Oral Health and Cardiovascular Disease.

Several studies have examined a potential relationship between periodontal disease and cardiovascular disease. This article aims to update the evidence for a potential association by summarizing the evidence for causality between periodontitis and comorbidities linked to cardiovascular disease, including hypertension, atrial fibrillation, coronary artery disease, diabetes mellitus, and hyperlipidemia. We additionally discuss the evidence for periodontal therapy as a means to improved management of these comorbidities, with the larger goal of examining the value of periodontal therapy on reduction of cardiovascular disease risk.

Surgical Repair of Idiopathic Mid-Forearm Radial Artery Aneurysm Using a Reversed Greater Saphenous Vein Interposition Graft.

Idiopathic, non-traumatic, radial artery aneurysms are rare in medical literature. This report presents the case of a 56-year-old man who was incidentally found to have a 1.01 cm × 1.31 cm left radial artery aneurysm during a carpal tunnel workup. The patient had no other aneurysms, nor any known predisposing diseases that could explain his condition. We proceeded with surgical intervention to prevent future complications. We describe the use of a greater saphenous vein interposition graft for the repair of an idiopathic mid-forearm radial artery aneurysm. The patient had an uncomplicated recovery course following repair.

Total Neoadjuvant Treatment for Pancreatic Ductal Adenocarcinoma Is Associated With Limited Lymph Node Yield but Improved Ratio.

INTRODUCTION: The lymph node yield (LNY) and lymph node ratio (LNR) of nodal metastases following pancreatoduodenectomy (PD) have been reported as prognostic parameters in patients with pancreatic ductal adenocarcinoma (PDAC). However, they have not been compared in the setting of various neoadjuvant therapy modalities. METHODS: A single institutional retrospective study identified 134 patients diagnosed with resectable, BLR- and LA-PDAC who underwent PD at Fox Chase Cancer Center between 2010 and 2019. Patients were categorized based on first-line treatment as follows: surgery first (SF), total neoadjuvant therapy (TNT), and single modality neoadjuvant therapy (SMNT). The histopathological reports of the surgical specimens were examined to obtain LNY and determine the counts of lymph nodes with metastases. Subsequently, LNR was calculated as the number of positive lymph nodes divided by the number of lymph nodes examined. RESULTS: Overall, 49, 38, 27, 12, and 8 patients underwent SF approach, SMNT, incomplete TNT, induction TNT, and consolidation TNT, respectively. There was no difference in R0 resection and vascular resection between the groups (P = 0.096 and 0.794, respectively). The median counts of LNY were 22, 15, 21, 11.5, and 10, respectively (P < 0.001). The average LNR was 0.16, 0.07, 0.03, 0.02, and 0.02, respectively (P < 0.001). There were statistically significant differences in overall survival in the TNT groups (log-rank test P = 0.030). CONCLUSIONS: PDAC patients who undergo the TNT modality exhibit lower LNY and improved LNR compared with the SF approach and SMNT neoadjuvant therapy groups. This is likely explained by the increased treatment response and lymph node obliteration associated with the TNT approach. Our results question the minimal requirement of 11-18 harvested lymph nodes for PD following TNT.

A Virtual Tumor Board Platform: A Way to Enhance Decision-Making for Complex Malignancies.

INTRODUCTION: Multidisciplinary tumor boards (TBs) are crucial for decision-making and management of patients diagnosed with complex malignancies. The social distancing conditions imposed by coronavirus disease 2019 presented an opportunity to compare virtual versus in-person TBs. METHODS: A retrospective analysis of attendance data from an National Cancer Institute-designated cancer center's gastrointestinal (GI) TB participant data from September 2019 to October 2020. In addition, an online survey assessing the virtual TB experience was sent to participants of all TBs. Interrupted time series analyses were performed to evaluate preintervention and postintervention GI TB attendance only. RESULTS: The overall mean attendance for GI TB was 30 participants; turnout was higher for virtual format compared to in-person (32 versus 23 attendees, P < 0.001). This increase was seen across all participant categories: attending physicians (15 versus 11 attendees, P < 0.001), trainees (11 versus 8, P < 0.001), and support staff (6 versus 3, P < 0.001). There was no significant difference in the mean number of cases discussed between TB formats. The majority of the 141 survey respondents (across all TB) were attending physicians with >20-year experience. Most supported a permanent virtual or hybrid TB format, 72.5% found this format to be more time efficient and with similar productivity, and 85.8% found it easier to attend. The majority (89.9%) felt confident that the decision-making process was not affected by virtual interactions. CONCLUSIONS: A virtual platform for multispecialty TBs allows for greater attendance without sacrificing the decision-making process. This survey supports continuing with a virtual or hybrid format, which may increase attendance and facilitate access to multidisciplinary discussions leading to improved patient care.

Low Recruitment in a Double-Blind, Placebo-Controlled Trial of Ocrelizumab for Autoimmune Encephalitis: A Case Series and Review of Lessons Learned.

