BUSM Study Reveals Potential Immune Benefits of Vitamin D Supplements in Healthy Individuals
Research from Boston University School of Medicine (BUSM) shows that improving vitamin D status by increasing its level in the blood could have a number of non-skeletal health benefits. The study, published online in PLOS ONE, reveals for the first time that improvement in the vitamin D status of healthy adults significantly impacts genes involved with a number of biologic pathways associated with cancer, cardiovascular disease (CVD), infectious diseases and autoimmune diseases. While previous studies have shown that vitamin D deficiency is associated with an increased risk for the aforementioned diseases, these results go a step further and provide direct evidence that improvement in vitamin D status plays a large role in improving immunity and lowering the risk for many diseases.
Michael Holick
Vitamin D is unique in that it can be both ingested and synthesized by the body with sun exposure. It is then converted by both the liver and kidneys to a form that the body can use. An individuals’ level of vitamin D, or their vitamin D status, is determined by measuring the level of 25-hydroxyvitamin D in the blood. Vitamin D deficiency, which is defined as a status of less than 20 nanograms per milliliter (ng/mL) of 25-hydroxyvitamin D, can cause a number of health issues, including rickets and other musculoskeletal diseases. Recently, however, data suggests that vitamin D deficiency (<20 ng/mL) and vitamin D insufficiency (between 21-29 ng/mL) is linked to cancer, autoimmune diseases, infectious diseases, type 2 diabetes and cardiovascular disease.
The randomized, double-blind, single-site pilot trial involved eight healthy men and women with an average age of 27 who were vitamin D deficient or insufficient at the start of the trial. Three participants received 400 International Units (IUs) of vitamin D per day and five received 2,000 IUs per day for a two-month period. Samples of white blood cells (immune cells) were collected at the beginning of the two-month period and again at the end. A broad gene expression analysis was conducted on these samples and more than 22,500 genes were investigated to see if their activity increased or decreased as a result of the vitamin D intake.
At the end of the pilot, the group that received 2000 IUs achieved a vitamin D status of 34 ng/mL, which is considered sufficient, while the group that received 400 IUs achieved an insufficient status of 25 ng/mL.
The results of the gene expression analysis indicated statistically significant alterations in the activity of 291 genes. Further analysis showed that the biologic functions associated with the 291 genes are related to 160 biologic pathways linked to cancer, autoimmune diseases, infectious diseases and CVD. Examining gene response elements, or sequences of DNA bases that interact with vitamin D receptors to regulate gene expression, they also identified new genes related to vitamin D status. To ensure that their observations were accurate, the researchers looked at 12 genes whose level of expression does not change, and those genes remained stable throughout the trial period.
“This study reveals the molecular fingerprints that help explain the non-skeletal health benefits of vitamin D,” said Michael F. Holick, PhD, MD, professor of medicine, physiology and biophysics at BUSM and leading vitamin D expert who served as the study’s corresponding author. “While a larger study is necessary to confirm our observations, the data demonstrates that improving vitamin D status can have a dramatic effect on gene expression in our immune cells and may help explain the role of vitamin D in reducing the risk for CVD, cancer and other diseases.”
This research was supported by a pilot grant from the National Institutes of Health’s Clinical Translational Science Institute under grant award # UL-1-RR-25711.
To view the full article, visit http://dx.plos.org/10.1371/journal.pone.0058725.
BUSM Researchers Find Better Management Needed for Use of IVC Filters – BMC Institutes Protocol as a Result of Findings
Researchers from Boston University School of Medicine (BUSM) have found that the use of Inferior Vena Cava (IVC) filters for the prevention and treatment of venous thrombotic events (VTE) may result in poor outcomes due to mechanical filter complications–largely due to low filter retrieval rates and inconsistent use of anticoagulants–and high rates of venous thromboembolism. The study, which was conducted at New England’s largest trauma center, Boston Medical Center (BMC), currently appears on-line in JAMA-Internal Medicine and is believed to be one of the first to retrospectively review retrieval options of IVC filters.
In response to this study, BMC is now using a multi-disciplinary team approach to achieve the tracking and timely retrieval of these filters, incorporating specialists from vascular surgery, interventional radiology, cardiology and hematology. BMC is one of a small group of hospitals nationwide to define and address the problem, as well as implement a system to tackle this national safety issue.
