Objective: Medical and dental providers are not addressing prenatal oral health (POH) with patients despite knowledge of the risks. The objective of this study was to determine how training in dental schools and OB/Gyn residencies may contribute to this paradox.

Methods: We conducted a national survey of 60 dental school deans and 240 obstetrics and gynecology residency program directors. Questions assessed the number of hours of POH education, topics addressed, awareness of guidelines, and barriers to including more POH training.

Results: Response rates were 53% and 40% for dental schools and OB/Gyn residencies, respectively. 94% of dental schools provide some POH education, with 61% of schools offering 3+ hours. Only 39% of OB/Gyn residencies provide some POH education, most only 1-2 hours. 65% of dental programs and 45% of OB/Gyn residencies are aware of current POH evidence-based guidelines. Those OB/Gyn residency programs with POH training were three times as likely to expose their residents to these guidelines. A similar trend was observed for dental schools. Barriers to POH education include space in the curriculum and competing clinical priorities. 76% of OB/Gyn directors affirmed the importance of addressing oral health needs among prenatal patients; however, only 23% agreed that the ACGME should add POH competencies. The majority of respondents agreed they would add more POH education if the American College of Obstetrics and Gynecology issued a policy statement or practice bulletin.

Conclusions: The majority of dental schools teach POH but clinical exposure is limited. Less than half of OB/Gyn residencies include POH training. Future efforts should include distribution of POH guidelines/consensus statements to educators and learners, increasing exposure of dental students to pregnant patients, and developing faculty expertise in residencies.

Purpose: The purpose of this study was to determine whether there is a difference in gene expression in epicardial fat of patients with and without coronary artery disease and if there is a difference, whether these differentially expressed genes participate in the inflammatory pathways.

Methods: EAT and paired subcutaneous adipose tissue (SAT) samples collected from cardiac surgery patients with and without coronary disease were fixed for microscopy and frozen for RNA extraction. RNA was hybridized to Affymetrix Human Gene 1.0 ST chips. We used an unbiased approach to identify genes highly and differentially expressed in EAT vs. SAT (FC>3.0). The probe intensities for these resultant genes were then correlated with the severity of atherosclerosis in each patient as determined by the Gensini score.

Results: 35 genes were differentially expressed in EAT at >3.0 fold change (p<0.05). Of these, 14 genes were significantly correlated with the degree of atherosclerosis, quantified by Gensini score. Integrin αvβ8 (ITGB8) and transglutaminase 2 (TGM2) were both more highly expressed in EAT than in SAT (p<0.009) for all patients. Expression of ITGB8 had the strongest positive correlation (r=0.94, p<0.01), while TGM2 had the strongest negative correlation (r=-0.80, p<0.01) (Fig. 1). Importantly, expression of neither ITGB8 nor TG2 in SAT correlated with the extent of atherosclerosis.

Conclusions: Using an unbiased whole genome approach, we identified ITGB8 and TG2 as genes whose expression is correlated with CAD severity. ITGB8 has been previously shown to be expressed by fibroblasts and functions to activate TGFβ. TGFβ signaling has also been correlated with advanced atherosclerosis. We speculate that EAT expression of ITGB8 may have pro-inflammatory effects, possibly by activating TGFβ, and stimulating recruitment of dendritic cells or T cells to secondary lymphoid organs in EAT. Whether or not this is the case is a goal of future studies.

Purpose: The purpose of this study was to evaluate the intraoperative, postoperative, and total opioid consumption of patients undergoing total hip and knee replacements in an effort to develop a multi-modal approach to decrease opioid consumption, minimize adverse effects secondary to narcotic administration, and to achieve better pain control. This MMA was achieved by administering oxycodone, gabapentin, celecoxib, and acetaminophen starting before surgical incision.

