Medication-related osteonecrosis of the jaw: A disease of significant importance for older patients

Background

Medication-related osteonecrosis of the jaw (MRONJ) is clinically defined as a non-healing jawbone ulcerative-necrotic lesion appearing after dental therapy or minor trauma in patients treated previously with anti-resorptive, anti-angiogenic or immunomodulators. Older patients with osteoporosis and cancer receive these pharmacological agents regularly. As these patients are long-term survivors, efficient treatment is of paramount importance for their quality of life.

Methods

Literature searches via PubMed were conducted to identify relevant MRONJ studies. Basic information on MRONJ classification, clinical features, and pathosphysiology is presented herein as well as various clinical studies dealing with MRONJ in patients with osteoporosis and cancer. Lastly, we discuss current managment of patients and new trends in treatment of MRONJ.

Results

Although close follow-up and local hygiene have been advocated by some authors, severe forms of MRONJ are not responsive to conservative therapy. At present, there is no “gold standard” therapy for this condition. However, as the physiopathological basis of MRONJ is represented by the anti-angiogenic action of various pharmacological agents, new methods to increase and promote local angiogenesis and vascularization have recently been successfully tested in vitro, limited preclinical studies, and in a pilot clinical study.

Conclusions

It appears that the best method implies application on the lesion of endothelial progenitor cells as well as pro-angiogenic factors such as Vascular Endothelial Growth Factor (VEGF) and other related molecules. More recently, scaffolds in which these factors have been incorporated have shown positive results in limited trials. However, these studies must be replicated to include a large number of cases before any official therapeutic protocol is adopted.     

Computing hospitalization rates in presence of repeated events: impact and countermeasures to avoid misinterpretation

Rationale, aims and objectives The admission rate, including both first and recurrent events, is a clear overall measure of hospital utilization, its variability accounting for individual propensity to disease recurrence. Method In this paper, we compared two variance estimators derived from the Poisson and negative binomial distribution of directly and indirectly age/gender‐standardized hospitalization rates allowing for multiple events. The latter approach accommodates departures from the assumption of randomness of repeated events required by the Poisson distribution. We apply these methods to a retrospective cohort based on hospital discharge data in 2001 of Piedmont (north‐western Italy) residents. Results Estimated standard errors under the negative binomial for both directly and indirectly standardized rates result in almost twice those under the Poisson distribution. Conclusion Our analysis confirms that ignoring the typical non‐random nature of repeated events underestimates the true variance of rates and can lead to biased optimistic interpretation of study results.     

Up-regulation of brain-derived neurotrophic factor by application of fibroblast growth factor-2 to the cut optic nerve is important for long-term survival of retinal ganglion cells

Application of basic fibroblast growth factor (FGF-2) to the optic nerve after axotomy promotes the survival of retinal ganglion cells (RGCs) in the frog Rana pipiens and results in a rapid up-regulation of brain-derived neurotrophic factor (BDNF) and TrkB synthesis by the RGCs. Here we investigate whether this up-regulation is maintained over the long term and whether it is required for FGF-2's survival effect. At 6 weeks after axotomy and FGF-2 treatment, we found more RGCs immunopositive for BDNF protein and higher intensity of BDNF and TrkB immunostaining, accompanied by increases in BDNF and TrkB mRNA in RGCs. Application of fluorescently labeled siRNA targeted against BDNF to the cut RGC axons showed that it was transported to the cell bodies. Axonal siRNA treatment eliminated the increases in BDNF immunostaining and mRNA that were induced by FGF-2 and had no effect on TrkB mRNA. This reduction in BDNF synthesis by siRNA greatly reduced the long-term survival effect of FGF-2 on RGCs. This, taken together with previous results, suggests that, although FGF-2 may initially activate survival pathways via ERK signaling, its main long-term survival effects are mediated via its up-regulation of BDNF synthesis by the RGCs.     

Microsurgical nonmicrovascular flaps in forearm and hand reconstruction

Relatively new method in flap's surgery, perforator flaps tends to monopolize nowadays the surgeon's interest. The question is: could these flaps be used not only as free flaps, as were mainly used until now, but also as local or regional flaps? On the basis of our experience with 115 operated cases, we will try to demonstrate that a lot of simple or composite defects in the forearm and hand could be covered, in selected cases, by using local or regional perforator flaps. This may have as result, in the future, a dramatic decrease in the indication for free flap transfers. Because these flaps need a microsurgical dissection, but do not need microvascular sutures, they could be defined as “microsurgical nonmicrovascular flaps.” The main advantages of these flaps could be summarized as: no microsurgical sutures, no main vascular pedicles sacrifice, same surgical field, shorter hospitalization time. © 2007 Wiley‐Liss, Inc. Microsurgery, 2007.     

Levothyroxine Absorption in Morbidly Obese Patients Before and After Roux-En-Y Gastric Bypass (RYGB) Surgery

Background  

Roux-en-Y gastric bypass (RYGB) modifies the anatomical structure of the upper intestine tract, reduces gastric acid secretion, and may impair LT4 absorption. The aim of this study was to evaluate the LT4 absorption in morbidly obese patients before and after RYGB.     

Steroid-refractory ulcerative colitis and associated primary sclerosing cholangitis treated with infliximab

Primary sclerosing cholangitis is an infrequent extraintestinal manifestation of ulcerative colitis.Damage to bile ducts is irreversible and medical therapies to prevent progression of the disease are usually ineffective.We describe a patient with long-standing ulcerative colitis,which was refractory to corticosteroid therapy who developed primary sclerosing cholangitis(biochemical stage Ⅱ/Ⅳ) in the course of his pancolitis.Treatment with infliximab(5 mg/kg as an induction dose followed by maintenance doses every two months) was indicated because of steroid-dependent disease associated to primary sclerosing cholangitis as well as sacroiliitis and uveitis and previous episode of severe azathioprinerelated hepatic toxicity.At present,after two years of follow-up,the patient is asymptomatic with normal liver tests and complete resumption of daily life activities.This case draws attention to the usefulness of antitumor necrosis factor-alpha therapy for the management of primary sclerosing cholangitis as extraintestinal manifestation of inflammatory bowel disease.