IVC filters are used to prevent pulmonary embolism, a potentially fatal condition where a blood clot breaks off from one of the large veins in the legs and lodges in the lungs. They are generally used only when people are unable to safely receive blood thinning medications. Most filters are designed to be temporary, meaning that they should be removed when the risk of pulmonary embolism has subsided.
National data has shown that many IVC filters are left in place indefinitely. Despite a lack of randomized, controlled trials demonstrating their long-term safety and efficacy, the use of IVC filters continues to increase each year.
In the study, a review of IVC filter usage between August 2003 and February 2011 was conducted at BMC. During that timeframe, IVC filters were placed in 978 patients. Charts were reviewed to determine the indication for filter placement, use of anticoagulant medication, complications resulting from filter placement and details regarding patient follow up and filter retrieval.
Of 679 potentially retrievable IVC filters inserted, only 8.5 percent were successfully removed. Unsuccessful retrieval attempts were made in 18 percent of patients. VTEs occurred in 7.8 percent of patients after filter placement, including 25 pulmonary emboli, all of which occurred with the filter in place. Forty-eight percent of VTEs were in patients without venous thromboembolism at the time of filter placement and 89 percent occurred in patients without anticoagulation. Many filters placed after trauma, were inserted when the highest bleeding risk had subsided and anticoagulation may have been more appropriate. While many of these filters were placed due to a perceived contraindication to anticoagulation, 25 percent of patients were discharged on therapeutic anticoagulation.
J. Mark Sloan
According to the researchers, more than 259,000 filters were inserted in 2012 and while many professional groups have guidelines regarding filter insertion, they vary widely and often conflict. The American College of Radiology and Society of Interventional Radiology Guidelines state that a filter can be placed as prophylaxis for any patient at high-risk of developing deep venous thrombosis (DVT) or pulmonary embolism, while the American College of Chest Physicians guidelines recommend against an IVC filter unless the patient has an acute proximal lower extremity DVT and cannot be anticoagulated. “These conflicting guidelines reflect the absence of good quality data to guide clinical practice,” explained senior author J. Mark Sloan, MD, an assistant professor of medicine at BUSM and a hematologist/oncologist at BMC.
Sloan stresses that this study highlights the importance of an institution developing a proper protocol for the safe retrieval of these filters. “As a result of these findings, a ‘filter insertion procedure note’ that specifies the indication for filter placement and the anticipated duration of placement is now mandatory for all IVC filter insertions at BMC. Patients are also given educational material after filter placement stating that most filters should be removed once the risk for blood clots has subsided or anticoagulation is tolerated.”
At BMC, every IVC filter is now promptly entered into a central interdepartmental registry and tracked until retrieval. In addition, for filters not deemed permanent at the time of insertion, a designated administrator schedules timely retrieval or a clinic visit specifically to assess for the appropriateness and timing of retrieval. Since this new protocol went into effect at BMC, 47 filters have been inserted. Of the 36 eligible for retrieval, 10 have been successfully retrieved. However, not all patients whose filters are currently in the BMC database are eligible for retrieval at this time.
Another example of the hospital’s commitment to this important issue was a BMC patient safety grant that was awarded to Dr. Jeffrey Kalish, BMC’s Director of Endovascular Surgery, for his work titled “Retrieval of IVC Filters to decrease associated complications”.
“BMC is leading the way to improve safety for our patients,” said Stanley Hochberg, MD, senior Vice President for Quality, Safety and Technology and Chief Quality Office at BMC. “Our leadership in this area will prove invaluable for all patients and may become the model for other institutions to follow,” he concluded.
Multicultural Week Activities March 18-22
Multicultural Week activities celebrate BMC’s diverse culture through art, food and entertainment. Activities throughout the week include live music in lobbies and ethnic foods from various nations for sale in the cafeterias. See the complete program book.
Monday, March 18
Newton Lobby, Noon-1 p.m.
Ulisses Ferreira (Latin music)
Moakley Lobby, 1:30-2:30 p.m.
Linda LaSalle
Harpist
Tuesday, March 19
Menino Lobby, Noon-1 p.m.
Lance Martin Band (North American Rhythm and Blues/Jazz/Gospel)
Wednesday, March 20
Newton Lobby, Noon-1 p.m.
Yasko Kubota and Archie K Duo (Asian/Japanese Instrumental)
Thursday, March 21
Shapiro Lobby, 10 a.m.-2 p.m.
