Assessment of the quality of oral biopsy procedure videos shared on YouTube.

OBJECTIVE: The aim of this study was to assess the quality of free-to-access videos on oral biopsy procedures on the YouTube platform. MATERIALS AND METHODS: We conducted a search on YouTube using the term "oral biopsy" and selected the first 100 videos in order of relevance. The following exclusion criteria were applied: language other than English, videos that did not cover oral biopsy techniques, videos on nonhuman specimens, postoperative instructions, personal experiences, exfoliative cytology, or "brush biopsy." Forty-seven selected videos were classified based on their duration, country of origin, date of upload to the system, author, information source and number of views, and likes and dislikes. Video quality was analyzed using DISCERN, the Global Quality Scale (GQS), and the Video Information and Quality Index (VIQI). RESULTS: The majority (78.7%) of analyzed videos were uploaded by dentists, originating from India (48.9%), with a mean duration of 11.8 min (SD, 20.4), with 104.5 likes (SD, 186.4) and 7.1 dislikes (SD, 10.55). The mean values for DISCERN, GQS, and VIQI were 1.3 (SD, 0.52), 2.1 (SD, 1.04), and 9.62 (SD, 1.69), respectively. CONCLUSION: The majority of videos on oral biopsy published on YouTube are of low quality.

Blue light-emitting diodes in hair regrowth: the first prospective study.

Different studies highlight photo-receptors' presence on the hair follicle that seems to be capable of eliciting hair growth. This study aims to demonstrate blue light's effectiveness on hair growth in patients affected by androgenetic alopecia. Twenty patients enrolled at Magna Graecia University Unit of Dermatology, affected by androgenetic alopecia, were treated with a blue LED light device at 417 ± 10 nm, fluence of 120 J/cm2, and power intensity of 60 mW/cm2 ± 20%. The treatments were performed twice a week for ten consecutive weeks. Patients were evaluated before and 1 month after the end of therapy clinically using standardized global photographs and dermoscopically estimating hair density and hair shaft width. An increase in hair density and hair shaft width was recorded in 90% of patients after 10 weeks. Photographic improvement was noted in 80% of the patients. No serious adverse events have been reported. The only side effect consisted in a darkening of the hair, perhaps due to melanic stimulation due to blue light in 2 patients. Blue light therapy is a promising therapy for patients affected by androgenetic alopecia and other diseases characterized by hair loss. Further studies will be necessary to confirm the findings of this preliminary study.

Psoriasis and skin pain: real-life effectiveness of calcipotriol plus betamethasone dipropionate in aerosol foam formulation.

BACKGROUND/OBJECTIVE: Although 40% of psoriasis patients reported skin pain, this symptom is often underestimated. A new formula of calcipotriol plus betamethasone dipropionate (Cal/BD) has been recently approved for psoriasis treatment. Therefore, we aimed to evaluate the efficacy of Cal/BD aerosol foam on skin pain of patients with plaque psoriasis. METHODS: A real-life 4-week prospective, open study on Cal/BD aerosol foam (not compared to vehicle or emollient cream) was performed in adult psoriasis patients attending three Dermatology units located in Campania region, Italy, between March and October 2018. Inclusion criteria were a history of skin pain over the last week and psoriatic involvement of the palmar area. Before (t0) and after a course of once daily application of Cal/BD aerosol foam for 4 weeks (t1), the following items were evaluated: Psoriasis Area and Severity Index (PASI), Physician Global Assessment (PGA) index of target plaque on palmar region, subjective skin pain features through Pain Qualities Assessment Scale questionnaire and skin pain threshold measured by pressure digital algometer at palmar psoriatic plaques. RESULTS: Seventy-five patients (43 male, mean age of 43.2 years) were enrolled. After 4 weeks of therapy with Cal/BD aerosol foam, a significant improvement in both PASI (mean: 6.5 ± 2.1 at t0 vs. 2.3 ± 1.6 at t1) and palmar plaques PGA (mean: 3.6 at t0 vs. 1.7 at t1) was observed (P < 0.001). The mean intensity score of skin pain decreased from 7.6 to 1.3 (P < 0.001); among skin pain qualities, intense, sensible, aching and unpleasant showed the highest rate of reduction (t0-t1: 6.3, 6.3, 6.1 and 5.8, respectively). Pain threshold of palmar skin lesions increased at t1. CONCLUSIONS: Our real-life study suggested that Cal/BD aerosol foam may represent a valid topical anti-psoriatic treatment, not only improving skin lesions, but also relieving cutaneous pain, thus contributing to ameliorate patients' quality of life.