Methods: The study sample consisted of 192 patients undergoing total hip and knee replacements over a 10-month period between June 2012 and March 2013 at UMASS Memorial performed by five orthopedic surgeons. The main objective was to record intraoperative, postoperative, total opioid consumption, and patient satisfaction amongst these patients. Furthermore, the patients were subdivided based on the type of procedure (hip vs knee), type of anesthetic (general vs spinal), and the presence or absence of an indwelling catheter to deliver anesthetic (catheter vs no catheter).

Results: The data showed a large variability among the surgeons in regards to the amount of opioid used intraoperatively, postoperatively and total opioid consumption. In terms of type of anesthetic, the patients undergoing spinal anesthesia used statistically significantly less opioids intraoperatively but not postoperatively, compared to general anesthesia. As for catheter use with general and spinal anesthesia, surprisingly, there was no significant difference in opioid consumption compared to the non-catheter counterpart. Furthermore, there seems to be no correlation between body mass index (BMI) and intraoperative or postoperative opioid use. Patient satisfaction was another variable that showed no correlation with opioid use intraoperatively or postoperatively. In terms of age, the data suggests that older patients use less opioids postoperatively in both hip and knee replacements.

Conclusions: Our results quantitatively show spinal anesthesia to be far superior than general anesthesia in both joint replacements. Spinal anesthesia provides better pain control intraoperatively which allows one to use less opioids, thereby minimizing the adverse side effects of narcotic administration which include respiratory depression, urinary retention, nausea and post-operative ileus to name just a few. One surgeon’s patients required significantly less opioids intraoperatively compared to the rest of the surgeons. Further studies might warrant examining this surgeon’s technique or the demographics of his patient population to determine how better pain control and less opioid consumption could be achieved across all joints with all participating surgeons.

Objectives: We proposed to study historic trends in the IMR of the city of Worcester, MA, the second largest city in New England with a population of 181,045 (census 2010), over a 100 year period. We evaluated trends in the overall infant mortality rate as well as by specific causes of death. We further looked at known changes in medical innovation as well as community living conditions that may have had an effect on these rates.

Methods: From August through September 2012, infant death certificates housed in the Worcester City Hall, Office of the City Clerk, were reviewed and entered into an Excel spreadsheet. The first year, 1906, was selected due to a particularly high IMR. Following 1906, years were chosen at 10-year intervals through 1976. Beginning in 1986, data was available through a downloadable file. Data collected included the record number, the date of death, the age of the infant in months and years, cause of death, city of residence, and place of birth of mother. Specific causes of death were transformed into 13 general categories. A subsequent comparative analysis was performed.

Results: A total of 2929 hard copy death certificates were reviewed and an additional 116 records were added through downloadable files. Because 1956 was the last year to include stillbirth in infant mortality records, analysis was conducted excluding numbers of stillbirths. In 1906, the overall IMR was 143 (per 1000 live births). By 1936, the total IMR had already dropped significantly to 52, a drop of 64%. By 2006, the IMR had dropped to 4.6, a decrease of almost 97%. Much of this drop reflected changes in the IMR due to infection, which dropped from 75 in 1906 to 15 in 1936 and to .4 by 2006. In total, the decrease in IMR due to infection was responsible for more than half of the total decrease in IMR, with 80% of the drop in infection-related IMR occurring before 1936. Over this time period, the IMR due to congenital malformations also slowly decreased from 8 in 1906, to 7.3 in 1976 and then to 2.0 in 1986 and .8 in 2006. Interestingly, 83% of the decreases in IMR due to malformation occurred after 1976. IMR due to prematurity was 34 in 1906, decreased to 14.7 in 1976 and further decreased to 6.4 in 1986 and to 3.1 in 2006. Again, 89% of the decreases in IMR due to prematurity occurred after 1976.