Music! Dancing! Fun! Come to BMC’s Multicultural Fair in the Shapiro lobby. The fair showcases BMC employees’ cultures through posters, photos, clothing, and other mementos. Musical performances will be held:
Noon
Classical Indian Dance
Performed by: Sonali Sengupta, BMC Development Department
12:15 p.m.
Irish Music
Performed by: Kevin Muldoon, BMC Information Technology Services and Eric Norris
12:30 p.m.
African Drum and Dance
Performed by: Sidi Joh Camara
Friday, March 22
Step About Boston (BU Irish Step Dancers), Noon
BU Fine Arts String Quartet, 12:30-1:30 p.m.
BUMC Goes Latin! Celebrate Multicultural Diversity with Students, Faculty, Staff, Patients and Musicians
On Sunday, April 7, the great variety and rhythmic wonders of Latin music will be highlighted on the BU Medical Campus. A concert featuring a select group of Berklee College of Music artists, the BUMC Band, and other guest musicians associated with the Medical Campus Arts Outreach Initiative will be performing. The program will review the origins of Latin music beginning with the music of Spain, traveling across Latin America and the Caribbean, until reaching the Latin influence in American music.
During this event two Latino physicians will be recognized for their contributions to Boston Medical Center and Boston University School of Medicine.
Admission is free on a first come first served basis. Parking for concert attendees is available at the 710 Albany Street garage. Please have your ticket validated at the concert entrance.
This event is presented by
- Boston University School of Medicine, Office of Diversity and Multicultural Affairs,
- Latino Medical Student Association
- Medical Campus Arts Outreach Initiative
BU Researchers, Nation’s Health Journalists Confer: Boston Conference to Target Strategies for Better Coverage
BU is cohosting Health Journalism 2013, a conference of the Association of Health Journalists, a gathering of 750 health reporters from all media, today through Sunday.
A number of BU faculty will have a rare opportunity this week to weigh in with the nation’s leading health care reporters on how the media can better cover the latest issues in their fields. From stem cell researchers to experts on caring for an aging population, BU scientists will feature prominently in a crucial dialogue about how to accurately, engagingly, and responsibly translate developments in their fields to the lay public at Health Journalism 2013, a four-day Association of Health Care Journalists (AHCJ) Center for Excellence in Health Care Journalism conference being held in Boston. Boston University is hosting the conference along with Boston Children’s Hospital and Harvard’s Medical School and School of Public Health .
Expected to draw a record 750 journalists, the annual conference, which runs today through Sunday, March 17, features prominent speakers, news briefings, and expert panels aimed at helping reporters, editors, and news producers enhance their coverage of topics related to health care and research. Among the participating BU researchers is James Collins, a William Fairfield Warren Distinguished Professor and a College of Engineering professor of biomedical engineering. Addressing journalists in a lunch session during a daylong field trip to Boston Medical Center, Collins will talk about his research on combating antibiotic-resistant bacterial infections and the vibrating insoles he designed to improve balance and mobility among the elderly. “I hope to convey to them a sense of the exciting research going on in bioengineering and how it could impact health care,” says Collins, the first biomedical engineer to win a MacArthur genius award, “but with a sober sense of the long timeline that is involved in moving cool science from a university lab to the clinic.”
On their field trip, the journalists will also experience some unexpected but intriguing corners of BMC. They’ll visit the Preventive Food Pantry —the first of its kind in the country—which connects physicians directly with the nutrition needs of patients, many of whom suffer from diabetes, obesity, and heart disease. Reporters will hear from Deborah Frank, a School of Medicine professor of pediatrics, about the pantry’s mission to teach patients about healthful eating. Patients and their families are able to visit the pantry twice a month, taking home about four days’ supply of fresh fruits, vegetables, and meats. In 2011, the pantry provided food to more than 80,500 patients and their household members. A cooking demonstration with BMC nutritionist Tracey Burg will follow.
Reporters will also witness a live simulation training session at the BMC Solomont Center, hosted by Ron Medzon, a MED associate professor of emergency medicine and simulation director of the Clinical Training Center. Media will watch medical students, residents, and nurses honing their individual and team skills in an operating room that stages complex patient care scenarios using computer-assisted mannequins. The health care providers then review videotapes of the session and discuss what worked and what didn’t.
