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Background/aim Clonogenicity is a key feature of stem/progenitor cells. The present study aimed to enrich stem/progenitor cells from dental pulp cells by means of culturing the cells at a low clonal density with spatial separation and the evaluate differentiation potential of the surviving cells. Materials and methods Pulp cells derived from wisdom teeth were seeded into wells of a 96-plate at a mean density of 1 cell/well and cultured for 2 weeks. Surviving cells were harvested, pooled together and subjected to differentiation into adipocytes, osteoblasts and neurons using respective inducing conditions for 3 weeks. The former two types of cells were examined by staining with Oil Red O and Alizarin Red, respectively. Neuron-like cells were inspected for their morphology and immunostained for microtubule-associated protein 2 and β-tubulin III. Results Vital cells were obtained in eight wells of a 96-well plate, corresponding to a survival rate of 8%. Since fewer than two wells would be expected to contain more than four cells at seeding, the majority of surviving cells likely grew from 1-3 cells, which is a very low density. These cells differentiated into functional adipocytes and osteoblasts, and morphologically neuron-like cells. Conclusion Low-density seeding with spatial separation enables statistical estimation of cell number in wells and provides an effective strategy for enriching stem/progenitor cells and for isolating clonal dental pulp cells.

BioMed research international 2017, 1-9 (2017). doi:10.1155/2017/3848207, Published by Hindawi, New York [u.a.]

Purpose. The purpose of the study was to evaluate the influence of a continued antiplatelet therapy with clopidogrel on postoperative bleeding risk in patients undergoing skin tumor resection and reconstruction with local flaps or skin grafts under outpatient conditions.Patients and Methods. The authors designed and implemented a retrospective clinical cohort study at the General Hospital Balingen. The primary endpoint was the bleeding ratio in patients with clopidogrel treatment in comparison to patients without any anticoagulant or antiplatelet therapy. Wound healing was evaluated on days 1, 3, 5, 7, 10, and 14.Results. 650 procedures were performed, 123 of them under continued clopidogrel therapy. There were significantly more postoperative bleeding complications among patients with continued antiplatelet therapy. Regarding the whole study population, malignant lesions, a larger defect size, and skin grafts were accompanied by a higher rate of bleeding incidents. However, there were no significant findings in the univariate analysis of the clopidogrel group. All bleeding incidents were easily manageable.Conclusion. Despite an increased bleeding ratio among patients under continued clopidogrel therapy, the performance of simple surgical procedures can be recommended. However, cautious preparation and careful hemostasis are indispensable.

Having one hand occupied with the endoscope is the major disadvantage for the surgeon when it comes to functional endoscopic sinus surgery (FESS). Only the other hand is free to use the surgical instruments. Tiredness or frequent instrument changes can thus lead to shaky endoscopic images.We collected the pose data (position and orientation) of the rigid 0° endoscope and all the instruments used in 16 FESS procedures with manual endoscope guidance as well as robot-assisted endoscope guidance. In combination with the DICOM CT data, we tracked the endoscope poses and workspaces using self-developed tracking markers.All surgeries were performed once with the robot and once with the surgeon holding the endoscope. Looking at the durations required, we observed a decrease in the operating time because one surgeon doing all the procedures and so a learning curve occurred what we expected. The visual inspection of the specimens showed no damages to any of the structures outside the paranasal sinuses.Robot-assisted endoscope guidance in sinus surgery is possible. Further CT data, however, are desirable for the surgical analysis of a tracker-based navigation within the anatomic borders. Our marker-based tracking of the endoscope as well as the instruments makes an automated endoscope guidance feasible. On the subjective side, we see that RASS brings a relief for the surgeon.

Purpose Microvascular free tissue transfer allows major ablative defects following oncologic surgical and traumatic reasons to be reliably reconstructed in the head and neck region. A retrospective analysis of the microvascular flap procedures which were performed within one year in a high volume training centre was performed. Patients and methods The microvascular free flap procedures of the year 2011 were reviewed and followed up until the 31st December 2012. The type and indication of the reconstructive procedure, operation time, operating team, experience and level of training of the surgeons involved, postoperative IMC (intermediate care unit) and/or ICU (intensive care unit) time, inpatient time, flap revisions, further postoperative complications, preoperative and postoperative radiation of the patients, the placement of dental implants were studied. Results From 1st of January 2011 to 31st of December, 2011, the data of 101 patients with 103 microvascular free flap procedures were analysed of which 72% (84 flaps) were harvested by residents. The patients ranged in age from 14 to 89 years (mean age 59 years, 71 males and 40 females). The mean operation time was 591 min with the longest operation times for scapular flaps (744 min) and the shortest operation times for ALT flaps (455 min). Mean inpatient time was 34.2 days with a minimal time for the fibular flaps of 27.2 days and a maximum of 45.7 days for the latissimus dorsi flaps. 24 flaps (23.3%) in total had to be revised with bleeding being the main cause of immediate revisions (41.7% of all revisions). 5 flaps (4.85% of all flaps) were lost despite a revision procedure meaning a successful revision rate in 79.2% of all revisions. Conclusion Microvascular reconstruction procedures are safe and should be considered as standard procedures for reconstruction of large defects especially in high volume training centres. Intensive flap monitoring and early revisions maximize the flap outcome.