Conclusions: The IMR in Worcester has undergone a dramatic reduction over the past 100 years, driven in large part by great reductions in number of deaths from infectious causes. Interestingly, a large part of the reduction in IMR secondary to infection occurred by 1936, prior to the development and widespread availability of antibiotics and vaccines against infectious diseases starting in the 1940s. Changes in public health infrastructure, changes in hygiene, including water, sewage and housing, and access to better nutrition and education likely played a significant role in decreased infant mortality due to infection prior to the development of medical interventions. A number of medical developments are likely responsible for decreased rates of infant mortality due to malformations and prematurity seen after 1976. These include the advent of neonatal surgery in the 1950s, the introduction of Neonatal Intensive Care Units (NICUs) in the 1960s, the use of fetal heart monitors and fetal distress as an indication for delivery by cesarean section in the 1960s to 1970s, the development of amniocentesis (for lung maturity and genetic testing) and ultrasound (for dating) in the 1970s, Roe vs. Wade in 1973, the advent of alpha fetoprotein testing and folic acid supplementation in the 1980s, and corticosteroids for fetal lung maturity in the 1980s-1990s. The large decrease in IMR due to infectious causes over the last 100 years highlights IMR’s sensitive relationship to societal factors and suggests that deteriorations in living conditions during recent difficult economic times could result in high and increasing IMRs among vulnerable subpopulations. We propose that interventions addressing societal factors could have the greatest impact in preventing infant mortality in Worcester.

Objectives: The primary objective of this population-based study was to describe trends in short and long-term survival in patients hospitalized with acute decompensated heart failure (ADHF). A secondary objective was to examine patient characteristics associated with decreased long-term survival.

Methods and Results: We reviewed the medical records of 9,748 patients hospitalized with ADHF at all 11 medical centers in central Massachusetts during 1995, 2000, 2002, and 2004. Patients hospitalized with ADHF were more likely to be elderly and to have been diagnosed with multiple comorbidities in 2004 compared with 1995. Over this period, survival was significantly improved in-hospital, and at 1, 2, and 5 years post-discharge. Five-year survival rates increased from 20% in 1995 to 28% in 2004. Although survival improved substantially over time, older patients and patients with chronic kidney disease, chronic obstructive pulmonary disease, anemia, low body mass index, and low blood pressures had consistently lower post-discharge survival rates than patients without these comorbidities.

Conclusion: Between 1995 and 2004, patients hospitalized with ADHF have become older and increasingly comorbid. Although there has been a significant improvement in survival among these patients, their long-term prognosis remains poor, as fewer than 1 in 3 patients hospitalized with ADHF in 2004 survived more than 5 years.

STUDY DESIGN: All adult patients (n = 185) admitted with a primary diagnosis of AC and who received CCT from 2002 to 2010 were identified retrospectively through billing and diagnosis codes.

RESULTS: Mean patient age was 71 years and 80% had >/=1 comorbidity (mean 2.6). Seventy-eight percent of CCTs were percutaneous CCT placement and 22% were surgical CCT placement. Median length of stay from CCT insertion to discharge was 4 days. The majority (57%) of patients eventually underwent cholecystectomy performed by 20 different surgeons in a median of 63 days post-CCT (range 3 to 1,055 days); of these, 86% underwent LC and 13% underwent open conversion or open cholecystectomy. In the radiology and surgical group, 50% and 80% underwent subsequent cholecystectomy, respectively, at a median of 63 and 60 days post-CCT. Whether surgical or percutaneous CCT placement, approximately the same proportion of patients (85% to 86%) underwent LC as definitive treatment.

CONCLUSIONS: This 9-year experience shows that use of CCT in complicated AC can be a desirable alternative to open cholecystectomy that allows most patients to subsequently undergo LC. Additional studies are underway to determine the differences in cost, training paradigms, and quality of life in this increasingly high-risk surgical population. rights reserved.

