Oral Health Clearance Outcomes for Cardiovascular Surgery.

Objective: To determine the risk of morbidity and mortality in patients receiving dental extractions before planned cardiovascular surgery (CVS) and examine factors that may affect the chance of oral health clearance. Patients and Methods: A retrospective medical record review was performed of patients who underwent dental screening before CVS from January 1, 2015, to December 31, 2021, at a major medical institution. A total of 496 patients met the inclusion criteria and were divided into 2 groups. Group 1 patients were cleared to advance to planned CVS (n=390). Group 2 patients were not cleared for surgery and subsequently underwent dental extractions before planned CVS (n=106). Results: Six patients (5.7%) experienced postoperative complications after dental extraction that resulted in an emergency room visit. No deaths occurred after dental extraction before CVS. However, 4 patients died within 30 days of CVS, 3 from Group 1 (0.77%) and 1 from Group 2 (0.94%). Dental extraction before planned CVS showed a borderline significant association with death based on unadjusted (P=.06) and age-adjusted analysis (P=.05). Patients who reported seeing a dentist routinely had a significantly higher chance of oral health clearance (P <.001). No differences were noted between the 2 groups with regard to age, sex, or 30-day hospital readmission rate. Conclusion: Patients who had dental extractions completed before planned CVS may be at an increased risk of mortality. Further studies are needed to examine this relationship. Emphasis should be on prioritization of routine dental visits before planned CVS.

Utilizing orthodontic appliances to retain and disguise a pediatric maxillary obturator throughout growth.

Unique challenges are encountered when providing an obturator for an adolescent patient. Challenges include the need to modify the obturator throughout growth, engaging the mixed dentition or partially erupted teeth with minimal undercuts, the psychosocial challenges of an actively maturing patient, and the possible need for coincidental orthodontic therapy. This clinical report describes the ongoing rehabilitation of a patient who presented at the age of 10 with a biopsy-confirmed palatal mucoepidermoid carcinoma. Incorporating orthodontic brackets for retention of innovative adjustable obturator clasps allowed for the favorable function of the obturator prosthesis and the ability to alter the prosthesis over time.

Getting to know today's maxillofacial prosthodontist.

Maxillofacial prosthetics (MFP) is a subspecialty of prosthodontics that focuses on the management of complex craniofacial prosthetic rehabilitation. With advancements in treatment techniques and technology, the MFP specialist's roles have also evolved. This presentation describes who today's maxillofacial prosthodontists are, what they do, and how they care for the special population of patients with complex and unique needs.

Impact of Robotic Surgery on Residency Training for Herniorrhaphy and Cholecystectomy.

Robotic surgery has increased for common general surgery procedures. This study evaluates how robotic use affects the case distributions of herniorrhaphy and cholecystectomy for general surgery residents according to postgraduate year (PGY). We reviewed Accreditation Council for Graduate Medical Education (ACGME) biliary or hernia cases logged by surgical residents in the academic year 2017-2018. Operative reports were reviewed to compare approaches (robotic, laparoscopic, and open) by resident role and PGY level. Open cholecystectomies were excluded. Overall, 470 hernia and 657 cholecystectomy cases were logged. Hernia repairs were performed robotically in 15.9%, laparoscopically in 9.5%, and open in 74.7%. Cholecystectomies were performed robotically in 16.4% and laparoscopically in 83.6%. Residents were teaching assistants in 1.8% of hernia repairs and 1.5% of cholecystectomies. Distribution of cases by technique and PGY level was significantly different for both procedures, with chief residents performing the majority of robotic cholecystectomies (52.6%, P < .0001) and hernia repairs (59.7%, P < .0001). Migration of robotic cases to senior resident level and low percentage of teaching assistant roles held by residents suggest exposure to common operations may be delayed during general surgery residency training. Introduction of new technology in surgical training should be carefully reviewed and may benefit from a structured curriculum.

Do Better Operative Reports Equal Better Surgery? A Comparative Evaluation of Compliance With Operative Standards for Cancer Surgery.

