Pericardial effusions in systemic sclerosis (SSc) may present as acute or chronic with or without clinical symptoms. Best treatment is unknown and whether patients receive medical therapy or a surgical procedure is clinician-dependent. To describe the clinical characteristics, treatment, and outcomes of patients with SSc and clinically symptomatic pericardial effusions treated in the inpatient setting. We evaluated all SSc admissions over a 10-year period to a tertiary care hospital which has a dedicated SSc clinic. Patients who had a clinically symptomatic pericardial effusion were evaluated based on their demographics, disease pattern, and medical or surgical management. From January 2005 till October 2015, there were 462 SSc admissions with 32 (6.9%) of them being for a clinically symptomatic pericardial effusion in 23 unique patients. Eleven (47%) of these patients had right heart failure, seventeen (74%) had pulmonary arterial hypertension (PAH), and 4 (17%) had tamponade physiology. Five (22%) patients were treated by a surgical procedure, while eighteen (78%) patients had medical therapy. Patients who received medical therapy tended to be older, have a lower serum Cr level, and more likely have right heart failure. Clinically symptomatic pericardial effusion is a rare cause for hospital admissions in SSc, with a high percentage of these patients having PAH. Medical therapy tends to be reserved for older patients with right heart failure, while surgical therapy was more likely in patients with higher serum Cr levels. Systemic sclerosis (SSc) is an autoimmune rheumatic disease characterized by visceral and skin fibrosis, vascular dysfunction, and immune dysregulation. Cardiac involvement in SSc has been suggested in 15% to 35% of patients . PericarLarge pericardial effusions or cardiac tamponade are very rare in SSc and at times can even manifest prior to skin involvement. Large pericardial effusions are associated with a poor prognosis with a mortality rate of up to 55% , 15. In Pericardial disease in SSc patients is usually treated with medical therapy such as corticosteroids, aspirin, NSAIDs, and colchicine, or in some cases surgical procedures such as a pericardiectomy or a pericardial window. Although pericardial disease leads to increased morbidity in systemic sclerosis, there is limited data on the outcomes of these treatments and the decision-making in regard to the specific therapies. With this study we attempt to characterize clinically symptomatic pericardial effusion management in hospitalized SSc patients and the predictors for the individual therapies.t-test as well as the Chi-square test for dichotomous variables.After receiving institutional review board approval, we performed a single-site, retrospective study on patients with SSc and acute pericardial effusions who required hospitalization. Subjects were selected from all the patients who were admitted to the hospital of the University of Pennsylvania from January 1, 2005 to October 30, 2015. ICD- 9 codes for SSc and pericardial disease were used to identify the subjects. The diagnosis of SSc was confirmed as well as the diagnosis of the specific pericardial disease by detailed chart review. Data collected included the age, sex, race, type of SSc, SSc related characteristics such as Raynaud's, digital ulcers, interstitial lung disease, and esophageal involvement. Presenting clinical symptoms, laboratory studies, and echocardiographic results was also recorded, and readmission within 90 days and death up to February 2017 was also documented. Continuous variables were described as a mean with a standard deviation. Group differences among the patients who received medical therapy versus the patients who received surgical care were analyzed using Student's We identified 462 admissions with a diagnosis of SSc. Among them, there were 32 (6.9%) admissions of 23 individual patients with clinically symptomatic pericardial effusions. The mean age of this cohort was 60 (range: 44–79) years of age, with 19 (83%) female and 4 (17%) male patients. Fourteen patients were Caucasian (61%), 5 African American (22%), 2 other, and 2 unknown. Eleven (47%) patients from the cohort had right heart failure and four (17%) had tamponade, while pulmonary arterial hypertension (PAH) was seen in 17 (74%) patients of our cohort. From the 23 patients evaluated 5 (22%) ended up receiving a pericardial surgical procedure during their admission to the hospital . Clinicap = 0.01). The main symptoms on presentation were shortness of breath , chest pain , and fever . None had hypoxia on presentation in the procedure group while 7 did in the medical group. White blood cell (WBC) count, hemoglobin (Hgb), platelet (Plt), and blood urea nitrogen (BUN) were not significantly different between the groups. Creatinine was found to be significantly higher in the surgically treated group as compared to the medically treated group (p = 0.03). Pro-b-type natriuretic peptide (pro-BNP) tended to be higher in the medical group; however there was no statistically significant difference likely due to the small sample size. ANA was reported in 12 patients in the medical group; among them 10 were positive. In the procedure group, 5 were reported and 4 were positive. Scl-70 antibodies were done in 12 of the medical group patients and 4 of the procedure group and they were all negative. RNA polymerase III antibodies were not performed in any of the patients. Notably, the size of the pericardial effusion tended to be larger in the procedure group; however 5 patients in the medical group were recorded with “large” effusion on echocardiography. Three patients in the procedure group and 6 patients in the medical group had pleural effusion shown on a computed tomography (CT) of the chest. Eleven patients from the medical group had right heart failure while none did in the procedure group. Fourteen patients (78%) in the medical group and 3 (60%) in procedure group had pulmonary artery hypertension, and the mean pulmonary artery systolic pressure estimated by echocardiography was 79.8 ± 45 mmHg in the medical group and 39.7 ± 11 mmHg in the procedure group (p = 0.06). There were 2 patients each with tamponade physiology in both groups (The mean age was 51.8 (SD 9.2) for the procedure group and 62.1 (SD 7.1) for the medical treatment group . The mean dosage of glucocorticoid given to the patients was 103 mg prednisone equivalent per day for medical therapy group and 345 mg for procedure group. Colchicine was administered to one patient in each group. Ten patients in the medical group received diuretics while 3 did in the procedure group. Two patients in the procedure group received azathioprine and cyclophosphamide, respectively. The results of fluid studies are included in Two patients in the medical group died during the admission. Within 90 days of discharge, 3 readmissions occurred in the medical group and 1 in the procedure group, receiving a pericardiocentesis. This patient subsequently received a pericardial window. The outpatient charts were evaluated up to February 2017 and five more patients in the medical group and one in the procedure group died during followup.p = 0.01) and have right heart failure and while not statistically significant, it had a higher estimated mean PAP on echocardiography (p = 0.06). The group that received the surgical procedure tended to have a higher mean Cr level. This clearly differentiates therapies as to the pathophysiologic mechanism behind the development of the clinically symptomatic pericardial effusion in SSc. The surgical group which tended to be younger had a mean Cr level greater than the medically treated group which suggests a uremic type of pericardial effusion, less associated with PAH and more likely to proceed with surgical management when this was warranted. In contrast to the medical management group, while having similar size pericardial effusions happened to be associated with higher PAP and right heart failure and the clinicians were less likely to use a surgical approach. This may relate to the fact that clinicians are aware that, in PAH patients who have a pericardial effusion a pericardiocentesis can lead to acute right heart decompensation and thus choose medical management instead. Of note, Maione et al. reported 47% of patients with scleroderma showed PAP > 30 mmHg. SSc patients with PAH and large pericardial effusions should have a right heart catheterization to evaluate in detail the hemodynamics of the right heart before even a pericardial surgical procedure is contemplated. In contrast patients who develop pericardial disease from other causes other than right heart failure, such as renal disease, may be more amenable to a surgical procedure and thus the clinical teams are more likely to recommend.The present study describes the clinical manifestations, treatment, and outcomes of SSc patients who were admitted to the hospital with a clinically significant pericardial effusion. The decision-making for procedures in this group did not necessarily depend on the size of the pericardial effusion; while the two groups are small, some statistical comparisons were significant and in some cases there were some apparent trends among the two groups. The group that received medical therapy tended to be older (Limitations of this study include the small number of patients included due to the rarity of the disease, the retrospective nature of the study, and the incomplete clinical data. Also the size description of the pericardial effusion is clinician-dependent. This is the largest cohort of SSc patients with clinically symptomatic pericardial effusions who were studied in the inpatient setting and our data suggest that the pathophysiologic mechanism of the pericardial effusion is taken into consideration when clinical decisions are to be made.