METHODS: A systematic search was performed of the available literature published between January 1980 and August 2010, using the PubMed, Ovid Medline, Ovid PsycINFO and ERIC databases. Eligible papers assessed the impact of pass/fail grading on medical student well-being, academic outcomes or both. Academic outcomes included but were not limited to objective measures, such as performance on the US Medical Licensing Examination, and subjective measures, such as student desirability by residency programmes. Reference lists in identified papers were searched and all identified papers were run through a citation index.

RESULTS: Four papers met the inclusion criteria for both well-being and academic outcomes. An additional five papers met the inclusion criteria for academic outcomes only. The four papers that focused on well-being reported improvement in specified areas. No significant difference was identified in any of the five papers examining objective academic outcomes or in those papers that examined the quality of residency programmes attained. Results from two studies suggested that some programme directors believe pass/fail grading creates disadvantages for students in attaining a residency, whereas a third study yielded mixed results about its impact on residency attainment.

CONCLUSIONS: Student well-being is enhanced and objective academic performance is not adversely affected by a pass/fail evaluation system, but students' ability to obtain a desired residency programme may be hindered by individual programme directors' preferences for tiered grading systems. There is an overall paucity of literature on this topic and additional study is needed.

METHODS: The financial impact on the neurosurgery division and demographics of the relevant patient groups were assessed. The billing records of neurosurgical patients from January 2007 to September 2008 were collected and analyzed.

RESULTS: Commonwealth Care comprised 2.2% of neurosurgical inpatients, and these patients did not have significantly different acuity or lengths of stay from the average. Length of stay of MassHealth patients was significantly greater, although acuity was significantly lower than the average. Increased free care reimbursement and increased MassHealth/Commonwealth Care enrollment resulted in a net gain in reimbursement of hospital charges.

CONCLUSIONS: The increased insurance rates have resulted in increased reimbursement for the neurosurgical division.

OBJECTIVE: To examine the effects of short-term stimulation near or in the ZI (contact 3) compared with stimulation of the STN using standard trajectories and targeting as measured by limbic and motor functions.

METHODS: Motor and limbic functions of 11 patients with STN DBS were assessed with the Unified Parkinson Disease Rating Scale-3, structured gait video analysis, Visual Analog Scale mood scales, task testing of impulsivity, and facial recognition under routine STN programming and under stimulation in or near the ZI. Postoperative magnetic resonance imaging confirmed the location of contact 3 near or in the ZI.

RESULTS: Data analysis with repeated-measures analysis of variance revealed that motor scores remained stable with both stimulation settings, with specific improvements in finger taps (P = .02) and rapid alternating movements (P = .03) in ZI stimulation. Stimulation near or in the ZI led to a decrease in self- reported anxiety and depression (P = .03 for both) and an improvement in fear recognition (P = .02).

CONCLUSION: We provide preliminary evidence that stimulation in or near the ZI results in maintained motor function while improving self-reported depression and anxiety in patients with bilateral STN DBS. Stimulation in or near the ZI may provide a useful programming setting for patients prone to psychiatric side effects.

OBJECTIVE: The aim of our study is to identify whether vertebral arteries (VA), normal or aberrant, are routinely described in cervical spine magnetic resonance imaging (MRI) interpretations.

SUMMARY OF BACKGROUND DATA: VA injury is a serious complication of anterior cervical spine surgery. Aberrant VA anatomy is a potential cause of such complications. Therefore, VA anatomy should be evaluated in cervical MRIs.

METHODS: Six neuroradiologists were blinded to the study design and were asked to interpret 79 cervical MRIs. Of these, 39 had aberrant VAs, whereas 40 had normal VAs. Initially, the indications for the study included only a description of patient's symptoms. The radiologists were then given the same MRIs with different indications. This time, the indications included the patient's symptoms, a request for annotations on the VA, and a definition of VA anomaly. All of the MRI interpretations were then evaluated for the frequency and accuracy of VA description.