IL17A polymorphism and elevated IL17A serum levels are associated with oral lichen planus.

OBJECTIVE: The aim of this study was to evaluate the association of IL17A G197A polymorphism and serum levels with oral lichen planus (OLP) susceptibility and clinical presentation. SUBJECTS AND METHODS: Eighty-three individuals diagnosed with OLP and 99 healthy controls (C) were consecutively recruited. All participants had desquamating oral mucosal cells collected and DNA isolated for IL17A (G197A) genotyping. Blood samples of 42 OLP individuals and 23 healthy controls were collected for evaluation of IL17A serum levels. RESULTS: IL17A G197A genotypes were associated with an increased chance of having OLP (GA/AA × GG, OR = 3.44, 95% CI = 1.87-6.33, p < .001). Overall A carriers (GA or AA) were more common in OLP (38.1%) than in C (20.2%; OR = 2.43, 95% CI = 1.53-3.87, p < .001). Serum levels of IL17A were higher among patients with OLP than in healthy controls (reticular, p = .0003; erosive, p < .001), but no difference was found among the disease types. CONCLUSIONS: IL17A G197A is associated with a higher susceptibility of developing OLP and these patients seem to present a considerable increase in IL17A serum levels. These findings suggest that Th17 cells, and IL17A in particular, may play a pivotal role in OLP pathogenesis.

Small-sized newborn dogs skeletal development: radiologic, morphometric, and histological findings obtained from spontaneously dead animals.

BACKGROUND: Very little is known about neonatal skeletal development in small-sized purebred dogs. In order to improve this knowledge, 27 spontaneously dead puppies belonging to small-sized breeds were enrolled in this study for radiologic, histological and morphometric investigations. RESULTS: The appearance of the limb secondary ossification centers and the onset of their formation were clearly observed by x rays and confirmed by histological evidences. Radiographic and anatomic measurements of limb bones length and skull length and width were positively correlated with body weight and age of the subjects and the body weight was positively correlated with radius bone mineral density, as demonstrated by dual-energy x-rays absorptiometry. CONCLUSIONS: These data provided original information on the growth of newborn small-sized breed dogs, and suggest that cadavers may be useful to study skeletal development.

Zika virus: oral healthcare implications.

Zika virus (ZIKV) infection has been recognised since 1947, but just recently it became a worldwide major public health problem. The most common features of ZIKV infection are fever, cutaneous rash, arthralgia and conjunctivitis but most affected patients with the clinical disease present with only mild symptoms. However, severe neurological complications have been described: there is an occasional association with Guillain-Barre syndrome, and emerging data indicate an association between vertical transmission of ZIKV infection and microcephaly, but no specific orofacial manifestations have yet been reported. ZIKV is present in body fluids and has also been demonstrated in the saliva, but there is as yet no reliable evidence to support ZIKV transmission via this pathway. Transmission in oral health care should be effectively prevented using standard infection control measures. There are currently no specific treatments for Zika virus disease and no vaccines available, so prevention of ZIKV is based on vector control.

Time to onset of bisphosphonate-related osteonecrosis of the jaws: a multicentre retrospective cohort study.

OBJECTIVES: Osteonecrosis of the jaw (ONJ) is a potentially severe adverse effect of bisphosphonates (BP). Although the risk of ONJ increases with increasing duration of BP treatment, there are currently no reliable estimates of the ONJ time to onset (TTO). The objective of this study was to estimate the TTO and associated risk factors in BP-treated patients. SUBJECTS AND METHODS: Retrospective analysis of data from 22 secondary care centres in seven countries relevant to 349 patients who developed BP-related ONJ between 2004 and 2012. RESULTS: The median (95%CI) TTO was 6.0 years in patients treated with alendronate (n = 88) and 2.2 years in those treated with zoledronate (n = 218). Multivariable Cox regression showed that dentoalveolar surgery was inversely associated, and the use of antiangiogenics directly associated, with the TTO in patients with cancer treated with zoledronate. CONCLUSIONS: The incidence of ONJ increases with the duration of BP therapy, with notable differences observed with respect to BP type and potency, route of administration and underlying disease. When data are stratified by BP type, a time of 6.0 and 2.2 years of oral alendronate and intravenous zoledronate therapy, respectively, is required for 50% of patients to develop ONJ. After stratification by disease, a time of 5.3 and 2.2 years of BP therapy is required for 50% of patients with osteoporosis and cancer, respectively, to develop ONJ. These findings have significant implications for the design of future clinical studies and the development of risk-reduction strategies aimed at either assessing or modulating the risk of ONJ associated with BP.