The American College of Obstetricians and Gynecologists (ACOG) recommends that most women with one prior low-transverse cesarean delivery should be offered a trial of labor after cesarean (TOLAC). However, very little is known about TOLAC in women with uterine anomalies.  A 32-year-old gravida-2 para-1 female with a history of uterine didelphys and one prior low-transverse cesarean section in the left uterine horn presented with a subsequent pregnancy in the left uterine horn. After extensive counseling on TOLAC versus repeat cesarean delivery, the patient decided to proceed with TOLAC and had a spontaneous vaginal delivery of a healthy infant at 38 3/7 weeks of gestation.  TOLAC can be considered in women with uterine anomalies using ACOG's standard TOLAC guidelines with informed consent and shared decision-making between the patient and obstetrician. The rate of cesarean delivery (CD) in the United States has increased more than six-fold between the years 1970 and 2016, with the most recent rate reported to be 31.9% [Obstetrics & Gynecology published a case report of a woman with a history of CD in the right horn of her didelphic uterus, followed by a vacuum-assisted vaginal delivery of a subsequent pregnancy in her contralateral left horn [However, little is known about TOLAC in women with uterine anomalies. Given the rarity of this situation, ACOG does not offer practice guidelines for TOLAC in women with uterine anomalies . In 2015eft horn . In contst percentile for weight. She was extensively counseled throughout her pregnancy on TOLAC versus repeat CD, and the patient decided to proceed with TOLAC.A 32-year-old gravida-2 para-1 female at 12 1/7 weeks of gestation presented to the office to establish prenatal care. The patient had a history of known uterine didelphys, with confirmation of two uteri, two cervixes, a vertical vaginal septum, and a normal renal system on magnetic resonance imaging. Her obstetrical history was significant for a prior low-transverse CD at 35 1/7 weeks for preterm labor with a fetus in the breech presentation in the left uterine horn three years prior. The current pregnancy was also located in the left horn. The patient declined cervical length screening and 17-alpha hydroxyprogesterone caproate for her history of preterm labor. She had an otherwise uncomplicated pregnancy, and at 32 0/7 weeks of gestation, a growth ultrasound showed that the fetus was growing well at the 51At 38 3/7 weeks of gestation, the patient presented to labor and delivery for early labor with spontaneous rupture of membranes. An epidural was received for analgesia. Labor was augmented with intravenous oxytocin and progressed well. During the second stage of labor, the patient's vaginal septum was manually displaced while pushing, and less than one hour later, the patient had a spontaneous vaginal delivery of a healthy female infant. The vaginal septum was noted to have torn during delivery, so the remainder of the septum was transected, and the incised edge was closed with polyglycolic acid suture in a running fashion for hemostasis. Estimated blood loss was 300 mL. The patient's postpartum course was uncomplicated, and she was discharged home on postpartum day 2.To the best of our knowledge, this is the first-ever published case of a successful vaginal birth after cesarean (VBAC) in a woman with uterine didelphys and a history of prior CD with a subsequent pregnancy in the same uterine horn. Although data are limited, TOLAC can be considered in women with uterine anomalies using ACOG's standard TOLAC guidelines with informed consent and shared decision-making between the patient and obstetrician.Uterine anomalies are associated with multiple obstetric complications, including recurrent early pregnancy loss , pretermP < 0.001) and that they were less likely to experience uterine rupture than women with normal uteri (0% vs. 0.002%) [P = 0.01) [Little is known about TOLAC in women with uterine anomalies, and only a few studies exist in the medical literature. A retrospective population-based study of 165 women with uterine anomalies found that these women were statistically less likely to have a VBAC than women with normal uteri  . These sThe actual rates of VBAC and uterine rupture in women with uterine anomalies are likely to be similar to or less favorable than those in women with normal uteri. Some authors hypothesize that uterine anomalies, especially unicornuate uteri, are associated with decreased uterine muscle mass , 10. If


We present a mathematical model of cartilage regeneration after cell therapy, to show how co-implantation of stem cells  and chondrocytes into a cartilage defect can impact chondral healing. The key mechanisms involved in the regeneration process are simulated by modelling cell proliferation, migration and differentiation, nutrient diffusion and Extracellular Matrix (ECM) synthesis at the defect site, both spatially and temporally. In addition, we model the interaction between mesenchymal stem cells and chondrocytes by including growth factors. In Part I of this work, we have shown that matrix formation was enhanced at early times when mesenchymal stem cell-to-chondrocyte interactions due to the effects of growth factors were considered. In this article, we show that the additional effect of co-implanting mesenchymal stem cells and chondrocytes further enhances matrix production within the first year in comparison to implanting only chondrocytes or only mesenchymal stem cells. This could potentially reduce healing time allowing the patient to become mobile sooner after surgery. It does have some drawbacks, in particular the need for an extra knee surgery procedure to harvest the chondrocytes, difficulties in obtaining an adequate number of chondrocytes and donor site morbidity.2 Mesenchymal stem cells (MSCs) are increasing in popularity as a cell source for regenerative medicine approaches for cartilage regeneration, such as cell implantation to treat articular cartilage defects of the joints.3 The benefits of using MSCs instead of chondrocytes have been well documented, including their larger availability within the body and their ability to undergo chondrogenesis and deposit matrix under the influence of growth factors.4Autologous chondrocyte implantation (ACI) is the most commonly used cell-based therapy to treat chondral defects.2 Lutianov et al.5 developed a mathematical model to simulate and compare the repair of a chondral defect with new cartilage following implantation of either chondrocytes (ACI) or MSCs (ASI) along the bottom of the defect. This model assumed that following implantation, MSCs only contributed to cartilage formation via their differentiation into chondrocytes. One difference between ACI and ASI according to this model was that cartilage formation after ASI started later than after ACI. As is now widely recognised, MSCs used in this way do not only contribute to the repair process via their differentiation into chondrocytes but also via their secretion of growth factors and cytokines, termed as their ‘trophic’ effect.7 Work by Wu8 identifies two growth factors, Fibroblast Growth Factor 1 (FGF-1) and Bone Morphogenetic Protein 2 (BMP-2), as particularly important during cartilage regeneration. These two growth factors were identified when investigating the effect of co-cultures of MSCs and chondrocytes on cartilage formation.8 They are released by MSCs and chondrocytes and mediate MSC-to-chondrocyte interaction, enhancing chondrocyte proliferation and MSC chondrogenesis (see 9). Their observations were modelled mathematically in Part I, which studied the effects of these growth factors after MSC implantation (ASI) into the defect.9 Our simulations showed that matrix formation following ASI was enhanced at early times when cell-to-cell interactions mediated by these growth factors were taken into account. This was mainly due to the presence of BMP-2, resulting in increased formation of chondrocytes via increased chondrocyte proliferation and MSC chondrogenesis, and hence enhancing early matrix production in comparison to the case when no growth factors are present. At later time points, no differences were found.An alternative cell-based therapy, denoted here as articular stem cell implantation (ASI), reproduces the approach of culture expansion and implantation, except MSCs are used instead of chondrocytes.11 In these mixtures, the chondrocytes could immediately start forming cartilage, and trophic effects due to the growth factors released in the system would boost this effect further.8 However, these in vitro studies are, by necessity, short-term studies, and it is therefore not clear how these differences develop in the longer term if they are maintained. To our knowledge, the only in vivo study used a rat model and found no difference in quality of cartilage defect repair 12 weeks after implanting scaffolds with either a 90:10 MSC:chondrocyte mixture or pure chondrocytes but did not study other time points.12Several in vitro studies have suggested that co-culturing a mixture of MSCs and chondrocytes increases matrix formation.9 where full details of non-dimensionalisation and a sensitivity analysis of the model has been conducted, which will not be shown here.In Part II of our work, we aim to explore the longer term patterns over time of cartilage defect healing following implantation of mixtures of MSCs and chondrocytes at various ratios, and investigate the differences between them. The plan of the article is as follows. In the section ‘Mathematical model’, we state the model equations, boundary and initial conditions. Next, section ‘Results’ shows the results of simulations for five co-implantation ratios and their comparison with respect to matrix density levels over healing time. Results showing sensitivity to variations in co-implantation ratios are also considered here, in particular, comparisons are made with 100% stem cell (ASI) and 100% chondrocyte (ACI) implantations. Finally, section ‘Discussion’ explores the implications of the model results on co-culture cell therapy and future work. We refer the interested reader to Campbell et al.9 with the initial cell implantation profile changed to accommodate a varying ratio of stem cells and chondrocytes. We only state the dimensionless equations, and boundary and initial conditions here. For more information on the formulation and non-dimensionalisation of these equations and assumptions made, the reader is referred to Campbell et al.9 and Lutianov et al.5Our mathematical model follows the same formulation as our earlier workWe consider a cartilage defect with a small depth to