For the convenience of conference attendees, the University has created a temporary BU Healthcare Experts website with contact information for Boston University researchers, some of whom are speaking at the conference and many others who have expertise in related fields.
A computer-assisted mannequin in the Solomont Center for Clinical Simulation and Nursing. (Len Bruzzese/AHCJ)
In addition to supporting high standards of health care reporting, AHCJ’s mission is to promote better understanding between journalists and news sources and address the difficulties in translating research into lay terms. Reporters are always on high alert for academic studies with practical applications to improve health care—the elusive, often misnamed “breakthroughs”—but “ultimately, all research is translational,” says Darrell Kotton, a MED professor of medicine and a director of BU’s Center for Regenerative Medicine, who along with George Annas, a William Fairfield Warren Distinguished Professor and a School of Public Health professor and chair of the health law, bioethics, and human rights department, will join a panel session on “hope” versus “hype” in stem cell research. Using the broad therapeutic promise of stem cell science as an example, Kotton hopes to convey to health journalists the “good that comes to a society that funds basic research.”
“I would like to address some of the potential impacts the cells are likely to have on biomedical research and will warn of the risks of overhyping these cells in the lay press, despite their accepted scientific promise,” he says. He and Annas will also consider whether the cells or their commercial products can or should be openly shared, and whether “a growing culture of exclusivity and restrictions are slowing the pace of progress in stem cell research,” Kotton says.
The conference will feature other noteworthy speakers, including Massachusetts Governor Deval Patrick and David Goldhill, president and CEO of GSN (formerly the Game Show Network), who attracted national attention with his book Catastrophic Care: How American Health Care Killed My Father—And How We Can Fix It.
Conference-goers will hear from Muhammad Zaman, an ENG associate professor of biomedical engineering, who says he hopes his talk about relating global health to local audiences will help journalists “be able to better understand and appreciate the remarkable enthusiasm and growth among engineering faculty and students in creating technologies that are transforming global health.”
Other BU researchers set to confer with journalists include Theresa Ellis (MED’05), a Sargent College assistant professor and director of the Center for Neurorehabilitation , and Sharon Levine, a MED professor of medicine, who will discuss the growing complications of coordinating care for seniors. Brian Jack, a MED professor and chair of family medicine, will talk to reporters about improving health behaviors through consumer use of technology. Christopher Nowinski, a codirector of the BU Center for the Study of Traumatic Encephalopathy, will join a panel on sports injury research, in which BU is a leader, and the future of school sports, and William Anthony, a Sargent College professor emeritus and former director of the Center for Psychiatric Rehabilitation, will discuss recovery in mental health with mental health researchers. Another panel will feature Alan Sager, an SPH professor of health policy and management, who with Kate Walsh, BMC president and CEO, and several journalists will debate the subject of hospital economics. Catharine Wang, an SPH associate professor of community health sciences, will be on a panel discussing the implications for patients of “personal genomics.” A panel on “tapping into cancer registry trends” will include Richard Clapp, an SPH professor emeritus.
This BU Today story was written by Susan Seligson.
Office of Financial and Business Affairs Has Moved
The Office of Financial and Business Affairs has moved to Charles River Campus, 25 Buick St, third floor. There is no longer an office at Harrison Court. “We look forward to continuing to support the BU Medical Campus from our new location,” said Director, Financial and Business Affairs Hiram Rodriguez.
Phone numbers will be changing, so please update the following:
- Hiram Rodriguez, 353-4177
- Lorraine Weiss, 353-7146
- Jannette Reese, 353-7142
Please use this address for mail and deliveries:
BUMC Financial & Business Affairs
25 Buick St., 3rd Floor
Boston, MA 02215
GSDM’s SNDA Hosts First Ever Impressions Day
On Saturday, March 2, 2013, Boston University Henry M. Goldman School of Dental Medicine’s (GSDM) Student National Dental Association (SNDA), American Student Dental Association (ASDA) and Hispanic Student Dental Association (HSDA) launched the first SNDA Impressions program in the School’s history.
Impressions is a flagship event for SNDA chapters nationwide. The program encourages and educates pre-dental students by inviting them to campus and introducing them to several aspects of dental school and GSDM in particular.
