed tibial system, performed through an anterior approach. Pre- and postoperative patient-reported outcomes were assessed using the Patient Reported Outcomes Measurement Information System (PROMIS). Pre- and postoperative implant alignment was assessed using medial distal tibial angle (MDTA) and tibiotalar angle (TTA) on anteroposterior, and sagittal tibial angle (STA) on lateral weight-bearing plain films. RESULTS: The average patient age was 60.6 (range, 39-77) years, with an average follow-up of 37.9 (range, 25.3-57.5) months. There was statistically significant improvement in all PROMIS domains. Short-term survivorship was 100%, with two participants (11.0%) requiring reoperation for postoperative complications: one underwent open reduction internal fixation of the tibia for a periprosthetic fracture, and another underwent medial gutter debridement and tarsal tunnel release for recurrent pain. There were no significant differences in pre- versus postoperative radiographic alignment measured by MDTA (89.9 vs 86.4), TTA (89.7 vs 88.1), or STA (85.2 vs 85.3). CONCLUSION: Custom 3D-printed TATR is a promising option for revision TAR. There was significant short-term improvement in pain and physical function, with excellent short-term survivorship and an acceptable postoperative complication rate.

Demineralized dentin matrix for bone regeneration in dentistry: A critical update.

Over the last few decades, several new materials and techniques have been developed for bone regeneration. Scaffolds based on demineralized dentin matrix (DDM) present an attractive option due to their availability and several animal and human studies have been conducted to ascertain their utility in regenerative dentistry. The aim of this review was to summarize the recent studies conducted on DDM and used for bone grafts. PubMed, Web of Science, and Scopus were used to search for studies published within the last 10 years. The keywords and terms used were: "demineralized dentine matrix", "bone grafting", "bone augmentation" and "guided tissue regeneration" in various combinations. Original studies (in vitro, animal and human) and systematic reviews were included in the literature search. The literature search initially identified 23 studies (16 animal studies and 7 clinical reports. Most studies included in this review indicate that DDM has demonstrated promising results in a variety of dental and regenerative medicine applications. Further studies are required to completely comprehend its characteristics and prospective applications. Future studies should also focus on optimizing the processing protocols for the production of DDM-based scaffolds.

The digital divide in rural and regional communities: a survey on the use of digital health technology and implications for supporting technology use.

OBJECTIVE: A digital divide exists for people from rural and regional areas where they are less likely and confident to engage in digital health technologies. The aim of this study was to evaluate the digital health literacy and engagement of people from rural and regional communities, with a focus on identifying barriers and facilitators to using technology. RESULTS: Forty adults living in rural/regional areas completed a survey consisting of the eHealth Literacy Scale (eHEALS) with additional items surveying participants' experience with a range of digital health technologies. All participants had used at least one digital health technology. Most (80%) participants had an eHEALS score of 26 or above indicating confidence in online health information. Commonly reported barriers to digital health technology use centred on product complexity and reliability, awareness of resources, lack of trust, and cost. Effective digital health technology use is becoming increasingly important, there may be a need to prioritise and support people with lower levels of digital health literacy. We present opportunities to support community members in using and accessing digital health technology.

An assessment of ten popular pregnancy applications (Apps) available for women in Australia.

OBJECTIVE: Given the growing popularity of health Apps, this study aimed to evaluate popular pregnancy Apps among Australian women. DESIGN: Ten popular pregnancy mobile device Apps accessible within Australia were assessed using the Deakin Health E-technologies Assessment Lab (HEAL) framework, the Australian Privacy Principles (APP) and other context-specific criteria. RESULTS: Most Apps were robust in use and user-friendly in terms of design. Based on the HEAL assessment, all the Apps scored between 70 and 89 out of 120. Only two of the ten Apps were locally hosted and operated. Only one App could search local health services using Victorian postcodes. All ten Apps were aligned with various privacy policy guidelines, but only one was reported to be fully aligned with the APP as it is locally hosted and operated. None of the Apps had accessibility features such as for visual or hearing difficulties. Only one App could be assessed as able to interface with the electronic medical record system in Australia due to a lack of publicly available information on this capability. CONCLUSIONS: Due to privacy concerns, pregnancy Apps accessible in Australia should be used with caution unless care is taken to select an App that fully complies with local requirements or international equivalents. All Apps were subjectively rated as moderate in quality, and more attention to accessibility and privacy features by App developers is recommended, along with the focus on integration with Australian digital health services.