Report on World Workshops on Oral Medicine (WWOM) IV and V: research themes and citation impact: WWOM VI steering committee.

The first World Workshop on Oral Medicine (WWOM) was held in 1988. The portfolio has continued to expand in scope and impact over the past 26 years. Five World Workshops were conducted between 1988 and 2010, focusing on creation of systematic reviews in biomedicine and health care of importance to the international oral medicine community. WWOM VI was conducted in April 2014 and further extended this modeling. This most recent Workshop also fostered creation of the inaugural joint meeting between the American Academy of Oral Medicine and the European Association of Oral Medicine, together with The British Society for Oral Medicine and the Oral Medicine Academy of Australasia. The goal of the WWOM portfolio is to strategically enhance international oral medicine research, education, and clinical practice. To this end, this report summarizes subject areas for WWOM IV (2004) and research recommendations for WWOM V (2010), as well as citation metrics relative to publications from these two conferences. The information is designed to provide research and clinical context for key issues in oral medicine as delineated by the WWOM portfolio over the past 10 years, as well as for projected outcomes of WWOM VI over the next 12 months.

Alendronate impairs epithelial adhesion, differentiation and proliferation in human oral mucosa.

OBJECTIVE: This study aimed at evaluating from a morphological point of view the effects of alendronate (ALN), a widely used nitrogen-containing bisphosphonate for the chronic treatment of osteoporosis, on the oral epithelium of healthy keratinized human oral mucosa. Bisphosphonate-related osteonecrosis of the jaw is a well-known severe consequence, but the effects during chronic therapy on the oral soft tissues are still matter of debate. MATERIALS AND METHODS: Six women over 60 year-old undergoing treatment of osteoporosis with 70 mg per week of oral ALN (lasting at least 2 years) were recruited and compared with a gender and age-matched group (n = 6). Proliferation, apoptosis, intercellular adhesion and terminal differentiation (TD) were investigated by immunofluorescence. In parallel, ultrastructural analysis was carried out. RESULTS: By immunofluorescence, a statistically significant decrease in keratinocyte proliferation was detected in the oral epithelium of the ALN group without any sign of apoptosis, but accompanied by a reduction in desmoglein 1 and keratin 10 expressions. In the uppermost layers of the oral epithelium of the ALN group, thin desmosomes were visible by transmission electron microscopy. CONCLUSION: Our results show that epithelial adhesion, TD and proliferation are affected by ALN therapeutic doses in clinically healthy human oral mucosa.

Vitiligo, NB-UVB and tacrolimus: our experience in Naples.

AIM: The aim of the present study was to evaluate the efficacy and safety of narrowband UVB (NB-UVB) compared with tacrolimus ointment 0.1% in patients with bilateral vitiligo. METHODS: In this comparative study, four groups of patients were randomized. Each group was composed by 12 patients with bilateral vitiligo; in each group, every patient was irradiated with NB-UVB (length: 311 nm) twice a week for 9 months and applied tacrolimus ointment 0.1% twice a day on the other area in the same period. Before starting therapy and after 3, 6 and 9 months of therapy, a clinical and photographic evaluation of percentage of repigmentation was performed and Dermatology Life Quality Index Questionnaire was fulfilled. RESULTS: A repigmentation at least partial occurred in 71% of patients after 36 weeks of treatment with tacrolimus ointment 0.1%; in the whole sample, 14 patients (29%) showed no repigmentation at all, with 2 of them discontinuing the therapy because of side effects (erythema and folliculitis-like manifestations). A homogeneous repigmentation at least partial occurred in 69% of patients after 36 weeks of treatment with NB-UVB; in the whole sample 15 patients (31%) showed no repigmentation at all, with 1 of them discontinuing the therapy because of side effects. CONCLUSION: The present study confirmed that the efficacy of NB-UVB phototherapy in vitiligo is comparable to tacrolimus ointment 0.1% therapy. On the basis of our study, we may suggest tacrolimus ointment 0.1% as an alternative to NB-UVB therapy for treating vitiligo.