diameter ratio see  which en9 and provided in Following the non-dimensionalisation given in Campbell et al.where9The estimated values of the parameters in dimensional form and the dimensionless parameters are provided in The non-dimensional boundary and initial conditions arewith t = 0).The new initial conditions representing the different co-culture ratios of stem cells and chondrocytes are highlighted in bold in ode15s. The dimensionless parameter values used in our simulations are given in We used a second-order accurate finite difference scheme to discretise the spatial derivatives in The initial stem cell and chondrocyte density spatial profile is 9 and in Lutianov et al.5 and hence are not repeated in detail here. The main focus of our simulations is to vary the initial stem cell and chondrocyte implantation densities through the parameter The general evolution characteristics of the cell and matrix densities, nutrient and growth factor concentrations using this model are described in Part I of this work Campbell et al.We simulate cartilage repair following implantation of five mixtures, namely, t = 11 and 22 days, respectively. Matrix production near 5), but using a far smaller number of chondrocytes . This larger chondrocyte density comes not only with increased matrix production but also with increased uptake of nutrients. The latter results in a drop of chondrocyte density towards the bottom of the defect once the nutrient concentration falls below the minimum threshold level Over the course of the first few months, chondrocyte density is generally larger in the co-implantation case compared to the 100% stem cell and 100% chondrocyte implantation cases (compare 5 and 9).At later times , matrix 9 This decreases chondrocyte proliferation at the bottom of the defect, meaning diffusion of cells to higher concentrations of nutrients will be the main driver of defect healing. As time continues, we see that the general evolutionary characteristics of the simulations remain similar to our 90:10 case, albeit with slightly higher matrix levels due to the higher proportion of chondrocytes inserted into the defect. The defect is observed to fill up with new cartilage within 18 to 24 months, which is in line with our previous results.9Next we show simulations of We next show the simulations corresponding to  compare  and 6.Figures 11:10 case , for ins:10 case , 6 and 9:10 case , matrix We finally show the results for a 90% chondrocyte and 10% MSC mixture corresponding to  (10:90) –16. HereNext, we make a comparison between the five co-implantation cases with ACI and ASI to identify both spatial and temporal differences in matrix and cell densities.5), the additional nutrient demands of the stem cells bring the nutrient concentration below the minimum threshold value, resulting in matrix densities much lower than the 0:100 case  has the largest amount of matrix . Althoug100 case . In the 100 case .The 10:90 case has the highest level of matrix at 3 months , 100:0 (ASI) and two co-implantation strategies, 90:10 and 10:90. We choose to focus on 90:10 and 10:90 as they represent our two most extreme co-implantation cases, with all other results, that is, 70:30, 50:50 and 30:70, lying within the bounds of these two sets of results see  and 18. 9 and the balance of the effects of cell proliferation and nutrient levels. In our model, MSCs have a high demand for nutrients to support their high proliferation rate and their differentiation into chondrocytes. In the 90:10 case, the large concentration of MSCs therefore consumes a large amount of nutrients, leaving less for the chondrocytes to produce matrix. On the other hand, in the 10:90 case, the MSC density is lower, and therefore these cells consume less nutrients, leaving more nutrients for the chondrocytes to proliferate and deposit matrix. This difference is mainly observable at early times.In 9 We see a higher percentage difference when compared to 100:0 due to lower mean chondrocyte density at this time compared to 90:10 and 0:100  case is 136% higher than the 0:100 case (blue), and has an even higher percentage difference when compared with the 100:0 case (yellow). This marked increase in matrix density is due to the effects of the growth factors.In n1=10−1 . This efn1=10−1 .9 This is likely to be the cause of the marked increase in MSC levels in the defect at this time.In 11 Opting for the lower proportion of chondrocytes in these co-implantation therapies could mean sufficient chondrocytes can be isolated from the cartilage harvest obtained during arthroscopy for a successful co-implantation procedure.13 This alleviates the need for expansion of cells in vitro if the fresh chondrocytes are combined with allogeneic stem cells, allowing cells to be harvested and inserted into the defect region during one procedure.14 Alternatively, the fresh chondrocytes can be mixed with fresh bone marrow, which despite the lower total cell number has been suggested to be clinically effective.15This study aimed to develop a mathematical model to explore the longer term patterns over time of cartilage defect healing following implantation of mixtures of MSCs and chondrocytes at various ratios, and investigate the differences between them. First, our simulations suggest that co-implanting MSCs and chondrocytes will increase matrix deposition within the first half year of healing when compared with 100% MSC (ASI) or 100% chondrocyte (ACI) implantation therapies, indicating a chondral defect could fill with new cartilage at earlier times when a co-culture procedure is the chosen treatment. Although 10:90 appears to have the highest matrix density at early times, clinically a co-implantation ratio that uses less chondrocytes is desirable if the aim would be to develop a single-stage ACI procedure.16 We compared these to ACI (100% chondrocytes) and ASI (100% MSCs). When comparing co-implantation scenarios with the ACI and ASI results from our previous work,9 it is clear that a mixture of MSCs and chondrocytes delivers the desired effect of increased matrix deposition, as hypothesised in the literature17 and in previous experiments.8 This effect is especially marked during the first few months following cell implantation, but from around sixth month onwards, the differences, especially with ASI, become small. As time progresses, the 0:100 case continues to produce matrix at a steady rate, but the 100:0 and co-implantation cases soon surpass these levels. 14 Nevertheless, the larger matrix deposition at earlier time may give advantages with respect to the rehabilitation, which could be faster if matrix is formed earlier. This alone could be an important clinical advance in the treatment of articular cartilage damage.Our model enabled us to compare matrix densities following co-implantation of MSCs and chondrocytes at various ratios, not only visualising the cartilage matrix density distribution at any time point but also investigating how the concentrations of MSCs, chondrocytes and nutrients change within the defect in response to different co-implantation ratios. The five ratios we focused on were 90% MSCs plus 10% chondrocytes, 70% MSCs plus 30% chondrocytes, 50% MSCs plus 50% chondrocytes, 30% MSCs plus 70% chondrocytes and 10% MSCs plus 90% chondrocytes, with 90:10 and 50:50 having been or are being investigated clinically.8 In addition, the increase of matrix deposition and chondrocyte density at early times for our co-implantation cases is in part due to the lower proliferation rate of the chondrocytes, allowing more nutrients to be available in the defect for MSC proliferation and differentiation.A mixture of stem cells and chondrocytes produces more consistent levels of matrix due to the balance of nutrients used between the two cell types and the release of important growth factors that influence chondrocyte proliferation and stem cell differentiation. In our model, this effect is partly due to the cell–cell interactions between MSCs and chondrocytes, releasing growth factors such as FGF-1 and BMP-2 that cause an increase in matrix deposition from increased chondrocyte proliferation and enhanced chondrogenesis.7An important assumption in our model concerns the role of chondrogenesis, the differentiation of stem cells into chondrocytes. Our results suggest that stem cell differentiation played an important part in increasing the number of chondrocytes, and eventually the matrix, due to large quantities of chondrocytes, comparable to our 50:50 case, being present in the defect when 90% MSCs are implanted. Most in vitro co-culture studies suggest that the more important contribution from the stem cells is their positive effect on chondrocyte proliferation whereas their differentiation into chondrocytes is less important.18 The signal intensity is a measure of mean matrix density, and thus our chosen measure will give a clinically relevant comparison. However, other parameters such as the required time for cartilage matrix to fill the defect and the required time to achieve a threshold density at the surface might also be appropriate. The spatial distribution of matrix might also be relevant, as seen in 18 which would suggest that the repairs including stem cells, which form denser matrix at the defect surface, might be better. However, the distribution of matrix density is less homogeneous for these cases, and poor matrix homogeneity is associated with poorer clinical outcome.18 The limitations of our model dictate that all simulations are subject to nutrient concentration constraints, typically meaning an optimal split of MSCs and chondrocytes is not at all obvious; this would require further investigation. This effect of nutrient concentration impacting the overall healing process has been hypothesised in our previous model as well as similar work,19 with this co-implantation model now corroborating this hypothesis further. Availability of cell types, overall cost and efficacy of the procedure are factors that would also have to be considered when considering an optimal MSC–chondrocyte co-implantation ratio.Other mixtures of MSCs and chondrocytes could be investigated to find an ‘optimal’ MSC/chondrocyte ratio, where nutrient constraints are minimised and matrix deposition maximised. Our criterion for suggesting an optimal co-implantation ratio is based on mean matrix densities. However, other criteria could also be used to determine an optimal ratio. Some justifications of our current criterion are clinical data comparing magnetic resonance imaging (MRI) and clinical outcome that suggests the signal intensity on MRI correlates with better clinical outcome of ACI.