E-cadherin and TAC in GCF accurately discriminate periodontal health and disease.

OBJECTIVE: To investigate the accuracy of gingival crevicular fluid (GCF) E-cadherin and total antioxidant capacity (TAC) to discriminate periodontal health from disease. SUBJECTS AND METHODS: GCF samples were collected from participants with periodontal health (control), gingivitis, and periodontitis (n = 25 each group). The latter group was further subdivided according to stage (S) and grade. Periodontal parameters were recorded then levels of biomarkers were assayed using ELISA and antioxidant status by use of the Total Antioxidant Capacity Assay for E-cadherin and TAC, respectively. RESULTS: All periodontal parameters were significantly higher in periodontally diseased groups than controls. The GCF E-cadherin significantly increased in gingivitis and periodontitis (S2 to S4) cases as compared to controls. Level of this protein in GCF samples from periodontitis S3 was significantly higher than in gingivitis and S2 groups. The GCF-TAC level was significantly higher in controls than in periodontally diseased groups. No significant differences were observed in the levels of these proteins between grade B and C periodontitis. Both molecules could discriminate periodontal health from gingivitis and periodontitis stages and differentiating periodontitis S3 from gingivitis and other periodontitis stages. CONCLUSIONS: Levels of TAC and unbounded E-cadherin in GCF samples exhibited promising diagnostic abilities to differentiate periodontal health and disease.

Case Study: Design of an Approach for Assessing a Novel Health Capability Maturity Model.

Capability maturity models have been developed and are widely used within healthcare aiming to assess the degree of digitization of the organization, but empirical assessments of the models themselves has been undertaken infrequently. We present a mixed-method approach to assessing a novel health capability maturity model developed by a state government responsible for the management of 86 health services. The approach was designed to be suitable for system level assessment of services and pooled the wisdom and experience of subject matter experts and key stakeholders using a combination of survey and interviews to test and tune the proposed assessment approach and parameters. We applied the approach to assess the target capability model across a number of public health services in Victoria, Australia. The result showed sufficient validity to be able to generate recommendations for further improvement of the capability model and the assessment approach to enable broader application within Australia.

Fatal cerebral air embolism from atrio-oesophageal fistula following cardiac ablation.

A young woman with Rogers syndrome (thiamine-responsive megaloblastic anaemia, diabetes mellitus and sensorineural deafness) presented with headache, recurrent supraventricular tachycardia and features of an upper gastrointestinal bleed, 1 month after radiofrequency cardiac ablation for supraventricular tachycardia. She deteriorated rapidly after endoscopy and subsequently died. Brain imaging during the acute deterioration showed diffuse intracranial air embolism and hypoxic-ischaemic injury. Postmortem examination showed an atrio-oesophageal fistula, a rare complication of cardiac ablation. Clinicians should suspect this condition in patients with acute neurological deterioration after cardiac ablation who have diffuse air embolism on imaging.

Ability of gingival crevicular fluid volume, E-cadherin, and total antioxidant capacity levels for predicting outcomes of nonsurgical periodontal therapy for periodontitis patients.