Survey on patients' attitude towards the nutritional counselling in the dental setting.

AIM: A healthy diet could help to prevent both oral and systemic diseases, with dentists and nutritionists supplementing their skills. The dental setting, where patients periodically refer to seeking oral health care, represents a powerful opportunity for nutritional counselling. To the best of our knowledge, no study is available on patients' attitudes towards dietary counselling in the dental setting. This cross-sectional study investigates patients' attitude towards receiving nutritional support within the dental setting and it elucidates whether a transdisciplinary approach would be well accepted. MATERIALS AND METHODS: A questionnaire was administered to patients attending three different clinics: a private clinic, a hospital dental clinic of the national healthcare system and the private dental practice within the same hospital. RESULTS: Three hundred thirteen questionnaires were collected. Most dental patients acknowledged receiving nutritional advice from both dentists and nutritionists. The nutritionist within the dental setting was positively perceived, providing useful advice to prevent oral and systemic diseases and also drawing up a diet with periodic follow-ups. DISCUSSION AND CONCLUSION: These findings support the positive attitude of patients towards receiving nutritional counselling within the dental setting. The dental clinics can be pivotal in oral and systemic disease screening and prevention and a multidisciplinary approach is highly encouraged.

Interventions for treating oral lichen planus: a systematic review.

Oral lichen planus (OLP) is a common chronic inflammatory disease associated with cell-mediated immunological dysfunction. Symptomatic OLP is painful and complete healing is rare. The aim of this review was to assess the evidence for the efficacy and safety of treatments for symptomatic OLP. The Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched in January 2011 to identify all randomized controlled trials (RCTs) evaluating any intervention for the treatment of symptomatic OLP. A total of 28 trials were included in this Cochrane review. There was no evidence from three RCTs that topical pimecrolimus is better than placebo in reducing pain from OLP. There was weak evidence from two RCTs that topical aloe vera may be associated with a reduction in pain compared with placebo. There was weak and unreliable evidence from two small trials, at high risk of bias, that topical ciclosporin may reduce pain and clinical signs of OLP. There was no evidence (from five trials each evaluating a different steroid and/or calcineurin inhibitor) that there is a difference between treatment with topical corticosteroids (TCSs) compared with topical calcineurin inhibitors with regard to reducing pain associated with OLP or that any specific steroid therapy is more or less effective at reducing pain. Although TCSs are considered to be the first-line treatment, we did not identify any RCTs that compared TCSs with placebo in patients with symptomatic OLP. From the 28 trials included in this systematic review, the wide range of interventions compared means there is insufficient evidence to support the superior effectiveness of any specific treatment.

Chlorhexidine (CHX) in dentistry: state of the art.

Chlorhexidine (CHX) is one of the most commonly prescribed antiseptic agents in the dental field. It has a long-lasting antibacterial activity with a broad-spectrum of action and it has been shown to reduce plaque, gingival inflammation and bleeding. Its use is considered a powerful adjuvant to mechanical oral hygiene (brushing and flossing), especially in those cases in which it cannot be performed correctly. Available as mouthwash, gel, aerosol, spray and disks, CHX is considered a safe compound, with minimal and transitory local and systemic side effects. Data support its periodic use as an adjuvant to normal brushing and flossing in subjects unable to maintain proper oral hygiene due to physical and/or mental impairment, or lack of motivation, or decreased salivary rate. CHX is also a useful alternative to mechanical oral hygiene procedures in those cases in which they are contraindicated, e.g. after a surgical procedure, or as a preoperative rinse before procedures in which use of a dental dam is not possible. The aim of this article is to offer a complete review of literature regarding the characteristics, the applications and the problems associated with the use of chlorhexidine in the dental field.

A survey on the experience with dental tourism in a sample of Italian patients.