Forty-two pre-dental students from local colleges and universities joined forty GSDM student volunteers at the School to participate in the daylong program. Their schedule included presentations led by Assistant Dean of Students Dr. Joseph Calabrese and Director of Diversity & Multicultural Affairs Dr. Larry Dunham, information sessions from the GSDM Admissions Office and Kaplan Test Prep, a School tour, an interviewing skills workshop, a session in the Simulation Learning Center (SLC), and a presentation about taking the Dental Admissions Test (DAT).
Dr. Calabrese praised the results of the program. He said, “Our first SNDA Impressions program was very successful. A strong turnout from pre-dental students as well as our GSDM student volunteers created a buzz in the School. I look forward to the next Impressions program and hope we will maintain this level of excitement and participation from GSDM students and pre-dental students.”
Wyatt Traina DMD 14, Community Service Chairman of GSDM’s SNDA chapter was thrilled with the day’s outcome as well. “It was a smashing success,” said Traina. “The event ran smoothly and was well received. It was terrific when Dean Hutter came by to speak to some of the undergrads as well.”
“I enjoyed speaking with the pre-dental students regarding careers in dentistry, their current college and university experiences, and how they were enjoying their day at GSDM,” said Dean Jeffrey W. Hutter. “Thanks to all the GSDM students who participated in this wonderful event.”
The pre-dental students in attendance expressed their gratitude to GSDM for organizing the program. “On behalf of the UMass Amherst Pre-Dental society, I would like to say thank you for hosting us at this year’s BU Impressions Day, “ said Raquel Manley, President of the Pre-Dental Society at the University of Massachusetts Amherst. “Every society member I have talked to is definitely interested in applying in the coming years.”
Photos are available on Facebook and Flickr.
Submitted by GSDM Communications.
BUSM Study Reveals B cells as Therapeutic Targets to Alter Obesity-Associated Inflammation and Type 2 Diabetes
Barbara Nikolajczyk, PhD
New research from Boston University School of Medicine (BUSM) reveals that B cells regulate obesity-associated inflammation and type 2 diabetes through two specific mechanisms. The study, published in the Proceedings of the National Academies of Sciences, indicates the importance of continuing to explore B cells as a therapeutic target to treat these diseases. Barbara Nikolajczyk, PhD, associate professor of microbiology at BUSM, is the study’s senior author.
The incidence of diabetes continues to rise at alarming rates. According to the National Institute of Diabetes and Digestive and Kidney Diseases, the disease now affects approximately 25.8 million Americans. In 2007, the National Institutes of Health estimated that the direct and indirect costs of diabetes were a staggering $174 billion.
Type 2 diabetes, which is a common result of obesity, occurs when the body produces insulin but cannot use it properly (insulin resistance) or the body does not produce enough insulin. The body needs insulin to absorb glucose and generate energy. If the body does not produce and respond to insulin appropriately, it can, over time, lead to various complications such as cardiovascular disease, nerve damage, kidney disease and blindness.
Previous research has shown that B cells, which are white blood cells of the immune system, promote inflammation and can lead to the development of type 2 diabetes, but the mechanisms underlying B cell function were unclear.
The results of this study shed light on that question and indicate that B cells secrete a pro-inflammatory ratio of proteins called cytokines, which directly promote the insulin resistance that characterizes type 2 diabetes. The researchers also demonstrated that B cells directly regulate inflammatory T cells, an immune cell type known to cause insulin resistance in animal models of disease.
“Now that we have identified the specific mechanisms by which B cells promote inflammation, we can help develop novel, targeted approaches to treat type 2 diabetes,” said Nikolajczyk. “Our study supports the continued exploration of FDA-approved B cell depletion drugs, which are known to be generally safe and effective, as novel agents to prevent obesity-associated inflammation and type 2 diabetes.”
Research included in this study was supported in part by the National Institutes of Health’s National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) under grant award numbers R21DK089270 and R56DK096525 (PI: Nikolajczyk) and R56DK090455 (PI: Gerald Denis); the NIDDK’s Boston Area Diabetes Endocrinology Research Center Pilot Program and the Boston Nutrition Obesity Research Center under grant award number DK046200; the NIH’s National Institute of Dental and Craniofacial Research under grant award number 5R21DE021154 (PI: Nikolajczyk); the NIH’s National Institute of Allergy and Infectious Diseases (NIAID) Immunology Training Program under grant award number AI007309; the NIH’s National Heart, Lung, and Blood Institute’s Hematology Training Program under grant award number HL007501; and the Evans Center for Interdisciplinary Biomedical Research at BUSM (PI: Nikolajczyk and Denis).