To improve the quality of cancer operations, the American College of Surgeons published Operative Standards for Cancer Surgery, which has been incorporated into Commission on Cancer (CoC) accreditation requirements. We sought to determine if compliance with operative standards was associated with technical surgical outcomes. Oncologic operative reports from 2017 at a CoC and non-CoC institution were examined for documentation of Operative Standards essential steps. Lymph node (LN) yield for lung and colon cases and re-excision rates for breast cases were recorded. Correct documentation was poor for colon, breast, and lung cases with numerous elements documented in <10% of operative reports at both centers. For lung cases, there was no significant difference in meeting ≥10 LN benchmark or average LN yield between the 2 institutions. For colon cases, average lymph node yield was lower in the non-CoC facility, but there was no significant difference in meeting ≥12 LN benchmark. For breast cases, re-excision rates were similar in both programs. Many essential steps in Operative Standards were poorly documented in operative reports, regardless of CoC status. Achieving benchmark technical surgical outcomes was not associated with documented compliance with these standards. Whether improved documentation leads to better surgical outcomes requires further investigation.

Interdisciplinary rehabilitation of a primary intraosseous carcinoma including orthodontic archform management.

Squamous cell carcinomas arising from keratocystic odontogentic tumors are a rare phenomenon in head and neck cancer, accounting for only 1.45% of oral squamous cell carcinomas, and are classified as primary intraosseous carninomas. This cancer is locally aggressive, has a high potential for recurrence, and requires radical resection and subsequent rehabilitation. This case report describes a patient diagnosed with this uncommon tumor who was treated by dental specialists at Mayo Clinic. During convalescence, orthodontic changes to the maxillary dental archform were observed secondary to alterations in the soft tissue equilibrium following mandibulectomy and reconstruction with a microvascular fibula free flap. This highlights the need for treatment plan adaptability, the role of orthodontists in maintenance or treatment of pre-resection archforms, and the interdisciplinary nature necessary in managing the complex oncologic, functional, and esthetic needs in patients undergoing treatment for head and neck cancer.

The Case for Improved Interprofessional Care: Fatal Analgesic Overdose Secondary to Acute Dental Pain during Pregnancy.

Prenatal oral health extends beyond the oral cavity, impacting the general well-being of the pregnant patient and her fetus. This case report follows a 19-year-old pregnant female presenting with acute liver failure secondary to acetaminophen overdose for management of dental pain following extensive dental procedures. Through the course of her illness, the patient suffered adverse outcomes including fetal demise, acute kidney injury, spontaneous bacterial peritonitis, and septic shock before eventual death from multiple organ failure. In managing the pregnant patient, healthcare providers, including physicians and dentists, must recognize and optimize the interconnected relationships shared by the health disciplines. An interdisciplinary approach of collaborative and coordinated care, the timing, sequence, and treatment for the pregnant patient can be improved and thereby maximize overall quality of health. Continued efforts toward integrating oral health into general healthcare education through interprofessional education and practice are necessary to enhance the quality of care that will benefit all patients.

The head module of Mediator directs activation of preloaded RNAPII in vivo.

The successful synthesis of a transcript by RNA polymerase II (RNAPII) is a multistage process with distinct rate-limiting steps that can vary depending on the particular gene. A growing number of genes in a variety of organisms are regulated at steps after the recruitment of RNAPII. The best-characterized Saccharomyces cerevisiae gene regulated in this manner is CYC1. This gene has high occupancy of RNAPII under non-inducing conditions, defining it as a poised gene. Here, we find that subunits of the head module of Mediator, Med18 and Med20, and Med19 are required for activation of transcription at the CYC1 promoter in response to environmental cues. These subunits of Mediator are required at the preloaded promoter for normal levels of recruitment and activity of the general transcription factor TFIIH. Strikingly, these Mediator components are dispensable for activation by the same activator at a different gene, which lacks a preloaded polymerase in the promoter region. Based on these results and other studies, we speculate that Mediator plays an essential role in triggering an inactive polymerase at CYC1 into a productively elongating form.

An integrated biochemistry and genetics outreach program designed for elementary school students.

Exposure to genetic and biochemical experiments typically occurs late in one's academic career. By the time students have the opportunity to select specialized courses in these areas, many have already developed negative attitudes toward the sciences. Given little or no direct experience with the fields of genetics and biochemistry, it is likely that many young people rule these out as potential areas of study or career path. To address this problem, we developed a 7-week (~1 hr/week) hands-on course to introduce fifth grade students to basic concepts in genetics and biochemistry. These young students performed a series of investigations (ranging from examining phenotypic variation, in vitro enzymatic assays, and yeast genetic experiments) to explore scientific reasoning through direct experimentation. Despite the challenging material, the vast majority of students successfully completed each experiment, and most students reported that the experience increased their interest in science. Additionally, the experiments within the 7-week program are easily performed by instructors with basic skills in biological sciences. As such, this program can be implemented by others motivated to achieve a broader impact by increasing the accessibility of their university and communicating to a young audience a positive impression of the sciences and the potential for science as a career.

