Positive HLA‐B27 and sacroiliitis is not always spondyloarthritis

A 36‐year‐old man was treated for several years with multiple agents for ankylosing spondylitis based on positive human leukocyte antigen‐B27 and sacroiliitis. He was also diagnosed with osteoporosis and hypophosphatemia. Over these years, from being an avid runner, he became dependent on a walker for ambulation. The lack of treatment response and the low phosphorus were clues that eventually led to a diagnosis of tumor‐induced osteomalacia. This case discusses the importance of not solely relying on genetic markers and sacroiliitis for diagnosing ankylosing spondylitis as other conditions can cause similar presentations.     

The journeys of three ASPIRE winning medical schools toward excellence in student assessment

Abstract

Introduction: ASPIRE Excellence Awards in Student Assessment are offered to medical schools with innovative and comprehensive assessment programmes adjudged by international experts, using evidence-based criteria.

The journeys of three ASPIRE-winning medical schools toward “assessment excellence” are presented. These schools include Aga Khan University Medical College (AKU-MC), Pakistan, Southern Illinois University School of Medicine (SIUSOM), USA, and University of Leeds School of Medicine, UK.

Methods: The unfolding journeys highlighting achievements, innovations, and essential components of each assessment programme were compared to identify differences and commonalities.

Results: Cultural contextual differences included developed-versus-developing country, east-west, type of regulatory bodies, and institutional-versus-national certifying/licensing examinations, which influence curricula and assessments.

In all, 12 essential commonalities were found: alignment with institutional vision; sustained assessment leadership; stakeholder engagement; communication between curriculum and assessment; assessment-for-learning and feedback; longitudinal student profiling of outcome achievement; assessment rigor and robustness; 360° feedback from-and-to assessment; continuous enrichment through rigorous quality assurance; societal sensitivity; influencing others; and a “wow factor.”

Conclusions: Although the journeys of the three medical schools were undertaken in different cultural contexts, similar core components highlight strong foundations in student assessment. The journeys continue as assessment programmes remain dynamic and measurement science expands. This article may be helpful to other institutions pursuing excellence in assessment.     

Comparison of outcomes between minimally invasive and median sternotomy for double and triple valve surgery: A meta-analysis

Background

Limited data exists demonstrating the efficacy of minimally invasive surgery (MIS) compared to median sternotomy (MS) for multiple valvular disease (MVD). This systematic review and meta-analysis aims to compare operative and peri-operative outcomes of MIS vs MS in MVD.

Methods

PubMed, Ovid, and Embase were searched from inception until August 2019 for randomized and observational studies comparing MIS and MS in patients with MVD. Clinical outcomes of intra- and postoperative times, reoperation for bleeding and surgical site infection were evaluated.

Results

Five observational studies comparing 340 MIS vs 414 MS patients were eligible for qualitative and quantitative review. The quality of evidence assessed using the Newcastle-Ottawa scale was good for all included studies. Meta-analysis demonstrated increased cardiopulmonary bypass time for MIS patients (weighted mean difference [WMD], 0.487; 95% confidence interval [CI], 0.365-0.608; P < .0001). Similarly, aortic cross-clamp time was longer in patients undergoing MIS (WMD, 0.632; 95% CI, 0.509-0.755; P < .0001). No differences were found in operative mortality, reoperation for bleeding, surgical site infection, or hospital stay.

Conclusions

MIS for MVD have similar short-term outcomes compared to MS. This adds value to the use of minimally invasive methods for multivalvular surgery, despite conferring longer operative times. However, the paucity in literature and learning curve associated with MIS warrants further evidence, ideally randomized control trials, to support these findings.

     

Whole Salivary Interleukin‐6 and Matrix Metalloproteinase‐8 Levels in Patients With Chronic Periodontitis With and Without Prediabetes

Background: The cytokine profile in unstimulated whole saliva (UWS) of patients with prediabetes and chronic periodontitis (CP) remains uninvestigated. The aim of this study is to assess interleukin (IL)‐6 and matrix metalloproteinase (MMP)‐8 levels in UWS of patients with CP with and without prediabetes. Methods: Eighty‐eight males (aged 39 to 51 years) were divided into three groups: group 1: 28 patients with CP and prediabetes; group 2: 30 patients with CP and without prediabetes; and group 3: 30 controls. Fasting blood glucose (FBG) and hemoglobin A1c (HbA1c) levels, periodontal parameters (plaque index, bleeding on probing, probing depth, attachment loss, and marginal bone loss), and number of missing teeth were recorded. UWS samples were collected, and UWS flow rate (UWSFR) was measured. IL‐6 and MMP‐8 were measured in UWS using enzyme‐linked immunosorbent assay. P values <0.05 were considered statistically significant. Results: Mean FBG and HbA1c levels were significantly higher in group 1 (119.3 ± 3.1 mg/dL and 6.1% ± 0.2%) than group 2 (80.1 ± 3.5 mg/dL and 4.8% ± 0.5%; P <0.001) and group 3 (75.3 ± 2.2 mg/dL and 4.3% ± 0.2%; P <0.05). UWSFR was significantly higher in groups 2 (0.53 ± 0.1 mL/minute; P <0.05) and 3 (0.51 ± 0.1 mL/minute; P <0.01) than group 1 (0.33 ± 0.05 mL/minute). Periodontal parameters were worse in group 1 (P <0.05) and group 2 (P <0.05) than group 3. There was no difference in periodontal parameters, numbers of missing teeth, or salivary IL‐6 and MMP‐8 levels between patients in groups 1 and 2. Conclusion: Salivary IL‐6 and MMP‐8 levels are elevated in patients with CP with and without prediabetes.     