BUSM Study Reveals Potential Target to Better Treat, Cure Anxiety Disorders
Subimal Datta
Researchers at Boston University School of Medicine (BUSM) have, for the first time, identified a specific group of cells in the brainstem whose activation during rapid eye movement (REM) sleep is critical for the regulation of emotional memory processing. The findings, published in the Journal of Neuroscience, could help lead to the development of effective behavioral and pharmacological therapies to treat anxiety disorders, such as post-traumatic stress disorder, phobias and panic attacks.
There are two main stages of sleep – REM and non-REM – and both are necessary to maintain health and to regulate multiple memory systems, including emotional memory. During non-REM sleep, the body repairs tissue, regenerates cells and improves the function of the body’s immune system. During REM sleep, the brain becomes more active and the muscles of the body become paralyzed. Additionally, dreaming generally occurs during REM sleep, as well as physiological events including saccadic eye movements and rapid fluctuations of respiration, heart rate and body temperature. One particular physiological event, which is a hallmark sign of REM sleep, is the appearance of phasic pontine waves (P-waves). The P-wave is a unique brain wave generated by the activation of a group of glutamatergic cells in a specific region within the brainstem called the pons.
Memories of fearful experiences can lead to enduring alterations in emotion and behavior and sleep plays a natural emotional regulatory role after stressful and traumatic events. Persistence of sleep disturbances, particularly of REM sleep, is predictive of developing symptoms of anxiety disorders. A core symptom of these disorders frequently reported by patients is the persistence of fear-provoking memories that they are unable to extinguish. Presently, exposure therapy, which involves controlled re-exposure to the original fearful experience, is considered one of the most effective evidence-based treatments for anxiety disorders. Exposure therapy produces a new memory, called an extinction memory, to coexist and compete with the fearful memory when the fearful cue/context is re-encountered.
The strength of the extinction memory determines the efficacy of exposure therapy. A demonstrated prerequisite for the successful development of an extinction memory is adequate sleep, particularly REM sleep, after exposure therapy. However, adequate or increased sleep alone does not universally guarantee its therapeutic efficacy.
“Given the inconsistency and unpredictability of exposure therapy, we are working to identify which process(es) during REM sleep dictate the success or failure of exposure therapy,” said Subimal Datta, PhD, director and principle investigator at the Laboratory of Sleep and Cognitive Neuroscience at BUSM who served as the study’s lead author.
The researchers used contextual fear extinction training, which works to turn off the conditioned fear, to study which brain mechanisms play a role in the success of exposure therapy. The study results showed that fear extinction training increased REM sleep. Surprisingly, however, only 57 percent of subjects retained fear extinction memory, meaning that they did not experience the fear, after 24 hours. There was a tremendous increase of phasic P-wave activity among those subjects. In 43 percent of subjects, however, the wave activity was absent and they failed to retain fear extinction memory, meaning that they re-experienced fear.
“The study results provide direct evidence that the activation of phasic P-wave activity within the brainstem, in conjunction with exposure therapy, is critical for the development of long-term retention of fear extinction memory,” said Datta, who also is a professor of psychiatry and neurology at BUSM. In addition, the study indicates the important role that the brainstem plays in regulating emotional memory.
Future research will explore how to activate this mechanism in order to help facilitate the development of new potential pharmacological treatments that will complement exposure therapy to better treat anxiety and other psychological disorders.
According to the National Institute of Mental Health, anxiety disorders affect approximately 40 million American adults each year. While anxiety can sometimes be a normal and beneficial reaction to stress, some people experience excessive anxiety that they are unable to control, which can negatively impact their day to day life.
Research included in this study was supported in part by the National Institutes of Health’s National Institute of Mental Health under grant award number MH 59839 (PI: Datta) and the National Institute of Neurological Disorders and Stroke under grant award number NS 34004 (PI: Datta).
GSDM Grand Rounds Provides an Answer: “What do you do if you don’t know what to do?”
On Feb. 27, 2013, for the second in the series of Grand Rounds for the 2012–13 academic year, Patrick Moore DMD 13 presented a case that he took on during his 10-week externship rotation at Dental Health Works in Keene, New Hampshire. His preceptor was Dr. Stephen Hoffman.