Activation of a poised RNAPII-dependent promoter requires both SAGA and mediator.

A growing number of promoters have key components of the transcription machinery, such as TATA-binding protein (TBP) and RNA polymerase II (RNAPII), present at the promoter prior to activation of transcription. Thus, while transcriptional output undergoes a dramatic increase between uninduced and induced conditions, occupancy of a large portion of the transcription machinery does not. As such, activation of these poised promoters depends on rate-limiting steps after recruitment of TBP and RNAPII for regulated expression. Little is known about the transcription components required in these latter steps of transcription in vivo. To identify components with critical roles in transcription after recruitment of TBP in Saccharomyces cerevisiae, we screened for loss of gene expression activity from promoter-tethered TBP in >100 mutant strains deleted for a transcription-related gene. The assay revealed a dramatic enrichment for strains containing deletions in genes encoding subunits of the Spt-Ada-Gcn5-acetyltransferase (SAGA) complex and Mediator. Analysis of an authentic postrecruitment-regulated gene (CYC1) reveals that SAGA occupies the promoter under both uninduced and induced conditions. In contrast, Mediator is recruited only after transfer to inducing conditions and correlates with activation of the preloaded polymerase at CYC1. These studies indicate the critical functions of SAGA and Mediator in the mechanism of activation of genes with rate-limiting steps after recruitment of TBP.

Paneth cell antimicrobial peptides: topographical distribution and quantification in human gastrointestinal tissues.

Antimicrobial peptides and proteins are key effectors of innate immunity, expressed both by circulating phagocytic cells and by epithelial cells of mucosal tissues. In the human small intestine, Paneth cells are secretory epithelial cells that express the antimicrobials human alpha-defensin-5 (HD5), HD6, lysozyme and secretory phospholipase A(2) (sPLA(2)), and recent studies have implicated reduced HD5 and HD6 expression levels in the pathogenesis of ileal Crohn's disease. However, expression levels of these molecules have not been determined routinely by techniques that readily permit quantitative comparisons of their distribution between tissues and samples. Using quantitative real-time PCR with external standards and Northern blot analysis, we compared expression levels of mRNA encoding these four Paneth cell antimicrobial peptides, as well as circulating human neutrophil defensins in several different gastrointestinal tissues and the bone marrow. HD5 and HD6 were the most abundant antimicrobials expressed in the small intestine. The concentration of HD5 mRNA is approximately 5 x 10(5) copies per 10ng RNA in the jejunum and ileum; HD6 mRNA levels were about six times lower than those of HD5. With the exception of low levels in the pancreas (10(3) copies/10 ng RNA), the expression of HD5 and HD6 in tissues other than small intestine was at or below detectable limits. The expression of sPLA2 and lysozyme mRNA was observed in the small intestine (approximately, 3 x 10(3) and 9 x 10(3) copies/10 ng RNA, respectively), but also in several other tissues. Lysozyme expression was high in the duodenum (10(5) copies/10 ng RNA), and the protein localized to both Brunner's glands in the lamina propria and Paneth cells. By comparison, the hematopoietic alpha-defensins HNP1-3 mRNA were detected at 6 x 10(5) copies per 10 ng RNA in the bone marrow. These quantitative RT-PCR data from healthy tissues represents the first quantitative topographical assessment of antimicrobial expression in the gastrointestinal tract and provides a means to directly compare expression levels between healthy tissues and disease specimens for multiple antimicrobial peptides.

Paneth cell trypsin is the processing enzyme for human defensin-5.

The antimicrobial peptide human alpha-defensin 5 (HD5) is expressed in Paneth cells, secretory epithelial cells in the small intestine. Unlike other characterized defensins, HD5 is stored in secretory vesicles as a propeptide. The storage quantities of HD5 are approximately 90 450 microg per cm2 of mucosal surface area, which is sufficient to generate microbicidal concentrations in the intestinal lumen. HD5 peptides isolated from the intestinal lumen are proteolytically processed forms--HD5(56-94) and HD5(63-94)--that are cleaved at the Arg55-Ala56 and Arg62-Thr63 sites, respectively. We show here that a specific pattern of trypsin isozymes is expressed in Paneth cells, that trypsin colocalizes with HD5 and that this protease can efficiently cleave HD5 propeptide to forms identical to those isolated in vivo. By acting as a prodefensin convertase in human Paneth cells, trypsin is involved in the regulation of innate immunity in the small intestine.