OBJECTIVES: To determine the potential of gingival crevicular fluid (GCF) volume, E-cadherin and total antioxidant capacity (TAC) levels to predict the outcomes of nonsurgical periodontal therapy (NSPT) for periodontitis patients. BACKGROUND: NSPT is the gold-standard treatment for periodontal pockets < 6 mm in depth, however, successful outcomes are not always guaranteed due to several factors. Periodontitis-associated tissue destruction is evidenced by the increased level of soluble E-cadherin and reduced antioxidants in oral fluids which could be used as predictors for success/failure of NSPT. MATERIALS AND METHODS: Patients with periodontitis (n = 24) were included in this clinical trial and full-mouth periodontal charting was recorded for each patient. GCF samples from periodontal pockets with probing pocket depth (PPD) 4-6 mm from the interproximal surfaces of anterior and premolar teeth were obtained. These sites subsequently received NSPT and were clinically re-evaluated after 1 and 3 months. Levels of GCF E-cadherin and TAC levels were assayed using ELISA. RESULTS: All clinical periodontal parameters were significantly improved 3 months after completion of NSPT. These outcomes were associated with a significant decrease in E-cadherin levels and GCF volume, while TAC levels were significantly increased in samples obtained in follow-up appointments. Binary regression model analysis showed that PPD, GCF volume, E-cadherin, and TAC levels could significantly (p < .05) predict the outcomes of NSPT. The cut-off points for PPD, GCF volume, E-cadherin and TAC were 5 mm, 4 × 10-3, 1267.97 pg/mL and 0.09 µmol/g, respectively. CONCLUSION: NSPT improved clinical parameters along with increased antioxidants capacity and epithelial pocket lining integrity. Discrimination of favorable/unfavorable responsiveness of periodontally diseased sites to NSPT could be possible by using GCF volume, PPD, E-cadherin and TAC level assessments.

In Vitro Models Used in the Formation of Root Caries Lesions-A Review of the Literature.

The management of root caries remains a challenge for clinicians due to its unique anatomical location and structure. There is increasing interest in utilising artificial root caries lesions to develop new strategies for remineralisation. An ideal protocol has not yet been agreed upon. The aim of this review is to provide a structured overview of previously reported in vitro root caries models. The literature was screened and mined for information mainly on substrate selection, model systems utilised, and variables used in the models. Human roots (60%) were the most frequently used substrates, followed by bovine roots (40%). Chemical models (69%) were the most frequently utilised model systems, followed by microbiological models (27%), to form root caries lesions. Acetate buffer solution (80%), pH 5.0 or above (40%), and a demineralisation time of five days (25%) were the common variables used in the chemical systems, while mono-species biofilm was most frequently used (73%) in microbiological models and Streptococcus mutans was the most common bacterial strain utilised in these models (80%). This review highlights the variability amongst the experimental approaches, discusses the advantages and limitations of these approaches, and emphasises that standardisation of experimental conditions along with sustained research will benefit root caries research.

Development of a Large-Scale Pathogen Screening Test for the Biosafety Evaluation of Canine Mesenchymal Stem Cells.

BACKGROUND: The action of mesenchymal stem cells (MSCs) is the subject of intense research in the field of regenerative medicine, including their potential use in companion animals, such as dogs. To ensure the safety of canine MSC batches for their application in regenerative medicine, a quality control test must be conducted in accordance with Good Manufacturing Practices (GMP). Based on guidance provided by the European Medicines Agency, this study aimed to develop and validate a highly sensitive and robust, nucleic acid-based test panel for the detection of various canine pathogens. Analytical sensitivity, specificity, amplification efficiency, and linearity were evaluated to ensure robust assessment. Additionally, viable spike-in controls were used to control for optimal nucleic acid extraction. The conventional PCR-based and real-time PCR-based pathogen assays were evaluated in a real-life setting, by direct testing MSC batches. RESULTS: The established nucleic acid-based assays displayed remarkable sensitivity, detecting 100-1 copies/reaction of template DNA. They also exhibited high specificity and efficiency. Moreover, highly effective nucleic acid isolation was confirmed by the sensitive detection of spike-in controls. The detection capacity of our optimized and validated methods was determined by direct pathogen testing of nine MSC batches that displayed unusual phenotypes, such as reduced cell division or other deviating characteristics. Among these MCS batches of uncertain purity, only one tested negative for all pathogens. The direct testing of these samples yielded positive results for important canine pathogens, including tick-borne disease-associated species and viral members of the canine infectious respiratory disease complex (CIRDC). Notably, samples positive for the etiological agents responsible for enteritis (CPV), leptospirosis (Leptospira interrogans), and neosporosis (Neospora caninum) were also identified. Furthermore, we conducted biosafety evaluation of 12 MSC batches intended for therapeutic application. Eleven MSC batches were found to be free of extraneous agents, and only one tested positive for a specific pathogen, namely, canine parvovirus. CONCLUSION: In this study, we established and validated reliable, highly sensitive, and accurate nucleic acid-based testing methods for a broad spectrum of canine pathogens.

