Constrictive Pericarditis in the Presence of Remaining Remnants of a Left Ventricular Assist Device in a Heart Transplanted Patient.

Constrictive pericarditis (CP) is a severe subform of pericarditis with various causes and clinical findings. Here, we present the unique case of CP in the presence of remaining remnants of a left ventricular assist device (LVAD) in a heart transplanted patient. A 63-year-old man presented at the Heidelberg Heart Center outpatient clinic with progressive dyspnea, fatigue, and loss of physical capacity. Heart transplantation (HTX) was performed at another heart center four years ago and postoperative clinical course was unremarkable so far. Pharmacological cardiac magnetic resonance imaging (MRI) stress test was performed to exclude coronary ischemia. The test was negative but, accidentally, a foreign body located in the epicardial adipose tissue was found. The foreign body was identified as the inflow pump connection of an LVAD which was left behind after HTX. Echocardiography and cardiac catheterization confirmed the diagnosis of CP. Surgical removal was performed and the epicardial tubular structure with a diameter of 30 mm was carefully removed accompanied by pericardiectomy. No postoperative complications occurred and the patient recovered uneventfully with a rapid improvement of symptoms. On follow-up 3 and 6 months later, the patient reported about a stable clinical course with improved physical capacity and absence of dyspnea.

The vulnerable vessel. Vascular disease in diabetes mellitus.

Diabetes represents one of the most important risk factors for atherosclerosis, which is the leading cause of mortality worldwide. Recent imaging studies employing intravascular ultrasound or computed coronary angiography tomography clearly confirm that diabetes is associated with larger plaque burden and with more lesions displaying features of instability. Various molecular mechanisms promoting atherogenesis and plaque destabilization in diabetics have been described in the past. The current review specifically focuses on recent papers that have addressed the effects of diabetes and hyperglycemia (i) on myeloid cells, (ii) on oxidative stress, and (iii) on protein kinase C (PKC) activation. Thus, it has been demonstrated that hyperglycemia may promote myelopoiesis and differentiation of pro-inflammatory macrophages. Furthermore, novel studies emphasize the interplay between inflammation and oxidative stress at both the molecular and the genetic level. Finally, experimental studies shed light on the role of PKC-ß in diabetes-associated atherosclerosis. Several of these recent studies suggest that atherogenesis and plaque destabilization in diabetic individuals may be mediated by diabetes-specific mechanisms. This may open the door for developing tailored anti-atherosclerotic therapies for diabetic patients.

[How does gender influence oral health?]. / Welchen Einfluss hat das Geschlecht auf die Mundgesundheit?

Most oral diseases show gender-specific differences in prevalence. This is true for common diseases such as caries and periodontitis, which are considered the main causes of tooth loss, affecting women more often than men. Furthermore, other diseases, e.g. temporomandibular joint dysfunction, malignant oral tumours, and several diseases of the oral mucosa show differing incidences between men and women. This is confirmed by empirical evidence from studies in Germany and other European countries, the USA, and emerging nations in Amercia and Southeast Asia. The present article aims to summarize gender-specific knowledge on oral health and present perspectives for future research. The main focus is on tooth loss and edentulism, a key measure of oral health, and their main causes, i.e. caries and periodontitis.

PARP inhibition in atherosclerosis and its effects on dendritic cells, T cells and auto-antibody levels.

OBJECTIVE: Atherosclerosis is a chronic inflammatory process. Poly(ADP-ribose) polymerase-1 (PARP), a nuclear enzyme linked to DNA repair, has been shown to be involved in atherogenesis; however, the effects on dendritic cells, T cells and serum auto-antibody levels are not fully understood. METHODS: Male Apoe-/- mice on a western diet were treated with the PARP inhibitor INO-1001 (n = 15), while the control group (n = 15) received 5% glucose solution for 10 weeks. RESULTS: Inhibition of PARP markedly reduced atherosclerotic lesion development (p = 0.001). Immunohistochemistry and mRNA analysis revealed a reduced inflammatory compound inside the lesion. Focusing on dendritic cells, INO-1001 reduced number of cells (p = 0.04), grade of activation, represented by Il12 (p = 0.04) and Cd83 (p = 0.03), and grade of attraction, represented by Mip3α (p = 0.02) in the plaque. Furthermore, INO-1001 decreased number of T lymphocyte (p = 0.003) in the lesion and grade of activation after stimulation with oxLDL in vitro. Moreover, serum IgM antibody levels to oxLDL were significantly lower in INO-1001 treated mice (p = 0.03). CONCLUSIONS: Functional blockade of PARP by INO-1001 reduces atherosclerotic lesion development. The anti-atherogenic effect is beside already known mechanisms also moderated due to modulation of DC and T cell invasion and activation, DC attraction as well as IgM antibody levels to oxLDL.