We report a new tool for improved serological diagnostics in suspected tick-borne encephalitis (TBE) vaccine failure cases. Due to an increase in the incidence of disease as well as the number of vaccinees, specific and simplified diagnostic methods are needed. Antibody responses to TBE-virus (TBEV) non-structural protein 1 (NS1) are detectable post TBEV infection but not post vaccination. We have used samples from 14 previously confirmed Swedish TBEV vaccine failure patients to study antibody responses against NS1 and whole virus antigens, respectively. Our conclusion is that the detection of antibodies directed to TBEV NS1 antigen is a useful tool to considerably simplify and improve the quality in investigations regarding suspected TBEV infection in vaccinated patients. Long-term neurological sequelae and case fatalities can occur in tick-borne encephalitis (TBE) patients ,2, but aIn the second phase of the disease, when neurological symptoms are present, laboratory diagnosis is highly dependent on the detection of TBE-virus (TBEV)-specific IgM and IgG in blood and/or cerebrospinal fluid (CSF) . Viral RTBE is an important and growing public health problem in Europe; France reported a marked increase in TBE cases in 2016, and in Finland, the number of TBE cases has not only more than doubled during the last decade, but the virus has also spread to new geographical areas. The Netherlands, previously TBE-free, most recently reported its emergence. In Sweden, the number of notified cases is increasing and reached a record-high in 2017 (391 cases), with almost the same level in 2018 385 cases)  4]. Eff. Eff4].  cases  4Our recently published method for detection of non-structural protein 1 (NS1) and whole virus (WV) antibodies to TBEV using TBEV suspension multiplex immunoassay (SMIA) was proven to efficiently differentiate between antibodies induced by infection and vaccination. All but two (48/50) samples from TBEV-infected patients had antibodies to NS-1 antigen as compared to only three serum samples from the vaccinated group (3/50). In one case, it is possibly due to a TBEV infection during the study period . VaccinaOur aim in this study was to determine whether the presence of antibodies directed to the TBEV NS1 antigen could prove to be a useful tool for the diagnosis of TBEV infection in vaccinated patients. Samples from 14 previously confirmed TBE vaccine failure patients were tested in order to study the antibody responses against NS1 and WV antigens, respectively.The Luminex-based TBEV SMIA for the detection of antibodies to TBEV WV and NS1 antigens in serum was reported in 2018 . In thisSeventeen serum and 18 CSF samples drawn between 2006 and 2011 from 14 patients and previously analyzed at the Public Health Agency of Sweden were tested. The samples were primarily analyzed at different clinical microbiology laboratories in Sweden before they were sent to the Public Health Agency for further investigation. The mean age of the patients was 56 years (6–68) and the majority were men . The time from disease onset to the first sample was 4–30 days (mean: 11.5). In three cases, this information was not available, but these samples were all drawn from symptomatic patients, i.e. during the acute phase of the disease. All patients had a documented history of previous TBEV vaccination according to the schedule. Due to clinical and laboratory-suspected TBEV infection despite a completed vaccination schedule, the samples were sent to the Public Health Agency. After serological testing including IgG and IgM detection in sera and CSF together with neutralization test, they were all considered to be TBE vaccine failure cases .10.1080/Vaccine failure was defined as a TBEV infection despite adherence to the recommended vaccination schedule with at least two doses .Eleven out of 14 patients (78%) were found IgM antibody positive to TBEV NS1 antigen in serum or CSF by the TBEV SMIA, while all 14 patients (100%) tested positive for IgM and IgG to TBEV WV antigen . PatientAll 14 patients were found IgM and IgG positive against TBEV WV antigen, supporting exposure to TBEV from infection or vaccination. Eleven out of the 14 patients tested IgM positive to TBEV NS1 antigen in serum or in CSF, strongly supporting a current or recent TBEV infection. Ten patients were found IgM positive to TBEV NS1 antigen in serum alone.Three of the patients had no detectable antibodies to NS1 antigen either in serum or in CSF at the time of sampling. They all had IgM and IgG responses to WV antigen, suggesting that the patients were immune competent enough to respond to TBEV vaccination. If these patients developed anti-NS1 antibodies later or not at all is not known since there is no information on any follow-up tests or clinical data available. For that reason, any possible correlation between lack of anti-NS1 antibody response and more serious illness could not be investigated.In Sweden, there is an unexpected discrepancy between increased vaccination coverage and the number of diagnosed cases. The reason for this is not known but could be caused by a number of reasons including increased patient and doctor awareness, changed climate factors and/or host–vector relationships.We believe that the TBEV SMIA method is very useful as a new and relatively simple tool in the diagnostics of suspected vaccination failure cases. We will now continue using the method, both for larger study materials and for clinical samples in the laboratory, internal as well as external samples. The TBEV SMIA method will also be used in a study for seroprevalence of TBEV NS1 and WV antibodies in blood donors in different parts of Sweden, with an attempt to investigate the proportion of TBE-vaccinated individuals compared with TBEV exposed. Very limited data on this matter exist today.


Altogether our findings demonstrate that sebocytes are not only positioned at the end point of inflammation but are actively involved in shaping the inflammatory response with putative diagnostic and therapeutic relevance.Toll-like receptors (TLR) 2 and 4 are active in sebaceous glands and play a central role in the development of acne. Still, there is only limited knowledge on their effect on sebocytes. In this work we performed global gene expression profile analysis with functional clustering of the differentially regulated genes of TLR1/2 (PAM3CSK4)- and TLR4 (lipopolysaccharide [LPS])-activated SZ95 sebocytes. Both TLR1/2- and 4-activation promoted inflammation in a similar manner already at an early time-point (6 hours), regulating genes involved in inflammation, wound healing and chemotaxis reflecting a more complex cytokine and chemokine regulation than previously known. Importantly, lipid metabolism, the primary feature of sebocytes, was affected at the level of gene expression only at a later time point (24 hours) indicating that sebocytes prioritize to exert a pro-inflammatory phenotype when confronted with a danger signal. Supporting the biological relevance of our results, a meta-analysis revealed that the genes showing the strongest up-regulation were also found up-regulated in acne. Of these genes, serum amyloid A 1/2 (SAA1/2) was confirmed to be a suitable protein marker for  To elucidate the complexity of acne pathogenesis, histological analysis complemented with genome wide expression profiling of lesional tissue samples has lately been performed –3. AlthoPropionibacterium acnes (P. acnes), a Gram-positive bacterium present in the skin microbiome of acne prone areas  and 505 [PAM3CSK4]) at 6 hours, while at 24 hours the gene expression profile was almost identical (over 80% in case of PAM3CSK4 and 90% in case of LPS) .Hierarchical clustering of the genes that were expressed and changed between any conditions in unstimulated, TLR1/2- and TLR4-activated sebocytes exhibited changes mostly due to up-regulation, as only approximately 20% of the genes were down-regulated. This prominent induction in the number of regulated genes suggests that sebocytes respond to the activation of the TLR 1/2 and TLR4 pathways by adding a new profile to their transcriptome rather than losing the one from their untreated state. This was further supported by pathway analysis of the down-regulated genes that could not sort them into any functional category.The generated heat map also showed that of the genes reaching the level of significance at 24 but not at 6 hours, a very high number were already showing tendency of up-regulation at 6 hours, supporting that most of the changes observed at 24 hours occurred directly through the applied TLR stimuli and that sebocytes were already committed at this early time point towards their new profile .To assess the biological response and functions that TLR1/2- and TLR4-activated sebocytes could gain at the level of gene expression, we extended our studies with gene clustering and pathway analysis of the altered genes at 6 and at 24 hours. Notably, as it was expected from the previously detailed similarities in the genes regulated by TLR1/2 and TLR4 pathways, the functional analysis also resulted in the same clusters in both treatments. This was confirmed by using two independent softwares .Analysis of the altered genes from the 6-hour time point revealed that the most significant changes were related to genes involved in immune system/defense processes underpinning that TLR 1/2 and TLR4 pathways are also fully active in sebocytes and are a potential link between the inflammatory environment and the gene expression profile also in this cell type. The gene clustering provided many interesting clusters, as well as novel ones, to sebocyte research: such as a possible involvement in wound healing, regulation of cell proliferation, chemotaxis and a more complex cytokine and chemokine production than what was previously known besides the widely used detection of IL-6 and CXCL-8.ABCG1 that was down-regulated  , histolo5 , histopathways  in the pUsing a Venn diagram to visualize the up-regulated genes in the acne samples compared to healthy ones and in the TLR1/2- and TLR4-stimulated SZ95 sebocytes at 24 hours, a possible contribution of sebocytes with 92 of the 900 significantly altered transcripts in acne could be detected .To assess how sebocytes may contribute to acne pathogenesis, further analysis was performed using only the overlapping 92 genes . The gen(SAA1/2) was identified to be suitable marker to identify activated sebocytes at the level of gene expression  encode for proteins that are known serum markers for severe systemic inflammation in various diseases. Moreover, as revealed by a number of genes , sebocytes via their products might also contribute to wound healing which is also a novel field yet to be characterized and could bring us closer to understand the background of acne-associated scarring. Another interesting outcome of our analysis was the high number of cytokines induced at the level of gene expression, which besides IL1β, IL6 and CXCL8, have not yet been characterized in sebocyte research . Further clustering of these genes clearly showed that the wide repertoire of cytokines might have an effect on chemotaxis and thus have a role in initiating inflammation. This has been addressed in our recently published work, where after showing that TLR 2 and 4 activation of SZ95 sebocytes led to an induction also in the levels of the measured proteins  from the supernatants of cell cultures, we demonstrated a CXCL-8-dependent chemotactic effect of sebocytes on neutrophils, monocytes and T cells [From the detected clusters, the one showing the most significant changes and also including the highest number of genes was related to inflammation. Although this change was expected based on previous results, still it was surprising to see that many of the cluster-forming genes . Concluding on the enzymatic activity based on gene expression result would be oversimplified, still these data provide a strong piece of evidence, that sebocytes are indeed able to link inflammation to lipid metabolism in which the TLR1/2 and TLR4 pathways could have a pivotal trigger effect [Lipid metabolism, the primary function of sebocytes, is also greatly altered both in quantity as well as in quality under inflammation as revealed with the analysis of sebum from patients with acne as well as other diseases , 38–40. r effect , 40.P. acnes has its specific role in acne pathogenesis not (only) via the TLR2 pathway but with its various products that could interact with the inflammatory pathways, which is definitely a challenging field for future studies [Altogether, the detected changes in the induced genes and their clustering allowed two major conclusions: i., sebocytes are able to rapidly gain an immune-competent status in response either to TLR1/2 and or TLR4 activation. The clustering data fully support that sebocytes are not simply lipid-metabolizing cells, but should also be challenged as inflammatory modulators in a wide spectrum of dermatological diseases beyond acne. ii., The detected inflammatory responses were neither TLR1/2- nor TLR4-specific, in other words sebocytes are not able to sense and respond selectively to the two stimuli of different origin. This finding gains its importance when put into the current concept of pathogen-related inflammation of acne lesions suggesting that various stimuli, in and around the pilosebaceous unit capable of activating the TLR2 and TLR4 pathways, might all be able to modulate the inflammatory status of the sebaceous glands. Therefore, it is more likely that  studies , 42.in vivo studies, sebocytes also stained strongly positive for SAA1/2 suggesting that they may as well contribute to the levels of SAA1/2 in the local tissue environment and perhaps even in the serum, which calls for further studies to assess it in acne patients. Besides being a strong chemoattractant, SAAs also transport cholesterol that immediately puts forward the question whether sebocyte-produced lipids may contribute not just to sebum but might also make their way to the circulation via SAA. The finding that SAA has also been identified as a danger signal that triggers activation and IL-1β secretion, a key cytokine in acne pathogenesis, sets altogether the basis for intriguing speculations on sebocyte derived SAA to be tested as a possible therapeutic target [Another important outcome of our study was the identification of SAA1/2 as a marker protein for activated sebocytes, which might not only be a marker but could have a role as well in various disease settings. SAA1/2 is predominantly produced by the liver and by adipocytes, in strong association with the body mass , while ic target . Importac target , suggestc target . Based oP. acnes–TLR2 pathway and to reveal the TLR2 independent effects of P. acnes as well, which could provide clues to understand the exclusive pathogenic features of P. acnes in the pathogenesis of acne. Moreover, we suggest that the different mechanisms that could regulate the levels of the TLR2 and 4 receptors, or interact with their signaling pathways [In summary, our findings confirm that human sebocytes, with a primary role to metabolize lipids, are able to rapidly acquire an immune-competent status when exposed to danger signals and this function is structurally defined within the sebaceous glands. Thus sebocytes may not just be at the end-point of inflammation but also contribute to disease development , 47–54. pathways , 25, 55 S1 FigProtein levels of IL-6 and CXCL-8 were measured by ELISA as described in Materials and Methods. One-way ANOVA and Dunnett post-hoc test were used in the data analyses (n = 3); * = p < 0.05, ** = p <0.01, *** = p <0.0001.(TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.S3 FigOil Red O staining revealed no changes in the lipid body formation of TLR1/2- and TLR4-activated sebocytes neither at 24-hour nor at 48-hour time points. Arachidonic acid (AA) treatment inducing lipid body formation both in numbers and size was used as a positive control. At least three independent samples were stained per each treatment.(TIF)Click here for additional data file.S1 TableNote the significant up-regulation in the expression levels of the cluster forming genes with the exception of ABCG1.(DOCX)Click here for additional data file.