Tilt testing.

Tilt testing can help to diagnose unexplained syncope, by precipitating an episode during cardiac monitoring. The Italian protocol, now most widely used, involves giving sublingual nitroglycerine after 15 min, while monitoring beat-to-beat blood pressure (BP) and recording on video. Tilt testing is time-consuming but it is clinically useful and can guide therapy. Complications are rare. Syncope types include vasovagal syncope where BP falls after >3 min of tilt-up and later the heart rate falls; classic orthostatic hypotension where there is an immediate, progressive BP fall with minimal heart rate change; delayed orthostatic hypotension with a late BP fall after a stable phase but little or no heart rate rise; psychogenic pseudosyncope with apparent loss of consciousness, but no BP fall and a moderate heart rate rise; and postural orthostatic tachycardia syndrome where there is a significant heart rate rise but no BP fall.

Effects of glycation end-products on the dental pulp in patients with type 2 diabetes.

AIM: This ex vivo study aimed to compare protein expression of advanced glycation end-products (AGE) and receptor (RAGE), and the levels of selected genes associated with inflammation and collagen within dental pulp tissue from patients with type 2 (T2D) diabetes and non-T2D. METHODOLOGY: Noncarious extracted permanent molar teeth from patients with well-controlled T2D (n = 19) and non-T2D (controls) (n = 19) were collected and compared. The coronal pulp was examined using immunohistochemistry (IHC) (n = 10 per group) for anti-AGE and anti-RAGE. Quantitative PCR (n = 9 per group) was used to analyse the gene expression levels of NFKB, S100A12 and COLIA1. Data analyses were performed between the groups using GraphPad Prism using Pearson correlation, Shapiro-Wilk and Mann-Whitney U-tests, and multiple regression using SPSS. RESULTS: AGEs were distributed diffusely throughout the pulp extracellular matrix associated with collagen fibres and were present on several cell types. RAGE was expressed at the pulp-dentine interface and was observed on odontoblasts, immune cells, endothelial cells and fibroblasts. Semi-quantitative analysis of IHC samples showed significantly increased expression of AGE (p < .0001) and RAGE (p = .02) in T2D samples compared with controls. The expression of NFKB (p < .0001), S100A12 (p < .0001) and COLIA1 (p = .01) genes were significantly higher in the T2D pulp, and multivariate logistic regression analysis showed that these findings were not affected by age. CONCLUSION: T2D may exert a similar glycation response in the dental pulp to other body sites. This could occur through activation of NF-κB pathways with a concomitant increase in genes associated with inflammation and collagen.

Development, physicochemical characterization and in-vitro biocompatibility study of dromedary camel dentine derived hydroxyapatite for bone repair.

This study aimed to produce hydroxyapatite from the dentine portion of camel teeth using a defatting and deproteinizing procedure and characterize its physicochemical and biocompatibility properties. Biowaste such as waste camel teeth is a valuable source of hydroxyapatite, the main inorganic constituent of human bone and teeth which is frequently used as bone grafts in the biomedical field. Fourier Transform infrared (FTIR), and micro-Raman spectroscopy confirmed the functional groups as-sociated with hydroxyapatite. X-ray diffraction (XRD) studies showed camel dentine-derived hydroxyapatite (CDHA) corresponded with hydroxyapatite spectra. Scanning electron micros-copy (SEM) demonstrated the presence of dentinal tubules measuring from 1.69-2.91 µm. The inorganic phases of CDHA were primarily constituted of calcium and phosphorus, with trace levels of sodium, magnesium, potassium, and strontium, according to energy dispersive X-ray analysis (EDX) and inductively coupled plasma mass spectrometry (ICP-MS). After 28 days of incubation in simulated body fluid (SBF), the pH of the CDHA scaffold elevated to 9.2. in-vitro biocompatibility studies showed that the CDHA enabled Saos-2 cells to proliferate and express the bone marker osteonectin after 14 days of culture. For applications such as bone augmentation and filling bone gaps, CDHA offers a promising material. However, to evaluate the clinical feasibility of the CDHA, further in-vivo studies are required.