Cyclosporine withdrawal improves renal function in heart transplant patients on reduced-dose cyclosporine therapy.

Renal failure is a major cause of morbidity after heart transplantation. It is unclear whether calcineurin inhibitor (CNI) free immunosuppression provides more nephroprotection than low-dose CNI therapy. Thirty-nine patients with renal failure on low-dose cyclosporine A (CsA) were studied (62.9 +/- 8.7 years, five female, 8.2 +/- 4.3 years posttransplant, serum creatinine: 1.9 +/- 0.3 mg/dL, calculated GFR (cGFR): 48.2 +/- 18.3 mL/min, CsA C0 level: 64.0 +/- 19.9 ng/mL). All patients had been treated with low-dose CsA >6 months, renal function was stable or slowly decreasing (creatinine 1.7-3.5 mg/dL). Nineteen patients were randomized to discontinuation of CsA and overlapping rapamycin therapy initiation (RAPA), 20 patients continued low-dose CsA (control). Three patients (16%) discontinued rapamycin medication for side effects (diarrhea, skin rash), two patients developed pneumonia and pulmonary embolism, respectively, no rejection or other infectious complications were seen. After 6 months, renal function in the control group was unchanged. In the RAPA group, renal function markedly improved (creatinine: 2.08 +/- 0.15 to 1.67 +/- 0.13 mg/dL, cGFR: 48.5 +/- 21.4 to 61.7 +/- 21.4 mL/min (p < 0.001 within and between groups)). In carefully selected late survivors following heart transplantation who are at low risk of rejection, CNI-free rapamycin-based immunosuppression improves cGFR even in those already receiving low-dose CsA therapy. The results of this study warrant further confirmation in larger clinical trials that are powered to assess clinical outcomes.

Polymerase chain reaction-based simultaneous detection of selected bacterial species associated with closed periapical lesions.

PURPOSE: The aim of this study was to identify microorganisms which might be present in closed periapical lesions and to determine their relationship to conventional clinical parameters. - METHODS: In 11 patients, samples were taken with paper points from 14 teeth with periapical radiolucency, in seven cases two samples were taken from two different sites of the same tooth (n=21). Clinical parameters were determined. The 16S rDNA of eleven bacterial species could be simultaneously detected via a modified polymerase chain reaction (PCR) based technique. - RESULTS: All samples contained more than one bacterial species. Most frequently, M. micros was detected alone or in combination with E. faecalis, P. aeruginosa, E. coli, F. nucleatum or S. sanguinis. When apical palpation was positive, often M. micros and F. nucleatum were both present. Other clinical symptoms like tenderness to percussion were not associated with a particular microflora. - CONCLUSIONS: In closed periapical lesions detected by radiography, specific bacteria were identified by means of a modified PCR technique. No clear associations between clinical symptoms and these bacteria were found. Surgical intervention might be indicated for some of the persistent lesions.

Temporomandibular joint function in patients with longstanding rheumatoid arthritis - I. Role of periodontal status and prosthetic care - a clinical study.