So far, there is no published randomized clinical trial investigating the effectiveness of the adoption of AgNO3 solution and NaF varnish containing fTCP in arresting dentine caries in preschool children. The objective of this study is to compare the effectiveness of a 25% AgNO3 solution plus a 5% NaF varnish containing fTCP and a 25% AgNO3 solution plus a 5% NaF varnish in arresting coronal dentine caries among preschool children when applied semi-annually over a 30-month period.Dental caries in primary teeth is prevalent, affecting millions of children around the world. Functionalized tricalcium phosphate (fTCP) has been incorporated into sodium fluoride (NaF) varnish to enhance the remineralization process. NaF varnish with the adjunctive application of silver nitrate . Confounding factors, such as demographic background and oral hygiene behaviors, will be collected through a parental questionnaire.This is a randomized, double-blind controlled trial. The null hypothesis tested is that no difference exists between the effectiveness of a 25% AgNO3 solution followed by a 5% NaF varnish with fTCP in arresting coronal dentine caries among preschool children remains unknown. Because the proposed caries-arresting methods are simple, noninvasive and low cost, these can be widely recommended for caries control in young children.The effectiveness of the topical application of a 25% AgNONCT03423797 on 6 February 2018.ClinicalTrials.gov (U.S.): The online version of this article (10.1186/s13063-018-2741-1) contains supplementary material, which is available to authorized users. Dental caries in primary teeth is a common chronic disease in childhood. It has been ranked as the 12th most prevalent condition, affecting around 560 million children worldwide . These aResults of systematic reviews have suggested that the progression of dental caries could be slowed down or halted without operative procedures . The app3) and NaF with fTCP reduced the damage of dentine caries by cariogenic biofilm [To enhance the remineralization process, fTCP has been recently incorporated into NaF varnish. fTCP is a novel calcium phosphate system . Calcium biofilm . Althoug3 solution followed by application of NaF varnish has been advocated to improve caries-arrest effectiveness.Despite its caries-preventive effect, NaF varnish is ineffective at arresting coronal dentine caries . Adjunct3 solution has been used as an antimicrobial agent for years. However, the adoption of AgNO3 solution diminished because of the discovery of fluoride for caries management in the mid-nineteenth century [3 solution has strong antibacterial properties and NaF varnish has remineralizing properties, the application of AgNO3 solution followed by NaF varnish was reintroduced to manage caries in young children [3 solution followed by a 5% NaF varnish in remineralizing artificial dentine caries and inhibiting the degradation of collagen [3 solution followed by a 5% NaF varnish in arresting dentine caries among preschool children [AgNO century . Becausechildren . A retrochildren . Subsequcollagen . A 12-mochildren .3 solution and NaF varnish containing fTCP in arresting dentine caries in preschool children.So far, there is no published randomized clinical trial investigating the effectiveness of the adoption of AgNO3 solution in preschool children over 30 months. The secondary objective is to compare the effectiveness of a 5% NaF varnish with fTCP and that of a 5% NaF without fTCP in preventing dental caries in preschool children over 30 months.The objective of this randomized, double-blind controlled trial is to compare the caries-arresting effectiveness of a 5% NaF varnish with fTCP and that of a 5% NaF without fTCP when applied semi-annually following the application of a 25% AgNO3 solution in preschool children over 30 months.The null hypothesis is that there is no difference between the caries-arresting effectiveness of the semi-annual application of a 5% NaF varnish with fTCP and that of a 5% NaF without fTCP following the application of a 25% AgNOThis is a double-blind, two-armed, parallel-design randomized controlled trial. The Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 Statement will be followed in this trial  be generally healthy, (2) have written parental consent and (3) have at least one cavitated dentine carious lesion. The exclusion criteria are as follows: (1) children who are uncooperative or who refuse examination and (2) children who have major systemic illnesses or are on long-term medications. A tooth with pulpal exposure or with any signs and symptoms of irreversible pulpitis or a non-vital pulp, such as tooth discoloration, will be excluded.Oral examination and treatment will take place in kindergartens during school hours. An outreach dental team is comprised of dentists and research assistants. Prior to conducting the study, they will be trained by experienced specialists (ECML and CCH). A calibrated examiner will screen all children who have had parental consent given. After that, participants who meet the inclusion criteria will be recruited.Clinical examination of the children will be performed mainly through a careful visual inspection with the aid of a World Health Organization CPI probe  and a disposable dental mirror with an attached light-emitting diode for intra-oral illumination . Tooth status  scores), tooth mobility and tooth discoloration will be recorded. Caries will be diagnosed at the cavitation level. The visual-tactile assessment will be adopted to assess the status of carious lesions. They will be gently explored with a CPI probe in the centre of the lesion. Great care will be taken to avoid damaging the tooth. For the posterior teeth, all five surfaces  will be assessed, while four surfaces  of the anterior teeth will be examined.The oral hygiene status will be measured using the Visible Plaque Index (VPI). The buccal and lingual surfaces of six index teeth  will be examined. The presence or absence of visible plaque on the carious surface will also be recorded. No dental radiograph will be taken because this study will be conducted in a school-based setting.A trained dentist will perform the examinations (baseline and follow-ups) throughout the 30-month study. The intra-examiner agreement on the plaque and caries assessment will be performed in 10% of the children at each stage of the study.A parental questionnaire regarding each child’s oral hygiene, snacking habits, use of fluoride agents, dental-visit behavior, parental educational level and family monthly income will be administered at baseline and at 12-, 18- and 30-month follow-up visits. To assess the children’s oral-health-related quality of life, the translated and validated Chinese-language Early Childhood Oral Health Impact Scale (ECOHIS) will be adopted in the parental questionnaire. The questionnaires will also assess parental satisfaction with their child’s oral health and dental esthetics. In the follow-up questionnaire, parents of the study children will also be asked to report the post complications of assigned treatments, such as pain, from a treated tooth and gingival irritation around a treated tooth.Participating children with dental caries will be categorized into two strata by the number of carious surfaces they have (one to three or more than three tooth surfaces). The children will be then allocated by a stratified randomization method with a block size of 6 into two groups. The allocation sequence will be generated by a technician who will not be involved in the oral examination and patient allocation. A pile of sealed opaque envelopes with the allocation numbers will be prepared. Those envelopes will be held by a dental assistant in the field. The assistant will know the treatment allocation only when they open the envelope.Application of the assigned treatment will be carried out after the oral examination. Children’s compliance to fluoride treatment will be recorded and monitored at each treatment visit by an assistant. A double-blinding arrangement will be conducted in this clinical trial. One examiner will perform all the clinical examinations during the study period. The examiner will be blinded to the treatment allocation. The children and their parents also will not be informed of the treatment assignment. The solution and varnish will be applied by an independent operator after the oral examination.A dentist who is not involved in the assessment of the carious lesions will apply the solution and varnish with a micro-brush on the carious lesion according to the assigned treatment group after the oral examination.3 solution  followed by a 5% NaF varnish ,Group A: a 25% AgNO3 solution  followed by a 5% NaF varnish with fTCP .Group B: a 25% AgNOTwo intervention groups in this study are as follows:After applying the solution and varnish on the carious lesion(s) for arrest purposes, the assigned 5% NaF varnish (0.25 ml) will be applied on all tooth surfaces of each child to prevent dental caries according to their assigned treatment group. After the treatment, the children will be instructed not to eat or drink for 30 min. The intervention will be provided every 6 months.An individual report on the child’ s oral health status will be distributed to the parents or guardians with a note asking them to report to the study dentist if there are any adverse effects on the treated tooth and/or the surrounding gum and mucosa after treatment. A referral letter will be provided to seek the appropriate dental treatment if needed. Parents and teachers will be informed that if the treatment has successfully arrested the carious lesions, yellow and soft carious surfaces will become hard and black in color.Follow-up clinical examinations will be conducted semi-annually by the same examiner in kindergartens for 30 months. The same diagnostic criteria, equipment and clinical procedures that were used in the baseline examination will be adopted in the follow-up evaluations. The caries status (dmfs index) and oral health status (VPI) of the children will be recorded. In addition, the status of the carious surfaces included in the study at baseline examination and the presence of visible plaque on those carious surfaces will be assessed. Newly developed carious lesions will be recorded and treated with the assigned treatment intervention. The examiner will also look for related side/adverse effects, including blackening of the treated carious surfaces, discolored teeth, tooth mobility and abscess formation during the follow-up oral examinations. Reasons for tooth loss prior to follow-up will be recorded.Outcome measures will be collected at baseline and semi-annually thereafter for 30 months. The primary outcome measure of this study is the proportion of soft (active) carious surfaces that become hardened (arrested). Lesion activity will be assessed based on visual and tactile sensation. A lesion will be recorded as active if softness is detected upon gentle probing, and it will be classified as arrested caries if the lesion is hard , 24.The secondary outcome measure is the caries increment or the change in the dmfs score over time, which will be measured by a calibrated dental examiner who is masked to the group assignment. Visual and tactile inspection without x-rays will be adopted.