INTRODUCTION: Observational data suggest that B-cell-depleting therapies are effective for antibody-mediated autoimmune encephalitis. However, randomized controlled trials are needed. Here, we report challenges encountered in a randomized, placebo-controlled trial of ocrelizumab for autoimmune encephalitis that failed to meet recruitment goals. METHODS: This was a single-center, 12-month, randomized, double-blind, placebo-controlled trial. Patients with autoimmune encephalitis were randomized in 1:1 fashion to placebo or ocrelizumab infusion after receiving first-line immunotherapy. The primary endpoint of the study was clinical worsening, defined as a perceived decline by the patient or clinician or a decrease in the Lawton and Brody Instrumental Activities of Daily Living Scale (IADL), along with either worsening on the Texas Functional Living Scale (TFLS) or hospitalization for symptoms of encephalitis. RESULTS: Among 16 eligible patients, only three enrolled in the study, which closed due to poor recruitment. Two participants were randomized to the ocrelizumab arm and one to the placebo arm. The single patient in the placebo arm (NMDAR+) met the primary endpoint at 12 weeks and received open-label ocrelizumab with improvement. In the ocrelizumab arm, one participant (NMDAR+) demonstrated marked improvement, and the second (LGI1+) remained clinically stable. There were no serious adverse events associated with ocrelizumab. CONCLUSION: Clinical trial recruitment for autoimmune encephalitis is challenging, and our trial did not meet recruitment goals. Large, multicenter clinical trials are still needed, and careful attention must be given to study design, endpoints, and patient selection. Instrumented functional rating scales will be valuable outcome measures for future studies. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03835728.

Reconsidering gender relative to risk of rupture in the contemporary management of abdominal aortic aneurysms.

OBJECTIVE: Abdominal aortic aneurysms (AAAs) may rupture at smaller diameters in women than in men, and women may be at higher risk and have poorer outcomes in elective and emergent interventions because of age and comorbidities. Practice guidelines recommending elective AAA repair at >5.5 cm are gender neutral and may not adequately reflect increased risks in women or the potential advantages of elective lower risk endovascular procedures. METHODS: Patients with a diagnosis of AAA discharged from a single referral hospital during a 14-year period were identified for retrospective analysis. RESULTS: A total of 2121 patients with AAAs were studied, 499 women (23.5%) and 1622 men (76.5%). Women were older and had a greater incidence of hypertension, smoking, chronic obstructive pulmonary disease, dyslipidemia, and renal insufficiency. Intact AAAs in 467 women had a mean diameter of 4.4 ± 1.3 cm compared with 1538 men at 5.0 ± 1.4 cm (P < .01). The ruptured AAAs in 32 women (6.4%) had a mean diameter of 6.1 ± 1.5 cm compared with 84 men (5.2%) at 7.7 ± 1.9 cm (P < .01). Women had a twofold increased frequency of AAA rupture than men at all size intervals (P < .01). The frequency of ruptured AAAs <5.5 cm among 10 of 32 women with ruptured AAAs was 31.3%; among 7 of 84 men with ruptured AAAs, it was 8.3% (P < .01). The frequency of ruptured AAAs <5.5 cm in all 383 women with AAAs <5.5 cm was 2.6%; in 1042 men, it was 0.6% (P < .01). Of the 1211 AAA repairs, 574 (47.4%) were open aneurysm repair (OAR) and 637 (52.6%) were endovascular aneurysm repair (EVAR). Mortality after elective OAR in 475 patients of both sexes was 5.1%; for EVAR in 676 patients, mortality was 1.6% (P < .01). No differences in mortality with respect to OAR or EVAR were found between the female and male cohorts in either intact or ruptured AAAs. CONCLUSIONS: Women with AAAs are older and have a higher frequency of cardiovascular risk factors than men. Women rupture AAAs with a greater frequency than men at all size intervals and have a fourfold increased frequency of rupture at <5.5 cm. No differences in surgical mortality between women and men were found. Current practice guidelines for elective AAA operative intervention should be reconsidered and stratified by gender.

Aspergillus thromboembolism from a mycotic ascending aortic pseudoaneurysm.

This case report describes an immune-competent patient with acute upper extremity ischemia caused by thromboembolism from an Aspergillus-infected ascending aortic pseudoaneurysm. Efforts to identify the source of an acute arterial thromboembolic occlusion should be made, and a high index of suspicion for mycotic infection should be maintained in patients with an atypical presentation, such as fevers of unknown origin. Additional measures, such as pathologic examination of thromboembolic debris, blood cultures, and positron emission tomography, should be performed to identify the etiology in these unexplained situations.

Direct and consensual murine pupillary reflex metrics: establishing normative values.