Professor of General Dentistry Dr. Carl McManama opened Grand Rounds by saying that he wished that the sessions occurred every week rather than a few times a year. Introduced by Dr. McManama, Dean Jeffrey W. Hutter added that “Grand Rounds is among the most important things we do here.”
Attending Grand Rounds and welcomed by Dean Hutter were four students from the University of Hong Kong Prince Philip Dental Hospital—Carrie Kar Wing Tse, Michelle Yu, Law Shuet Wah, and So Stephanie Yuen Ting—who are spending two weeks at Boston University Henry M. Goldman School of Dental Medicine to observe how the School delivers its dental education.
Moore began his Grand Rounds presentation by describing a patient that presented unique treatment challenges. His patient was a 51-year-old man with Down Syndrome whose mother was his lifelong caretaker. At the first visit to the office, the patient’s mother said, “We would like to get [patient name] some teeth.” The patient had had the remainder of his teeth extracted about five months before the visit. He presented with a small maxilla that had a shallow vault, a large tongue, and palatal asymmetry. He was born with a heart defect that was repaired in infancy and also has Type 1 Diabetes. He has a history of periodontal disease, un-erupted teeth, and severe caries.
Moore was faced with many questions and few straightforward answers. Will simply being in a dental chair pose a risk to the patient? Will he be able to tolerate the time in the chair? What implications do the patient’s conditions have for premedication? Will the patient be able to tolerate the dentures, whether fixed or removable? What about upkeep? What kind of challenges will the differences in muscle posture, bone shape, and tongue size present for implant fitting and cast making?
A textbook would not provide much help in determining a treatment plan for this special needs patient.
As Dr. McManama remarked after Moore’s presentation, Patrick followed a sound piece of wisdom by asking: “’What do you do if you don’t know what to do?’ The answer: ‘Ask someone smarter than you.’” Thus, to come up with a sensible treatment plan, Moore sought the experts and sources of research that would provide insight into the case.
The treatment plan that Moore ultimately established was comprised of multiple phases. The phases were organized so that after the completion of each, the treatment could be suspended if it became too challenging for the patient.
The cast-making for the lower denture presented significant difficulties. Over the process, Moore was forced to abandon a number of endeavors. He was never deterred in his efforts, however. After an attempt to solve the problem by putting together the lower cast from two pieces failed, he achieved success by working with a 3D printer.
Moore then talked about a “learning moment”: As he recounted the instant of “aha,” the dentures were ordered, he was lying in bed in Keene, New Hampshire, when he realized that the asymmetry in the patient’s mouth could be an underlying tooth! He had made the connection between the lesion that recently appeared on the asymmetry and a recently seen patient with an impacted canine erupting under her complete denture.
Indeed, his suspicions were confirmed. Though this posed further challenges, a lesson was learned, the problem was resolved by relieving the denture in that area, and the denture fitting finally took place. The upper denture was a success. Unfortunately, due to the large size of the patient’s tongue coupled with his narrow palate, the lower denture was not well tolerated.
As Moore tells it, at the end of every session with this patient, the patient would pop up from the chair, go straight to the mirror, and smile—hoping to see teeth. Imagine the satisfaction, then, when he went to the mirror and saw a toothy smile. Though the result of Moore’s efforts did not necessarily provide a functional improvement, the aesthetic and emotional improvement is real.
When Moore finished his presentation, Dr. McManama commended him for his work with this exceptional case that presented so many unique challenges. He then opened the floor for discussion. There was a lively debate that included the future role of 3D printing in dentistry, possible alternatives to the treatment plan chosen by Moore, and the presence of a huge underserved population of people with special needs.
Moore had the following to say of his experience with this patient: While there were a lot of challenges and a few brief moments of frustration, I would say that the dominant emotion while working on this patient was a whole lot of fun. The chance to do something a little out of the normal grind, to work hard, be creative, and think outside the box while providing a service to someone was a real privilege. I really have to thank my preceptor for giving me the autonomy to try something different, and for providing insight and guidance along the way.
While Moore conveyed insights in a number of specific areas of treatment, the overarching message from this Grand Rounds comes in the form of a reminder: While dental professionals may swiftly and easily decipher common problems in their day-to-day practice, there will always remain unique cases that will require intense research, continued education, and persistence.
Submitted by GSDM Communications.