Background For the further development of robot-assisted endoscope guidance in functional endoscopic sinus surgery (FESS), ground data about the workspaces and endoscope movements in conventional FESS are needed. Methods Applying a self-developed marker-based tracking system, we collected the pose data (position and orientation) of the endoscope and all other instruments used in five real sinus surgeries. Results The automated segmentation of the endoscope poses shows the shape of a hourglass, with a pivot region or pivot point at the 'waistline' of the hourglass, close to the nasal entrance in the nasal dome. Conclusion We were able to identify a pivot point at the waistline of the segmented endoscope poses. The size of the pivot point corresponds with the diameter of the 4 mm endoscope. Because of the reduction to four degrees of freedom for endoscope motions (three rotations and one translation), easier and safer robot-assisted endoscope guidance becomes feasible. Copyright © 2014 John Wiley & Sons, Ltd.

The purpose of this retrospective study was to examine the possible effect of immediate bony microvascular free flap reconstruction of mandibular defects after radical tumor resection of oral squamous cell carcinoma (OSCC) on the rate of local relapse. Our own data regarding recurrence rates for 1-step immediate reconstruction were compared to the published recurrence rates of 2-step reconstructions. A total of 21 patients (aged 45–77 years) with OSCC who underwent a primary surgical therapy with subsequent immediate bony microvascular free flap reconstruction of mandibular defects were followed up for 18–38 months. Four local relapses (19%) were recorded, all in patients with initial tumor stage of T4. Although intraoperative histological findings were R0 in all 21 cases, definitive histology later detected R1 status in the resected bone in 2 cases (10%). Immediate bony free flap reconstruction of mandibular defects after radical surgical resection of OSCC does not seem to increase the risk of local recurrence nor affect patient survival when compared with the 2-step surgical approach.

Objective Dental osteotomy, the removal of an impacted, ankylosed, or severely destroyed tooth requiring an osteotomy, is more invasive than other minor dental procedures and therefore also has a higher bleeding risk. A considerable number of patients under antiplatelet therapy interrupt their therapy perioperatively, which, however, increases the risk of thromboembolism. Study Design This retrospective study assessed postoperative bleeding incidence for a total of 297 dental osteotomies with continued aspirin therapy, compared with that of 179 similar procedures on patients who were not on any anticoagulation or anti-platelet therapy. All procedures were carried out on an outpatient basis. Results Postoperative bleeding event was rare in both groups, 5 (1.7%) and 2 (1.1%), respectively, and the difference was not significant ( P = .7). Conclusions Continued aspirin therapy in patients undergoing dental osteotomies has no effect on the incidence of postoperative bleeding and should not be interrupted.

This chapter deals with functions, their limits and their derivatives. We start with sequences and their limits. Then we discuss the continuity of functions and derivatives. We introduce some rules which make derivations easier: linearity, product rule, and chain rule. We discuss the laws of the mean, Taylor series, and Bernoulli-L’Hospital rules. We lay the foundation for the analysis of functions in one variable using the notions of monotinicty, local extrema, and convexity. We explain Newton’s algorithm to calculate zeroes of functions of one real variable. Then we turn to functions of several variables: their continuity, and their partial derivatives. The chain rule is explained, as well as Euler’s partial differential equation. We finish this chapter discussing implicitly given functions.

This final chapter deals with some more philosophical issues: why do we use models, what are they good for, and the lines of logic they develop along. These laws are the same in engineering, natural sciences, economics, mathematics, physics, and philosophy. Starting from a given, obviously complete, model, one finds some contradicting facts. A new model is developed and then corroborated until new contradicting facts turn up and the same process begins anew.

This chapter introduces some important nonlinear functions: the exponential and the logarithmic functions using their functional equations. The exponential function is then used to explain compound interests. Another type of nonlinear functions are the generalized homogeneous functions and their application in production theory. The chapter ends with the investigation of nonlinear systems of equations and Banach’s fixed point theorem.

In Chap. 1 we introduced, among others, the concepts of sets, numbers and vectors. In this chapter we start to apply them to fundamental definitions, formulation of problems, indicating also elementary and intuitive methods for solving them. We will get acquainted with concepts like production system, production process, technology, efficiency and optimisation. The knowledge gained from Chap. 1 suffices already for formulating basic problems of efficiency of production of goods and services and some ideas for their (approximative) solution. These are problems, in particular linear optimisation problems.

It starts introducing as set valued functions production correspondences which must fulfil Shephard’s axioms. Competitive equilibria are discussed and Kakutani’s fixed point theorem is proven. The chapter ends with an application of this theorem in the theory of games. It investigates the existence and uniqueness of Nash (repelling) equilibria.