β = 0.1) and a two-sided 95% confidence interval (α = 0.05) as the statistical significance level by using the G*Power Version 3.1.9.2 . Therefore, at least 820 active carious tooth surfaces need to be included, or 410 in each study group. Based on the results of epidemiological surveys, we anticipate that the mean number of active caries tooth surfaces of 3-year-old children in Hong Kong is approximately three [The results of previous clinical trials showed that around 70% of the active dentine caries became arrested after 30 months . The antly three . The intly three . Followily three , the desly three ; thus, 4The collected data will be entered into an Excel file by two persons separately, and the data will be proofread to minimize data-entry error. Data will be analyzed using the software SPSS 24.0 for Windows . The statistical significance level for all tests will be set at 0.05.An intra-examiner agreement in the diagnosis of dental caries will be assessed by Cohen’s Kappa statistics. An intention-to-treat analysis will be undertaken. The dropout rates of the two groups will be expected to be similar as the treatment protocols and treatment outcomes (arrested caries with blackening of the lesion) are similar.t test will be performed, as appropriate, to analyze the differences between the groups regarding the children’s demographic background, oral hygiene and baseline caries experience (dmfs score). A chi-square test will also be conducted to study the difference in dropout rates between groups during the follow-ups. A paired t test will be used to compare the changes in ECOHIS, while the McNemar test will be used to compare the changes in oral-health-related behaviors at baseline and follow-up examinations between the different groups. Although the distribution of data for the primary outcome may not be normal, making use of the central limit theorem with the relatively large sample size in this research, the distribution of the mean will be considered normal.A chi-square test and 3 and a 5% NaF varnish with or without fTCP in arresting dentine caries. A two-level model will be used: level 1, tooth surface level, and level 2, subject level. Multilevel logistic regression models with a clustering effect adjustment will be performed to analyze the effect of independent variables on the caries-arresting outcomes at the 12-, 18- and 30-month follow-ups. Besides treatment group assignment, other potential variables, such as demographic characteristics (sex and age), oral hygiene status, oral-health-related behaviors, level of parental education, family income, caries condition , also will be included in the model as covariates.Because more than one carious lesion may be included from one child, these lesions will possibly be correlated or clustered. Therefore, an adjustment of the clustering effect will be required. Multilevel logistic regression analysis will be adopted to assess the relative effectiveness of a 25% AgNOt test will be performed to assess the difference in the caries increment between the two groups at all follow-up examinations. Multilevel generalized linear models will be adopted to assess the effect of independent variables on the caries increment between two groups at 12, 18 and 30 months.The secondary outcome (preventive effect) is the mean of caries increment at the 6-, 12-, 18-, 24- and 30-month examinations. A paired Ethics approval was obtained from the Institutional Review Board of The University of Hong Kong/Hospital Authority Hong Kong West Cluster (HKU/HAHKWIRB) (IRB reference number: UW17–176). An information sheet about this study will be distributed to parents or legal guardians, and parental consent will be obtained prior to a child’s participation. Children and their parents/legal guardians maintain their rights to receive dental treatment by other dentists. From our previous experiences in conducting clinical trials , 18, mos3 solution followed by a 5% NaF varnish with/without fTCP among preschool children. The caries-preventive effect, parental satisfaction, changes in oral-health-related quality of life of the study children and the adverse effects of the two intervention groups also will be evaluated.This is a randomized, double-blind clinical trial aiming to investigate the caries-arresting effectiveness of the semi-annual application of a 25% AgNODue to the limitations of the study, the use of dental radiographs is unavailable and unsafe when conducting a trial in kindergartens , 24. The3 solution was developed [3 solution in preschool children.Although clinical trials have demonstrated that SDF is effective in arresting dentine caries in primary teeth, there was a significant increase of new caries development during the trials, as SDF is only applied on the existing cavitated lesions , 29. Howeveloped ; howevereveloped , 14–17, Because the proposed caries management method in this study is simple, noninvasive and low cost, it can be widely recommended and adopted for caries prevention and caries arrest in young children, children with special needs or those living in disadvantaged communities. The results of this study will be beneficial for clinicians and dental health policy-makers when adopting noninvasive approaches to tackle the burden of early childhood caries.ClinicalTrials.gov (U.S.) with the registration number NCT03423797  Checklist. (PDF 831 kb)Additional file 2:Parental Consent. (PDF 183 kb)Additional file 3:World Health Organization (WHO) Trial Registration Data Set. (PDF 365 kb)


The National Bariatric Surgery Registry (NBSR) is the largest bespoke database in the field in the United Kingdom.Our aim was to analyze the NBSR to determine whether the effects of obesity surgery on associated co-morbidities observed in small randomized controlled clinical trials could be replicated in a "real life" setting within U.K. healthcare.United Kingdom.All NBSR entries for operations between 2000 and 2015 with associated demographic and co-morbidity data were analyzed retrospectively.2. Over 5 years of follow-up, statistically significant reductions in the prevalence of type 2 diabetes, hypertension, dyslipidemia, sleep apnea, asthma, functional impairment, arthritis, and gastroesophageal reflux disease were observed. The "remission" of these co-morbidities was evident 1 year postoperatively and reached a plateau 2 to 5 years after surgery. Obesity surgery was particularly effective on functional impairment and diabetes, almost doubling the proportion of patients able to climb 3 flights of stairs and halving the proportion of patients with diabetes related hyperglycemia compared with preoperatively. Surgery was safe with a morbidity of 3.1% and in-hospital mortality of .07% and a reduced median inpatient stay of 2 days, despite an increasingly sick patient population.A total of 50,782 entries were analyzed. The patients were predominantly female (78%) and white European with a mean age of 45 ± 11 years and a mean body mass index of 48 ± 8 kg/mObesity surgery in the U.K. results not only in weight loss, but also in substantial improvements in obesity-related co-morbidities. Appropriate support and funding will help improve the quality of the NBSR data set even further, thus enabling its use to inform healthcare policy. The increasing prevalence of obesity in the United Kingdom (U.K.) is well known and remains depressing. It is less well recognized that body mass index (BMI) on its own is a poor predictor of disease burden at the individual level and of mortality at the population level Large case-control studies and randomized controlled trials (RCTs) have shown that bariatric surgery reduces obesity-related morbidity and/or mortality from conditions such as cancer The uptake of obesity surgery in the U.K. has been slower and more cautious compared with other parts of the world. In an attempt to collect data on disease burden of the operated population and to increase the openness and transparency of surgery outcomes, the British Obesity and Metabolic Surgery Society in collaboration with the Association of Laparoscopic Surgeons of Great Britain and Ireland and the Association of Upper Gastrointestinal Surgeons and in partnership with Dendrite Clinical Systems Limited launched the National Bariatric Surgery Registry (NBSR) in January 2009. It became mandatory to submit National Health Service (NHS) England data to the NBSR and publish surgeon-level outcomes in 2013. Unlike the NBSR, independently collected Hospital Episode Statistics or community databases do not collect systematic data on patient demographic characteristics or disease burden. Our aim was to determine whether the effects of obesity surgery on associated co-morbidities from RCTs could be replicated in a “real life” setting within the U.K. health service. We extracted data entries from the NBSR to examine the disease burden of 50,782 patients and the effects of obesity surgery on related co-morbidities up to 5 years postoperatively.N3 network. Surgeons performed most data entry, with some by specialist nurses/dieticians and obesity physicians. Two hundred six surgeons from 159 hospitals contributed to the current data set. Patient consent was not obtained because these were routinely generated clinical data. All entries are anonymized to comply with the data governance regulations, and data collection for this analysis was performed in compliance with the Declaration of Helsinki.The first 3756 entries in the NBSR (7.4%) from year 2000 to 2008 were entered retrospectively, and all entries from February 2, 2008 to January 12, 2015 were entered prospectively and analyzed retrospectively. The NBSR software is a bespoke