Regenerative endodontic procedures: are they more successful in mature permanent teeth with necrotic pulp than in immature teeth?

DATA SOURCES: Five scientific databases were electronically searched: PubMed, EMBASE, OpenGrey, Web of Science and Cochrane Library.  The search was conducted until 17 February 2022 without any restriction on date of publication but was restricted to English language. Relevant studies were also screened for related publications. The aim of this systematic review and meta-analysis was to evaluate the effectiveness of regenerative endodontic procedures (REPs) in mature and immature permanent teeth with necrotic pulp and to evaluate if the success rate was affected by the stage of root development. STUDY SELECTION: Types of studies: all of the included studies were randomised controlled trials (RCTs). TYPES OF PARTICIPANTS: people with necrotic permanent teeth (immature or mature) treated with regenerative endodontic procedures. Types of interventions: regenerative endodontic procedures. Language: RCTs published in English. EXCLUSION CRITERIA: Types of studies: (1) case reports, (2) retrospective cohort trials, (3) prospective cohort trials, (4) animal trials, (5) in-vitro trials, (6) non-randomised trials. POPULATION: primary teeth. Types of interventions: no details about the clinical procedures. Follow-up period: <6 months. DATA EXTRACTION AND SYNTHESIS: The titles and abstracts of the RCTs identified by the search strategies were independently screened by two reviewers. After the initial screening, the full text of the relevant trials were reassessed against the inclusion and exclusion criteria. Discrepancies and disagreements were resolved by consensus after including a third reviewer. RESULTS: Following the initial electronic and manual searches, a total of 3766 articles were initially identified. This was reduced to 2739 articles after duplicates were removed. However, after the initial screening phase, 35 articles were considered potentially relevant and qualified for full-text scrutiny. Out of the 35 articles, only 27 were considered eligible for inclusion. The differences in the success rate and the asymptomatic rate between the mature and immature permanent teeth with necrotic pulp were not statistically significant. However, the differences between the two groups were statistically significant in the rate of positive response to electrical pulp testing. CONCLUSIONS: Based on the results of this systematic review and meta-analysis, the authors concluded that REPs are an effective therapy and can achieve high success rates for both mature and immature necrotic permanent teeth. It was also concluded that the REPs were more successful in regaining vitality responses for mature compared with immature permanent teeth with necrotic pulps.

Horizontal gene transfer underlies the painful stings of asp caterpillars (Lepidoptera: Megalopygidae).

Larvae of the genus Megalopyge (Lepidoptera: Zygaenoidea: Megalopygidae), known as asp or puss caterpillars, produce defensive venoms that cause severe pain. Here, we present the anatomy, chemistry, and mode of action of the venom systems of caterpillars of two megalopygid species, the Southern flannel moth Megalopyge opercularis and the black-waved flannel moth Megalopyge crispata. We show that megalopygid venom is produced in secretory cells that lie beneath the cuticle and are connected to the venom spines by canals. Megalopygid venoms consist of large aerolysin-like pore-forming toxins, which we have named megalysins, and a small number of peptides. The venom system differs markedly from those of previously studied venomous zygaenoids of the family Limacodidae, suggestive of an independent origin. Megalopygid venom potently activates mammalian sensory neurons via membrane permeabilization and induces sustained spontaneous pain behavior and paw swelling in mice. These bioactivities are ablated by treatment with heat, organic solvents, or proteases, indicating that they are mediated by larger proteins such as the megalysins. We show that the megalysins were recruited as venom toxins in the Megalopygidae following horizontal transfer of genes from bacteria to the ancestors of ditrysian Lepidoptera. Megalopygids have recruited aerolysin-like proteins as venom toxins convergently with centipedes, cnidarians, and fish. This study highlights the role of horizontal gene transfer in venom evolution.