Effect of Glycemic Control on Self‐Perceived Oral Health,Periodontal Parameters,and Alveolar Bone Loss Among Patients With Prediabetes

Background: The effect of glycemic control on severity of periodontal inflammatory parameters in patients with prediabetes is unknown. The aim of the present study is to assess the effects of glycemic control on self‐perceived oral health, periodontal parameters, and marginal bone loss (MBL) in patients with prediabetes. Methods: A total of 303 individuals were included. Hemoglobin A1c (HbA1c) and fasting blood glucose levels (FBGLs) were recorded. Participants were divided into three groups: 1) group A: 75 patients with prediabetes (FBGLs = 100 to 125 mg/dL [HbA1c ≥5%]); 2) group B: 78 individuals previously considered prediabetic but having FBGLs <100 mg/dL (HbA1c <5%) resulting from dietary control; and 3) control group: 150 medically healthy individuals. Self‐perceived oral health, socioeconomic status, and education status were determined using a questionnaire. Plaque index (PI), bleeding on probing (BOP), probing depth (PD), and clinical attachment loss (AL) were recorded. Premolar and molar MBLs were measured on panoramic radiographs. Results: Periodontal parameters (PI, BOP, PD, and AL) (P <0.01) and MBL (P <0.01) were worse among individuals in group A than those in group B. Self‐perceived gingival bleeding (P <0.001), pain on chewing (P <0.001), dry mouth (P <0.001), and oral burning sensations (P <0.05) were worse among patients in group A than those in group B. There was no difference in periodontal parameters, MBL, and self‐perceived oral symptoms among patients with prediabetes in group B and healthy controls. Conclusions: Self‐perceived oral health, severity of periodontal parameters, and MBL are worse in patients with prediabetes than controls. Glycemic control significantly reduces the severity of these parameters as well as the state of prediabetes in affected individuals.     

Efficacy of systemic bisphosphonate delivery on osseointegration of implants under osteoporotic conditions: Lessons from animal studies

Background

The aim was to systematically review the role of systemic bisphosphonate (BP) delivery on osseointegration of implants under osteoporotic conditions.

Methods

The addressed focused question was “Does systemic BP delivery enhance osseointegration of implants under osteoporotic conditions?” PubMed/MEDLINE and Google-Scholar databases were searched from 1994 up to and including December 2013 using different combinations of the following keywords: “bone to implant contact”, “implant”, “bisphosphonate”, “osseointegration” and “osteoporosis”. Review articles, case-reports, commentaries, letters to the Editor, unpublished articles and articles published in languages other than English were excluded.

Results

Fifteen animal studies fulfilled our eligibility criteria. Osteoporotic conditions were induced via bilateral ovariectomy (OVX). BPs used in the studies were ibandronate, zoledronic acid and alendronate. Results from 12 studies showed that systemic BP delivery significantly increased bone volume and bone-to-implant contact under osteoporotic conditions. Two studies reported no significant difference in osseointegration among OVX animals with and without systemic BP delivery. In one study, systemic BP delivery negatively influenced implant osseointegration. Rough-surfaced and polished implants were used in 11 and one study respectively. In 3 studies implant surface characteristics remained unclear.

Conclusion

Within the limits of the present study, it is concluded that systemic BP delivery enhances implant osseointegration in animals with induced osteoporotic conditions. However, in a clinical scenario, the potential risk of BP related ONJ in osteoporotic patients undergoing dental implant therapy cannot be disregarded.     

Allergic rhinitis and its pharmacology

The pathophysiology of allergic rhinitis and its drug treatment is reviewed. Special emphasis is placed upon potential new treatments. Allergic rhinitis is characterized by allergen(s), symptoms (sneezing, itching, rhinorrhea, nasal congestion and nasal hypersensitivity), and signs such as invasion of nasal mucosa by inflammatory cells. Such pathological changes are due to inflammatory responses mediated by way of allergen-immunoglobulin E (IgE)-cell complex formation. The complexity of the disease and the multiple pathways involved offer many targets for drug treatment, but to date no single drug is totally effective. This review summarizes the current knowledge of allergic rhinitis, its prevalence, pathophysiology and experimental and clinical treatments. In the search for new drugs, different experimental animal models of allergic rhinitis are required. As a result the models have also been reviewed. Furthermore, particular aspects of the pathophysiology of allergic rhinitis are discussed in greater detail including the immune cells involved in the mediation of the disease, chemical mediators, their actions, and the receptors on which they act. Therapy, particularly that with current drugs, targets many of the known mediators and some of the cellular processes with varying success. Other drugs, for example, vasoconstrictors given to reduce rhinorrhea, provide symptomatic relief by counteracting symptoms. Since the incidence of allergic rhinitis is prevalent and growing in many parts of the world and current treatments are not ideal, it is important to continue to study the pharmacology of this disease as part of a search for better drugs.