PURPOSE: Temporomandibular joint (TMJ) dysfunction in rheumatoid arthritis (RA) occurs in 2 % to 86 % of RA patients. Dental factors possibly contributing to the development of TMJ dysfunction in RA patients have rarely been investigated in controlled studies. The present clinical study aimed 1) to compare patients with active, longstanding RA and healthy control subjects matched for age, sex, periodontal risk factors, dental and prosthetic status in order to obtain data on the prevalence of TMJ dysfunction in dentate RA patients and 2) to investigate a possible relationship between RA activity, general functional state and the severity of TMJ involvement. METHODS: 50 RA patients (38 F, 12 M; 54 +/- 9 years) were compared with 101 control subjects (76 F, 25 M; 54 +/- 11 years) with regard to dental, periodontal and prosthetic status and clinical TMJ findings as measured by the Helkimo indices. Clinical evaluation of RA patients included serological parameters, pain as measured by visual analog scale (VAS), a 28-joint count, a radiological destruction score, a functional status and measurement of grip strength. RESULTS: The sum of carious, missing and filled teeth was similar in both groups. RA patients had more missing teeth (p < 0.01), more gingival bleeding, deeper pockets and more attachment loss (p < 0.0001). They showed no differences with regard to the mean number of occluding pairs of teeth, tooth support, the percentage of dentures, the grade of prosthetic support. 36 % of RA patients had a unilaterally shortened dental arch compared with 11.9 % in controls (p < 0.05). 32 % of RA patients and 27.7 % of the control subjects reported TMJ or facial pain. The mean VAS was 50 +/- 19 for RA patients and 52 +/- 21 for controls. The anamnestic data and the clinical symptoms grouped according to the Helkimo index showed no significant differences between both subject groups. However, the maximal mouth opening capacity in RA patients was significantly lower (40.6 +/- 6.5 mm) than in controls (45.8 +/- 5.5 mm; p < 0.001). Analysis of the Helkimo symptom groups revealed a significantly reduced mobility index in the RA group and impaired TM-joint function in controls (p < 0.05). Grip strength was significantly correlated with mouth opening capacity, TMJ pain with tooth support. CONCLUSION: The prevalence of TMJ dysfunction in dentate patients with longstanding RA does not exceed that of healthy controls when structural risk factors predisposing to the development of temporomandibular dysfunction are taken into consideration. Maintaining adequate tooth support might help to prevent progressive TMJ impairment in the course of disease.

Evaluation of sulcular sulphide level monitoring using a portable sensor system.

PURPOSE: Volatile sulphur compounds (VSC) such as hydrogen sulphide and methyl mercaptan are toxic bacterial metabolites considered to contribute to the progression of periodontitis. However, the quantitative determination of sulcular VSC concentration requires costly time-consuming laboratory methods limiting its evaluation in large clinical trials. Recently, a portable monitor with a sulphide microsensor has been developed to measure sulcular VSC levels (SU). This cross-sectional study evaluated 1) the clinical usage of the sulphide sensor system, 2) the reproducibility of SU-measurements, 3) the distribution of SU-values in periodontal health and disease and 4) the relationship between SU and clinical parameters documenting periodontal disease severity. METHODS: The specificity, the measuring range and the reproducibility of the sensor system were tested with reference solutions in vitro. 10 probands with healthy gingiva, 23 patients with gingivitis and 30 patients with chronic periodontitis were examined recording periodontal parameters (clinical attachment loss, CAL, probing depth, PD, bleeding on probing intensity BI, plaque and gingival index PI, GI) and sulcular sulphide level (SU) measured by the portable monitor as a digital score ranging from 0.0 (< 10 superset -6 M of S2-) to 5.0 (10 superset -2 M of S superset 2-) in increments of 0.5. RESULTS: The in vitro testing confirmed the sensor s specificity for sulphide ions. The intraexaminer agreement (Pearson correlation coefficient) was 0.91 between two measurements (p < 0.05). However, positive SU-values decreased with measurement repetition due to the volatility of the sulphur compounds. SU and the percentage of positive SU-values per patient were correlated with disease severity. There were no positive SU-values in healthy probands, a mean SU of 0.11 +/- 0.08 in gingivitis and of 0.22 +/- 0.15 in periodontitis (p <0.001). SU was significantly correlated with PD in gingivitis, PD and CAL in periodontitis and the bleeding index in the analysis of all data. CONCLUSION: The portable sulphide monitor is a reliable method for the chairside determination of sulcular sulphide level in periodontal disease and in spite of its limitations a valuable supplementation of traditional clinical examination methods. It offers the possibility of relating in vitro results on the toxicity of VSC to clinical findings and might provide new insight into the impact of sulcular sulphide on the pathophysiology of periodontitis.

The effect of salt-containing dentifrices on gingival inflammation.

OBJECTIVE: This study examined the effect of an alkaline, salt-containing toothpaste, a toothgel of similar contents, and a conventional toothpaste on gingival inflammation. METHOD AND MATERIALS: One hundred fifteen patients suffering from mild to moderate chronic gingivitis were enrolled in a double-blind clinical study. All subjects had at least 20 teeth, probing depths of less than 6 mm, and a sulcular bleeding index of 50% or more. At the beginning of the study period, the subjects were randomly assigned to 3 study groups. The baseline examination recorded the number of decayed, missing, and filled teeth, an approximal plaque index, a sulcular bleeding index, and the gingival index. RESULTS: After an 8-week study period, statistically significant reductions in the plaque and bleeding indexes were observed in all 3 groups. There were no significant differences among the 3 dentifrices examined. CONCLUSION: The effectiveness of salt-containing dentifrices in patients with gingivitis was comparable to that of a conventional toothpaste.