RESULTS: When the indications for the study did not specifically request a comment on VAs, the VA was never described (0%). When the indications included the specific request and definition, all 6 commented on the VA (100%). Three of the 6 radiologists were 100% accurate in identifying all 40 normal and 39 aberrant VAs, whereas the other 3 identified all 40 normal and 38 of 39 aberrant VAs.

CONCLUSION: This study demonstrates that the VA is not a standard component of cervical spine MRI interpretations. Because of the significant complications related to its injury, VA anatomy, whether normal or variant, needs to be evaluated in cervical MRIs. When ordering a cervical MRI, surgeons should request a description of the VA and any anomalies.

METHODS: A neutralizing monoclonal antibody to C. difficile toxin A (CDA1) developed by MBL and Medarex, Inc. was studied in a phase II, randomized, double-blind, placebo-controlled trial in patients receiving standard of care treatment for C. difficile infection (CDI). Twenty-nine subjects received a single intravenous infusion of 10mg/kg CDA1 and 17 subjects received placebo and were evaluated for recurrence of CDI during the 56-day study period. Serum antibodies against C. difficile toxin A and B were measured by ELISA and cytotoxicity assay at various time points before and after infusion.

FINDINGS: CDI recurrence occurred in 5 of 29 (17%) in the CDA1 group and 3 of 17 (18%) (p=NS) in the placebo group with a trend toward delay in time to recurrence in the group treated with CDA1. The geometric mean concentration of antibody to an epitope of the receptor-binding domain of toxin B (0.300 and 1.20microg/ml, respectively; p=0.02) and geometric mean titer of neutralizing B antibody (8.00 and 100, respectively; p=0.02) at study day 28 were lower for those subjects with recurrence compared to those who did not recur. In addition, a significantly greater proportion of subjects who recurred were infected with the epidemic BI/NAP1/027 strain compared with those that did not recur (88% vs. 22%; p=0.002). Finally, in a multiple logistic regression analysis neutralizing anti-toxin B at day 14 (p<0.001), anti-toxin A at day 28 (p<0.001) and infection with the BI/NAP1/027 strain at enrollment (p=0.002) were all predictive of CDI recurrence.

INTERPRETATION: In this prospective study, lower concentrations of neutralizing anti-toxin B and anti-toxin A antibody and infection with the BI/NAP1/027 strain of C. difficile were significantly associated with recurrence of CDI.

METHODS: Using mouse models of methionine choline-deficient (MCD) diet-induced NASH and high-fat diet-induced NASH, we found up-regulation of the inflammasome [including NACHT, LRR, and PYD domains-containing protein 3 (NALP3; cryopyrin), apoptosis-associated speck-like CARD-domain containing protein, pannexin-1, and pro-caspase-1] at the messenger RNA (mRNA) level increased caspase-1 activity, and mature IL-1beta protein levels in mice with steatohepatitis in comparison with control livers. There was no inflammasome activation in mice with only steatosis. The MCD diet sensitized mice to LPS-induced increases in NALP3, pannexin-1, IL-1beta mRNA, and mature IL-1beta protein levels in the liver. We demonstrate for the first time that inflammasome activation occurs in isolated hepatocytes in steatohepatitis. Our novel data show that the saturated fatty acid (FA) palmitic acid (PA) activates the inflammasome and induces sensitization to LPS-induced IL-1beta release in hepatocytes. Furthermore, PA triggers the release of danger signals from hepatocytes in a caspase-dependent manner. These hepatocyte-derived danger signals, in turn, activate inflammasome, IL-1beta, and tumor necrosis factor alpha release in liver mononuclear cells.

CONCLUSION: Our novel findings indicate that saturated FAs represent an endogenous danger in the form of a first hit, up-regulate the inflammasome in NASH, and induce sensitization to a second hit with LPS for IL-beta release in hepatocytes. Furthermore, hepatocytes exposed to saturated FAs release danger signals that trigger inflammasome activation in immune cells. Thus, hepatocytes play a key role in orchestrating tissue responses to danger signals in NASH.