AIM: Dentistry in Italy is mainly private and therefore perceived as forcedly expensive. Dental tourism is becoming popular in order to get cheap dental care. The aim of this study was to carry out a survey aimed at investigating the perception of dental tourism by Italian patients who have recently received such dental care abroad. METHODS: A questionnaire was posted on the web site of an Italian consumers association (Altroconsumo) and members were invited to fill in the questionnaire in case they had experienced dental treatment abroad. RESULTS: Eighty-one complete forms were included in the study. The main motivation for turning to dental tourism was saving money. Another frequent reason for choosing dental tourism was that full rehabilitation was offered in a short time span, usually one week. Patients have often underlined that they appreciated different aspects of the foreign dentists, like speed, kindness, humanity, interest in the course of the treatment, the feeling of ease conveyed by the environment and the personnel. Past negative experiences with Italian dentists were in some cases advocated as reasons for searching dental care abroad. Such negative experiences resulted in a lack of trust in Italian dentists. Some patients reported that while the overall treatment abroad was carried out in a short time, single prosthetic sessions were very long, up to 6 hours. CONCLUSIONS: Most patients were satisfied with dental tourism.

Screening for the undiagnosed diabetes at dental chair-side of an Italian university clinic. A pilot prospective study.

AIM: In Italy there is about one undiagnosed case of diabetes for each known case. The dental office might represent an important setting for screening the glycemic status of patients. The aim of the present study was to evaluate the effectiveness of dental chair-side capillary blood sampling for the identification of undiagnosed hyperglycemia in a group of Italian patients. METHODS: Five hundred fifteen patients >45 years old consecutively visiting a public university dental clinic, where admission is regulated by medical or income criteria, were considered for the study. Demographic data, medical history, time of the last caloric intake and waist width were recorded for each participant. All participants underwent an oral examination. Glycemic values were obtained by capillary blood glucose testing. RESULTS: Of the 400 subjects who took part in the study, a low percentage of unaware diabetic individuals (1.7%) was identified. Inclusion criteria restriction to subjects between 50 and 75 years of age and a waist circumference >92 cm would have resulted in a proportion of diabetic patients of 4.3%. CONCLUSION: Dental chair-side in a public university clinic in Italy failed to disclose the expected number of unaware diabetic patients.

Dental unit water content and antibiotic resistance of Pseudomonas aeruginosa and Pseudomonas species: a case study.

Background: Many studies consider the contamination of dental unit waterlines (DUWLs), but few of them have studied the possible presence of antibiotic resistant Pseudomonas aeruginosa in the DUWLs. Aims: Investigation of the presence of P. aeruginosa and Pseudomonas spp. strains in DUWLs and evaluation of their resistance to six antibiotics (ceftazidime, netilmicin, piperacillin/tazobactam, meropenem, levofloxacin, colistin sulfate) at a public dental clinic in Milan, Italy. Results: Dental units were contaminated by P. aeruginosa with loads of 2-1,000 CFU/L and were mainly located on the mezzanine floor, with a range of 46-54%, while Pseudomonas spp. were primarily found on the first and second floors, ranging from 50 to 91%. P. aeruginosa was antibiotic resistant in 30% of the strains tested, andPseudomonas spp. in 31.8% . Cold water from controls was also contaminated by these microorganisms. Conclusion: Monitoring antibiotic resistance in the water and adopting disinfection procedures on DUs are suggested within the Water Safety Plan.

Human papillomaviruses in oral carcinoma and oral potentially malignant disorders: a systematic review.

OBJECTIVES: Human papillomavirus (HPV) in oral carcinoma (OSCC) and potentially malignant disorders (OPMD) is controversial. The primary aim was to calculate pooled risk estimates for the association of HPV with OSCC and OPMD when compared with healthy oral mucosa as controls. We also examined the effects of sampling techniques on HPV detection rates. METHODS: Systematic review was performed using PubMed (January 1966-September 2010) and EMBASE (January 1990-September 2010). Eligible studies included randomized controlled, cohort and cross-sectional studies. Pooled data were analysed by calculating odds ratios, using a random effects model. Risk of bias was based on characteristics of study group, appropriateness of the control group and prospective design. RESULTS: Of the 1121 publications identified, 39 cross-sectional studies met the inclusion criteria. Collectively, 1885 cases and 2248 controls of OSCC and 956 cases and 675 controls of OPMD were available for analysis. Significant association was found between pooled HPV-DNA detection and OSCC (OR = 3.98; 95% CI: 2.62-6.02) and even for HPV16 only (OR = 3.86; 95% CI: 2.16-6.86). HPV was also associated with OPMD (OR = 3.87; 95% CI: 2.87-5.21). In a subgroup analysis of OPMD, HPV was also associated with oral leukoplakia (OR = 4.03; 95% CI: 2.34-6.92), oral lichen planus (OR = 5.12; 95% CI: 2.40-10.93), and epithelial dysplasia (OR = 5.10; 95% CI: 2.03-12.80). CONCLUSIONS: The results suggest a potentially important causal association between HPV and OSCC and OPMD.