Pupillometry is a non-invasive technique, based on well-established neurophysiologic principles, that can be utilized to objectively characterize pathophysiologic demyelinating and neurodegenerative changes involving the pupillary reflex pathway. In animal models of human disorders, pupillometry derived reflex metrics could potentially be used to longitudinally monitor disease activity and responses to pharmacotherapies. These investigations would have important implications for translational initiatives focused on the identification and application of novel neuroprotective and restorative treatments for human diseases such as multiple sclerosis. Here, we have established normal reference values for various pupillary reflex metrics across different mouse strains. Ultimately, we anticipate that this new data will help to catalyze unique lines of inquiry using pupillometry methods.

"Let the drag race begin": the rewards of becoming a queen.

Drawing upon my ethnographic experiences in a drag venue called The Park in Roanoke, Virginia, this article explores the experiences of female impersonators in terms of their early motivations for doing drag, how they create and maintain drag personas and identities, and the obstacles to becoming a queen. Departing from previous researchers that have framed female impersonation as a deviant, stigmatizing, and pathological activity, this research analyzes the significant benefits some drag queens garner by donning women's attire. An experiential understanding of drag reveals that the significant rewards from the activity--contextual power and status, self-affirmation and empowerment--are powerful motivating factors. Instead of being deviant and/or partaking in pathological behavior, female impersonators can be seen as operating on an incentive system where the benefits of doing drag positively enrich the quality of the performer's life in a context where successful queens are held in the highest regard.

P23H and S334ter opsin mutations: Increasing photoreceptor outer segment n-3 fatty acid content does not affect the course of retinal degeneration.

PURPOSE: The n-3 polyunsaturated fatty acids (PUFA) facilitate retinal development and function. Rats carrying transgenes with P23H and S334ter rhodopsin mutations lose their photoreceptors and have lower levels of 22:6n-3 in rod photoreceptor outer segments (ROS) than wild type (WT) animals. We tested the hypothesis that the rate of retinal degeneration in these mutant animals could be sensitive to the n-3 fatty acid content of retina. METHODS: Beginning embryonic day 15, WT and heterozygous transgenic rats with P23H and S344ter rhodopsin mutations were fed semi-synthetic diets enriched in n-6 (safflower oil, SO) or n-3 (flaxseed oil, FO) PUFA. At 35 and 55 days of age, electroretinographic (ERG) response, outer nuclear layer (ONL) thickness, and fatty acid composition of plasma and ROS were determined. Student's t-tests and multivariate analysis of variance with post hoc tests determined statistical differences. RESULTS: Rats fed FO or SO diets had different n-6/n-3 PUFA ratios in plasma (1.3 and 62) and ROS (0.2 and 1.1, respectively). Although there were profound effects of the diets on the plasma fatty acid composition, there were only minor differences between WT and transgenic animals within each dietary regime. The ROS of FO fed rats had 70% more 22:6n-3 than those fed SO, and the WT had higher concentrations of 22:6n-3 than the transgenic animals (WT>P23H>S334ter). In contrast, there was no difference in 22:6n-3 levels in ROS of WT and transgenic rats fed the SO diet. At P55, both transgenic lines had diminished ERGs and ONL thickness relative to the WT. There was no detectable effect of ROS fatty acid enrichment on the rate of retinal degeneration in the transgenic animals. However, the FO-diet provided a modest protection of function (b-wave) in S334ter animals. CONCLUSIONS: Feeding n-3 fatty acids to rats with mutant rhodopsin transgenes significantly increased the levels of 22:6n-3 in ROS membranes, but had no effect on the rate of retinal degeneration. Therefore, the degeneration is not the result of low (or high) 22:6n-3 in ROS and supplementation with 18:3n-3 will not rescue dying photoreceptor cells in these animal models of inherited retinal degenerations.

Differences in neointima formation between impervious and porous polytetrafluoroethylene vascular patch material.

The aim of this study was to compare the neointima formation and blood loss of an impervious ePTFE with those of the porous ePTFE patch. Ten mongrel dogs were selected for the study. Both the impervious and porous ePTFE patches were implanted into the common iliac arteries in each dog. The blood loss of each patch was recorded and the patches were explanted 30-60 days later for microscopic analysis. The arteries with either the impervious or the porous ePTFE patch were all patent at the end of the study. The impervious ePTFE patch had a significant reduction in blood loss when compared with the porous ePTFE patch (p = 0.04). The neointima covering both patches showed no statistically significant difference in its thickness or in its cellular composition. It has been speculated that wall porosity is essential for tissue ingrowth, endothelial cell proliferation, and neointima formation. In this study, the impervious ePTFE patch did not inhibit neointima formation. Our study shows that graft porosity does not improve neointima formation or patency. Neointimization of the impervious ePTFE patch is the result of pannus ingrowth and deposition of circulating blood elements. There is a statistically significant reduction in blood loss (p = 0.04) with impervious ePTFE patch, compared with that of the porous ePTFE patch.