METHODS: Six-to-eight-week-old C57BL/6 chow fed mice were injected intraperitoneally with 0.5 mug/g bodyweight LPS and sacrificed 2, 4, 6, 18 or 24 h later. LPS-induced liver damage was confirmed by a biochemical assay to detect alanine aminotransferase (ALT) levels. To determine if LPS stimulation in the liver led to activation of the inflammasome, real-time quantitative polymerase chain reaction was used to evaluate the mRNA expression of components of the Nalp3 inflammasome. Enzyme-linked immunosorbent assays were used to determine the protein expression levels of several downstream targets of the Nalp3 inflammasome, including caspase-1 and two cytokine targets of caspase-1, interleukin (IL)-1beta and IL-18.

RESULTS: We found that LPS injection resulted in liver damage as indicated by elevated ALT levels. This was associated with a significant increase in both mRNA and protein levels of the proinflammatory cytokine tumor necrosis factor (TNF)-alpha in the liver, as well as increased levels of TNFs in serum. We showed that LPS stimulation led to upregulation of mRNA levels in the liver for all the receptor components of the inflammasome, including Nalp3, Nalp1, pannexin-1 and the adaptor molecule apoptosis-associated speck-like, caspase recruitment domain-domain containing protein. We also found increased levels of mRNA and protein for caspase-1, a downstream target of the inflammasome. In addition, LPS challenge led to increased levels of both mRNA and protein in the liver for two cytokine targets of caspase-1, IL-1beta and IL-18. Interestingly, substantial baseline expression of pre-IL-1beta and pre-IL-18 was found in the liver. Inflammasome and caspase-1 activation was indicated by the significant increase in the active forms of IL-1beta and IL-18 after LPS stimulation.

CONCLUSION: Our results show that the Nalp3 inflammasome is upregulated and activated in the liver in response to LPS stimulation.

MATERIALS AND METHODS: All animal experiments were approved by the institutional animal care and use committee. Elastase-induced saccular aneurysms were created at the root of the right CCA in 16 New Zealand white rabbits. Intramural and perivascular injection of Escherichia coli lipopolysaccharide (LPS) was performed with an endovascular approach to induce aneurysm inflammation. After intraarterial injection of an MPO-specific (di-5-hydroxytryptamide of gadopentetate dimeglumine, 0.1 mmol per kilogram of bodyweight) or a non-MPO-specific (di-tyrosine of gadopentetate dimeglumine, 0.1 mmol/kg) contrast agent, animals underwent 3-T MR imaging. Intramural presence of MPO in aneurysms in which LPS had been injected was confirmed at immunohistologic analysis. Active MPO activity was verified by measuring the spectrophotometric oxidation of guaiacol.

RESULTS: Endovascular injection of LPS resulted in inflammatory cell infiltration into the aneurysm wall, and there was a difference in active MPO expression between aneurysms in which LPS had been injected and control aneurysms (20.3 ng of MPO per milligram of tissue vs 0.12 ng of MPO per milligram of tissue, respectively; P < .002). MR imaging with di-5-hydroxytryptamide of gadopentetate dimeglumine revealed a difference in enhancement ratio between inflamed aneurysms in which LPS had been injected and control aneurysms (1.55 +/- 0.05 vs 1.16 +/- 0.10, respectively; P < .02). In inflamed aneurysms, di-5-hydroxytryptamide of gadopentetate dimeglumine exhibited delayed washout kinetics compared with the kinetics of di-tyrosine of gadopentetate dimeglumine. This finding enabled the verification of MPO specificity.

CONCLUSION: The findings of this pilot study established the feasibility of an animal model of saccular aneurysm inflammation that can be seen with clinical-field-strength MR imaging and use of the enzyme-sensitive MR contrast agent di-5-hydroxytryptamide of gadopentetate dimeglumine, which is a paramagnetic MPO substrate that specifically enhances MR signal.