Localised juvenile spongiotic gingival hyperplasia: A case of spontaneous resolution and a literature review.

AIM: Localised juvenile spongiotic gingival hyperplasia (LJSGH) is a benign lesion occurring in young patients as gingival erythema and overgrowth, typically localised on gingiva of maxillary incisors. The aim of this work is to report a case of LJSGH where complete spontaneous regression was achieved together with a review of the literature on the topic. CASE REPORT: An 8-year-old girl was referred for a gingival painless lesion, which had appeared spontaneously one year before and was refractory to periodontal treatment. Intraoral examination showed a well-defined, red gingival overgrowth involving the left maxillary central incisor, without involving the marginal gingiva. The clinical diagnosis of LJSGH was made, due to the pathognomonic aspect. The patient was periodically recalled for 43 months; at the last visit, the lesion was spontaneously resolved. RESULTS: LJSGH is not plaque-related and not responsive to periodontal treatment. Surgical removal of the lesions correlates with high recurrence, while spontaneous resolution over time has been hardly demonstrated. CONCLUSION: Follow-up of LJSGH may be an option of care, alternative to surgery, in selected cases.

Hepatitis C virus infection and lichen planus: a systematic review with meta-analysis.

OBJECTIVE: Hepatitis C virus (HCV) is one of the major causes of chronic liver disease worldwide but its morbidity is also due to a variety of extra-hepatic manifestations including mixed cryoglubulinemia, non-Hodgkin lymphoma, diabetes, porphyria cutanea tarda and lichen planus. The aims of this study were to conduct a systematic review and a meta-analysis on the prevalence of HCV in lichen planus patients and on the prevalence of lichen planus in chronic HCV infection. MATERIALS AND METHOD: Bibliographic searches were conducted in several electronic databases. Pooled data were analysed by calculating odds ratios, using a random effects model. RESULTS AND CONCLUSIONS: Thirty-three studies comparing the seroprevalence of HCV in lichen planus patients and six reporting the prevalence of lichen planus in patients with HCV infection were included in the meta-analysis. The summary estimate showed that LP patients have significantly higher risk (odds ratio 4.85; 95% confidence interval 3.58-6.56) than controls of being HCV seropositive. A similar odds ratio of having lichen planus was found among HCV patients (4.47; 95% confidence interval 1.84-10.86). Sub-analyses indicated that variability of HCV/lichen planus association seemed only partially depending on geographic effect.

Detection of survivin mRNA in healthy oral mucosa, oral leucoplakia and oral cancer.

BACKGROUND: Survivin is involved in modulation of cell death and cell division processes. Survivin expression in normal adult tissues has not been fully understood, although it is markedly lower than in cancer, where it is over-expressed. OBJECTIVE: To investigate survivin expression in normal, potentially malignant and cancerous oral mucosa. METHODS: We measured survivin mRNA levels by real-time RT-PCR in specimens of oral mucosa (15 from normal mucosa, 17 from potentially malignant lesions, 17 from neoplasms). Scores were compared using Kruskal-Wallis test and post hoc according to Conover. Chi-squared test was used for dichotomous data. RESULTS: The median relative levels of survivin mRNA resulted six for normal mucosa, eight for potentially malignant lesions, 13 for cancers: differences among these three groups were statistically significant, as between cancer and potentially malignant lesions. Expression in normal mucosa and potentially lesions group showed no significant difference. Low, but not marginal expression of survivin in normal mucosa is a new finding, and it could be explained with the higher sensibility of our methods. CONCLUSIONS: Survivin expression in oral potentially malignant lesions might indicate a progressive deregulation of expression paralleling oncogenesis, particularly during the first stages of process, suggesting a putative predictive role for survivin.