web registry application built by Dendrite Clinical Systems using their Intellect Web proprietary software, hosted on a secure server within the NHSNet The variables used in the analysis include baseline demographic data , weight, height, BMI, Edmonton Obesity Staging System (EOSS), and obesity-related co-morbidities  and changes in their prevalence over the 5-year follow-up , Table 2The vast majority of variables were recorded in a categorical manner. No standardized clinical definitions or laboratory ranges were used to define obesity-related co-morbidities; therefore, all entries were dependent on the judgment of the clinician submitting the data. Follow-up appointments were done at variable points, and therefore to standardize time-interval reporting only the closest data entry to the specific time points was included and all additional entries were excluded from the analysis. Complications, including death and reoperation, were recorded during the inpatient stay, within 30 days or at any time after surgery.To systematically identify erroneous entries , the robust regression and outlier removal method was applied. The robust nonlinear regression method was used to fit a curve not influenced by outliers, and the residuals of the robust fit then were analyzed to identify outliers. These were subsequently removed, and an ordinary least-squares regression on the remaining data was performed. The Q value, which determines how sensitively the potential erroneous entries are identified, was set to 10%.2 test with Yates’ continuity correction. Longitudinal continuous data were analyzed with a repeated measures one-way analysis of the variance with Dunnett’s correction for multiple comparisons. Sensitivity analysis was conducted to assess the impact of missing data, using the primary analysis methods, but under alternative missing data assumptions. Statistical significance was defined as P<.05.GraphPad Prism version 7 , was used for statistical analysis. Data are presented as absolute values, percentages, mean ± standard deviation, or median (25th–75th percentile). D’Agostino-Pearson Omnibus normality test was used to assess normality distribution. Nonnormally distributed continuous variables were compared over time using the Kruskal-Wallis test. Postbaseline categorical variables were compared with baseline values using the χP<.001). The distribution of EOSS scores over 15 years is shown in From February 2000 to December 2015, 50,782 procedures were recorded in the NBSR. The cohort consisted predominantly of middle-aged female patients of Caucasian ethnic background . The comOver the 5-year follow-up, statistically significant reductions were observed in the prevalence of T2D , hyperteThe most rapid weight loss took place during the first year after surgery and reached a nadir of 30 ± 12% total weight loss at 2 years. This was followed by weight regain and 24 ± 13% total weight loss at 5 years .Fig. 4WeThe most commonly performed operation was Roux-en-Y gastric bypass , followed by vertical sleeve gastrectomy  and gastric banding 19.7%; . Over thRecorded postoperative cardiovascular complications, such as dysrhythmia or myocardial infarction, were recorded in 0.3% patients. The total postoperative complications rate was reported as 3.1%, the most common being vomiting/poor oral intake . RecordeAt baseline, the domain with the highest rates of incomplete entries (17.4%) was gastroesophageal reflux disease, followed by PCOS/infertility (16.8%). Data entry for all health outcomes decreased substantially after the first postoperative year . The priUsing real-life data, we found that surgery reduces weight and improves health. Obesity-related physical and functional conditions were either ameliorated or even entered “remission” within 1 year after surgery, and this effect was durable at 5 years. These health benefits were achieved in the context of an increasingly “sick” patient population, with a reduction in the length of inpatient stay and with low rates of surgery-related morbidity and mortality.The most striking improvements were observed in patients with impaired functional status or T2D at baseline with “resolution” in 58% and 52%, respectively, at 1 year postoperatively. The proportion of patients who could climb only half a flight of stairs at baseline reduced from 19% to 8% 1 year after surgery. Obese patients have higher rates of unemployment compared with normal weight individuals and functional impairment is one of the major contributors. Studies from the United Kingdom and other European countries demonstrated that 14 months after obesity surgery patients’ paid working hours increased by 57% and state benefit claims decreased by 75% Patients with T2D experience rapid improvements in blood glucose, and 48% have no reported indication of diabetes within 1 year after obesity surgery. This has been shown to translate to less medication usage, fewer capillary glucose testing strips, fewer hospital encounters The surprising lack of an effect on PCOS/infertility is contrary to the published literature Choice of surgery is somewhat different to that reported worldwide. In both the IFSO Global Registry 2017 and NBSR, RYGB is the most commonly performed procedure, constituting 46.3% of all operations as per IFSO records and 51.4% in the NBSR. However, reported numbers of VSG worldwide are almost as high as the RYGB (43.6%), while in the United Kingdom only 1 in 5 bariatric procedures was VSG. Gastric band numbers differ even further with only 6% by IFSO and 19.7% by the NBSR. Some variations in the proportion of each procedure can be explained by the fact that the latest IFSO Registry covers 2013 to 2017; the U.K. data presented here cover 15 years before 2015, and these are the years when VSG was gaining popularity and the gastric band procedure was declining. Furthermore, there are clear region-based trends regarding the procedure performed. European surgery preferences are similar to the United Kingdom, whereas Australasia, Central and South America, as well as the Middle East present VSG as their procedure of choice.Performing obesity surgery in dedicated bariatric centers, along with use of laparoscopic techniques, enables low mortality and morbidity rates and short postoperative stays to be achieved. Even if there is underreporting of complications and postoperative deaths , the 0.07% mortality and overall 2.6% complication rate rank obesity surgery as one of the safest major elective surgical procedures. The low in-hospital mortality reported in the NBSR is consistent with the Hospital Episode Statistics mortality data collected in the NHS in England 2. More RCTs were thus able to be included in their analyses, leading to lowering of the BMI eligibility criteria for surgery to 30 kg/m2The major benefit of the NBSR is that its real-life data complement the findings of RCTs of much smaller sample size. If combined appropriately with other large data sets, “big data” can provide invaluable information in terms of patient prioritization for surgery, personalization of treatment, and health economic analyses. An additional benefit is that the NBSR has already changed healthcare policy in the United Kingdom. In the context of limited available evidence from relevant RCTs on the benefits of surgery on patients with T2D duration of<2 years, the National Institute of Healthcare Excellence examined the NBSR data, which showed that being underinclusive would exclude approximately 75% of eligible patients receiving bariatric surgery. As a result, National Institute of Healthcare Excellence extended the definition of recent-onset T2D to include patients with disease duration of 10 years and a BMI of 30 to 35 kg/m2 and therefore financially favorable The NBSR data set does not allow health economic analyses to be generated. However, the Health Technology Assessment program has already demonstrated that the incremental cost-effectiveness ratio per quality adjusted life year of obesity surgery was between £2000 and £4000 for a patient with a BMI ≥40 kg/mThe major limitation of the NBSR is sparse record of follow-up after 2 postoperative years. NHS England commissions surgical providers for 2 years of follow-up, with further follow-up in primary care after this. There is currently no mechanism to capture data from primary care in the registry After a comparison of baseline characteristics between those unobserved and observed at 1 and 5 years the Missing Completely at Random assumption was considered most plausible for the missing data in the analysis. However, as operating surgeons enter most of the data, it cannot be ruled out that there may be an underreporting bias for operative complications (excluding death) and an overreporting bias for the positive outcomes of surgery. The small proportion of retrospective entries between 2000 and 2008 is vulnerable to this bias. Also, the early or late complications of patients attending a unit other than the one at which they had surgery would not be captured. In addition, the data set does not contain specific fields for postoperative gallstone disease or internal hernias.The NBSR did not standardize definitions of specific diagnoses  and did not include continuous data , imaging, and other clinical investigation results or detailed medication usage. Therefore, all entries were dependent on the judgment of the clinician submitting the data, not necessarily on robust disease diagnosis and remission criteria. The data set did not contain other clinically important variables . The data set was chosen as a balance between collecting too much data (risking poor engagement and incomplete records) and collecting too little data to generate meaningful analysis. These limitations could potentially be overcome in the future through consensus on clinical definitions, inclusion of patient identifiable information, and infrastructure to collect follow-up data from primary care.The NBSR data demonstrate on a large scale that obesity surgery leads to weight loss and substantial improvements in obesity-related co-morbidities. Patients become healthier and more functional. Surgery is safe despite the patients having more obesity-related disease over time. Appropriate support and funding will help improve the quality of the NBSR data set even further, thus potentially increasing its effect on healthcare policy.The authors have no commercial associations that might be a conflict of interest in relation to this article.