The role of risk factors for periodontal disease in patients with rheumatoid arthritis.

There are conflicting reports whether patients with rheumatoid arthritis (RA) are at a higher risk for periodontal disease (PD). Analogous mechanisms of tissue destruction have been reported for both diseases. This cross-sectional study should quantify PD in patients with longstanding RA and examine a possible association between the two diseases. It should also be investigated whether PD in RA patients could be the result of reduced functional capacity or be amplified by concomitant medical treatment. 50 RA patients were matched for age, sex, smoking and oral hygiene with 101 healthy controls. Data on the medication over the last three years was obtained by questionnaire. Among the rheumatological parameters recorded were a 28-joint-count, C-reactive protein (CRP), grip strength testing, upper extremity function (Keitel Index) and the Larsen-score of radiological joint destruction. The oral examination included the recording of individual oral hygiene measures and sicca symptoms, a modified Approximal Plaque- and Sulcus-Bleeding-Index (SBI), probing depths and clinical attachment loss and the Community Periodontal Index of Treatment Needs. The mean duration of RA was 13 (+/- 7.9) years. RA patients under treatment with disease modifying antirheumatic drugs (DMARDs, n = 46; 92%), corticosteroids (n = 38; 76%) and non steroidal antirheumatic drugs (NSAIDs, n = 43; 86%) had a higher rate of gingival bleeding (+ 50%), probing depth (+ 26%), clinical attachment loss (+ 173%) and number of missing teeth (+ 29%) compared with controls. While no correlation between the rheumatological variables (radiological destruction, functional capacity, grip strength) and the periodontal measurements (SBI, probing depth, clinical attachment loss) could be demonstrated, a positive correlation was observed between the CRP and the periodontal attachment loss (r = 0.32; p <0.05). In spite of a strong correlation between the duration of DMARD- and cortisone-medication and the Larsen-score (r = 0.48 and 0.64; p = 0.0005 and 0.0001, rsp.), no correlation between the duration of pharmacotherapy and the periodontal parameters could be established. Patients with long-term active RA present a substantially higher degree of PD including loss of teeth compared with controls. Functional impairment of the upper extremity might amplify present PD. The longterm use of NSAIDs, corticosteroids and DMARDs shows no connection with the severe PD observed in these patients. Oral hygiene amplifies PD severity and treatment need. Intensive prophylactic measures are required to prevent or reduce the damage of the periodontal tissues in RA patients.

Periodontal disease in elderly patients.

In the elderly patients a greater loss of teeth is frequently seen in combination with periodontal diseases. This article presents an overview of the changes of oral structures during ageing as well as immunology, physical and psychological aspects. Also summarised are complications by systemic illnesses, drug medications and periodontal alterations. If possible illnesses and medications are taken into consideration, there should be no special problem for the elderly patients.

Risk for periodontal disease in patients with longstanding rheumatoid arthritis.

OBJECTIVE: To quantify periodontal disease in rheumatoid arthritis (RA) patients and controls, and to correlate the degree of destruction from periodontal disease and from RA. METHODS: Fifty RA patients were matched for age, sex, smoking status, and oral hygiene with 101 controls. Correlations between indices of chronic destruction in periodontal disease (gingival attachment loss) and in RA (Larsen radiographic score) were determined. RESULTS: Patients with longstanding active RA (mean +/- SD 13 +/- 8 years) who were receiving treatment with disease-modifying antirheumatic drugs (n = 46), corticosteroids (n = 38), or nonsteroidal antiinflammatory drugs (n = 43) had a higher rate of gingival bleeding (increased by 50%), greater probing depth (increased by 26%), greater attachment loss (increased by 173%), and higher number of missing teeth (increased by 29%) compared with controls. No correlation was found between the Larsen radiographic score and gingival attachment. CONCLUSION: Patients with longstanding active RA have a substantially increased frequency of periodontal disease, including loss of teeth, compared with controls. Antiinflammatory treatment interferes with periodontal disease and might have masked a possible correlation between the indices of chronic destruction in RA and periodontal disease.