Background Coeliac disease affects 1% of the population, but 75% remain undiagnosed. Objective To conduct a case finding feasibility and efficacy study for the detection of coeliac disease in community pharmacies. Setting Six community pharmacies across Sheffield, UK. Method A prospective study was performed using a point of care test, Simtomax® (IgA/IgG-deamidated gliadin peptide) (C-test) in pharmacies. Pharmacy customers with symptoms suggestive of or risk factors for coeliac disease were tested with the C-test. Positive individuals were referred for a gastroscopy with duodenal biopsies alongside conventional serology. People with known coeliac disease, those on a gluten free diet or those who were investigated for coeliac disease were excluded. Main outcome measure The case detection rate and the uptake rate of the C-test and gastroscopies. Results Five-hundred participants fulfilled the inclusion criteria and were tested with the C-test . The C-test uptake rate was 63%, and the positive rate was 7.2% (36/500). Twenty-seven positive participants (75%) underwent further investigations, confirming three new cases of coeliac disease (0.6%). Conclusion It was feasible to use the C-test as a case finding tool in pharmacies. There was good uptake for the C-test, although the case detection rate and the test specificity were low. Based on this, the C-test has a limited role in case finding in a community pharmacy setting. The use of the C-test as a case finding tool in community pharmacies in the UK is practically feasible with a good uptake rate from pharmacy customers.The case detection rate of the C-test in practice is relatively low at 0.6%. Additionally, the false positive rate is high at 89.9%, meaning that approximately only 1 in 10 individuals with a positive C-test will have have coeliac disease after further investigations.Case finding with the use of the C-test in the community pharmacy setting is not recommended, in view of the properties of the test.Coeliac disease is a systemic autoimmune disease associated with gastrointestinal and extra-gastrointestinal symptoms, triggered by gluten in genetically susceptible individuals affecting approximately 1% of the general population worldwide based on population screening studies . One of There has been an increased recognition of the changing presentation of coeliac disease in the past two decades, from the classical symptoms of diarrhoea and weight loss to the more commonly seen non-classical features such as fatigue and anaemia –10. ThesThus there has been a drive to screen for coeliac disease in at risk individuals in primary care. Previous primary care case finding studies have shown improved case detection rates through serological screening in high risk patients, with a coeliac disease detection rate of approximately 2–3% –13. A reDespite national serological screening guidelines, it appears that clinicians do not uniformly follow this practice. This was demonstrated in our multicentre study in the UK, where only 30% of anaemic patients had serology performed prior to their gastroscopies . This re®1 (C-test), had comparable diagnostic performance to conventional serology  [This necessitates an alternative approach to improve case detection. Community pharmacies could potentially provide a unique opportunity to recognise undiagnosed coeliac disease in primary care with the help of community pharmacists. It has previously been shown the deamidated gliadin peptide (DGP) based point of care test, Simtomaxibodies) . This fiWe aimed to evaluate the role of the C-test for the detection of coeliac disease in at risk or symptomatic individuals in a primary care community setting. The primary outcome measure was the coeliac disease detection rate. Secondary outcomes included the uptake rate of the C-test and subsequent gastroscopy with duodenal biopsies.The study protocol was approved by the Yorkshire and the Humber Research Ethics committee and registered with the local research and development department of Sheffield Teaching Hospital NHS Foundation Trust under the registration number STH19172. Written consent was obtained from all individual participants included in the study.A prospective case finding study was conducted in six community pharmacies across the city of Sheffield  over a 4-month period. Customers entering the pharmacies with symptoms or risk factors for coeliac disease indicated for coeliac screening by the National Institute of Clinical Excellence (NICE) were approached  manufactured by Augurix Diagnostics, Rheinfelden, Switzerland. It detects both IgA- and IgG-deamidated gliadin peptide (DGP), as well as the presence of IgA. The assay is based on lateral flow immunochromatography using colloidal gold antihuman antibodies as a signal detector. A sample of 25 μl of capillary venous blood was obtained through a simple finger prick technique. The blood sample was then applied to the test device, followed by the application of five drops of the provided buffer solution. The result was available after 10 min. Positive results were indicated by the presence of a solid red test line for IgA-DGP and/or IgG-DGP positivity. A second single red line indicated the presence of IgA. An in-built red control line ensured a correctly functioning test.SimtomaxIgA-tissue transglutaminase (TTG) antibodies were assayed using enzyme-linked immunosorbent assay (ELISA) kits . A TTG titre of > 7 U/ml was regarded as positive as per the manufacturer’s guidance. IgA-EMA was detected by immunofluorescence on primate oesophagus sections . Total IgA was measured on a Behring BN2 nephelometer .In total, at least five biopsies were taken from the duodenum with a single bite per pass technique, including at least one biopsy from the duodenal bulb and four quadrantic biopsies from the second part of the duodenum. Each biopsy was fixed in formalin at the time of the gastroscopy. Specimens were then processed, orientated and embedded in paraffin wax by the pathology department. Standard 3 μm thick sections at three levels were stained with haematoxylin and eosin, and reported by gastrointestinal histopathologists without knowledge of the C-test or serology results. Villous atrophy was graded according to the modified Marsh criteria.The definition of coeliac disease was based on positive serology (positive TTG and/or EMA) with Marsh 3 histology. Potential coeliac disease was defined as positive serology with no villous atrophy (Marsh 0–2). Supporting information such as human leucocyte antigen genotype, family history and response to a gluten free diet were taken into account.Data were summarised by descriptive statistics, including counts and percentages for categorical data, and medians and ranges for continuous parameters. The statistics department of the University of Sheffield was consulted for the sample size. We anticipated a 3% case detection rate in our cohort based on previous primary care case finding studies. Using an exact binomial test, a sample size of 500 would have 88% power to detect the difference between the estimated 3% prevalence in the study cohort and the estimated 1% prevalence of coeliac disease in the general population.Eight hundred and two pharmacy customers were approached for the study. Eight individuals (1.1%) who were approached already had a coeliac disease diagnosis and were therefore excluded. Five hundred individuals met the eligibility criteria and agreed to undertake the C-test at the pharmacies and further investigations if they were tested positive, giving a C-test uptake rate of 63% (500/794). There were 369 females (73.8%), and the age range was 18-87 (median age 49). Thirty-six participants (36/500 = 7.2%) were tested positive, of which 27 (75%) subsequently underwent further evaluation with conventional serology and a gastroscopy with duodenal biopsies. Of the remaining nine positive participants who did not have further investigations, seven participants changed their mind at the pharmacy and declined further investigations, one participant wanted time to consider further tests and eventually declined a gastroscopy, and one agreed to further tests but did not attend for the gastroscopy appointment and subsequently declined further tests over follow up phone call. Two participants were diagnosed with coeliac disease based on positive serology and Marsh 3 villous atrophy, and one was diagnosed with potential coeliac disease based on gluten related symptoms and positive serology without villous atrophy. The patient with potential coeliac disease was commenced on a gluten free diet in view of her gluten related symptoms. Excluding the nine patients who did not have gastroscopies to confirm the diagnosis, the coeliac disease prevalence was 0.6% (3/491) including the latter patient with potential coeliac disease. Table This is the first study to demonstrate both the feasibility and efficacy of using the C-test in community pharmacies for the detection of coeliac disease. Allied health care professionals are an asset for supporting and relieving the workload of clinicians. The aim of offering the C-test to at risk individuals at community pharmacies was to increase the detection of coeliac disease and reduce delays in diagnosis as an alternative approach in primary care.In this study we have shown that there was a good response from pharmacy customers in regards to the uptake rate of the C-test and subsequent further investigations as required. The positive C-test rate was 7.2%, which was similar to the 9.4% positive rate from the previous proof of concept study using the C-test in pharmacies by Urwin et al. , althougThe coeliac disease detection rate of 0.6% in our study was however much lower than anticipated. There are several possible reasons for this. One of the reasons could be because the existing caseload of coeliac disease is higher than average due to the presence of our tertiary referral centre for coeliac disease in Sheffield, and the heightened awareness for active coeliac testing by local general practitioners because of that. During the recruitment period, eight pharmacy customers approached for the study already had a known diagnosis of coeliac disease, giving a 1.1% known coeliac disease prevalence among the 802 individuals approached, which is higher than the UK average detected prevalence . ConductAlthough this study was not designed to assess the diagnostic accuracy of the C-test, it was observed that the false positive rate was very high when used in the pharmacy setting. Of the 27 customers with a positive C-test who all underwent further diagnostic testing, only three were found to have coeliac disease, giving a false positive rate of 88.9%. Based on the low specificity of this test when used in the community, the C-test cannot be recommended to be used as a case finding tool in the pharmacy setting due to the high number of positive individuals who would be subjected to unnecessary further investigations.We demonstrated the feasibility of using the C-test for the detection of coeliac disease in the primary care sector in community pharmacies. Although there was good uptake for undertaking the C-test among pharmacy customers, the coeliac disease yield was much lower than anticipated. The C-test did not increase case detection as estimated, therefore it may have a limited role as a case finding tool in a community pharmacy setting.