In this chapter we discuss the notions of proportionality, linear and affine functions, and homogeneity. The matrix algebra is introduced to explain some linear, economic models (Leontieff, von Neumann). We discuss systems of linear equations and their solution in full detail. For this we need determinants, Cramer’s rule, and the inverse matrix. Further we discuss the Gauss algorithm. We finish introducing functions of vector variables to explain aggregation in economics.

The chapter starts with a discussion of convex sets and functions in \({ \mathbb{R}}^{n}\) and approximation by quadratic functions. Then it continues with Bellman’s functional equation. For linear regression the method of least squares is used. Next extrema under equality constraints are investigated. We also use envelope theorems and the LeChatelier Principle to determine extrema. The case of inequality constraints is dealt with, too. The chapter ends with an excursion to the Kuhn-Tucker conditions and the optimisation of problems with several objective functions.

Here we deal again with linear optimisation, but we tackle more complicated problems than in Chap. 2 For this we use the method of steepest ascent and the simplex algorithm, which allow us to solve problems in more than two or three dimensions. This is followed by the notion of duality in linear optimisation, which is useful, among others, in the theory of two-person zero-sum games. It gives us the occasion to have an insight into that theory.

The buccal fat pad (BFP) as pedicled graft was originally used in reconstructing medium sized intraoral defects. Promising results concerning the use of BFP in cleft palate surgery have been published recently. The aim of this article is to report on the use of BFP as a pedicled graft in cleft palate surgery and to discuss promising results for this reconstructive surgical concept. A retrospective evaluation of 24 patients who had BFP pedicled flaps used for the prevention and repair of Type III (Pittsburgh Fistula Classification) cleft palate fistulas, to obstruct the retromolar space of Ernst and in case of wide clefts, from 2005 to 2010, was conducted. In all cleft palate patients, the recipient area fully epithelialized within 4 weeks or less. No recurrence was seen and the donor site healed well without aesthetic or significant functional impairment. This series confirms the excellent and predictable healing of BFP intraorally and the minimal morbidity associated with the use of such grafts. The results of this study allow the authors to recommend that the BFP pedicled flap is considered as a reliable alternative procedure to expand the therapeutic options. The BFP graft provides an advantage in reconstructive cleft palate surgery.

Resorbable alloplastic materials are used in many surgical applications. This retrospective study evaluated the clinical outcome after reconstruction of traumatic orbital floor defects using a polyglactin 910/PDS implant (Ethisorb™).Seventy patients with isolated blowout fractures of the orbital floor resulting in defect sizes of up to 2.5 cm(2) were included in this study. All patients were clinically examined 5 days after surgery at the time of suture removal (T1) and 18 months postoperatively (T2). Diplopia was graded as significant diplopia or diplopia in extreme gaze.At T1, diplopia was observed in 9% of the patients, swelling of the periorbital region in 6%, and enophthalmus in none of the patients. No persistent complications were observed at T2.Reconstructive surgery of the orbit is one of the most demanding challenges in maxillofacial surgery. For traumatic defects of the orbital floor, reconstruction using a polyglactin 910/PDS implant (Ethisorb(™)) seems to be a reliable method for the repair of small-to-moderate defects.

Malignant tumors in the oral cavity are relatively rare. About 5% of all malignant growths in the body are localized in the oral cavity. The vast majority of oral malignancies are primary tumors with squamous cell carcinoma being the most frequent and sarcomas occurring very seldom. Secondary tumors caused by hematogenous spread arising from a tumor localized elsewhere in the body are extremely rare. About 1% of all oral cancers are metastases to the jawbones and the surrounding soft tissues. Metastases to the jaws are mainly caused by malignant tumors of the breast, lung, kidney, bone, and colon. They occur in the late state of the disease and are regularly detected by staging examinations including scintigraphy. Even more rare are metastases into odontogenic cysts. Odontogenic cysts include dentigerous cysts, periapical or radicular cysts, and the keratocysts-nowadays declared as keratocystic odontogenic tumor. The incidence of odontogenic cysts is about 10% to 15% of all oral biopsies and therefore general dentists are frequently faced with these types of lesions. The aim of this study was to review the literature regarding metastasis into odontogenic cysts and to further highlight this rare entity with the help of a clinical case.

Summary Purpose The results of primary bone grafting in terms of initial cleft width, existence or absence of a lateral incisor and scar formation in the donor area are compared. Methods After primary osteoplasty with calvarian bone at an average age of 24 months (4–56 months) radiographic assessment was carried out in 31 patients with 40 alveolar clefts. The bone formation in the grafted area was assessed using dental radiographs taken at 66 months on average (13–114 months) after primary bone grafting. According to the Abyholm classification patients were assigned to 4 groups (indices I–IV) with indices I and II being rated as a success. Results We observed success (indices I and II) in 76% and poor results (index IV) in 14%. The causes for the poor results were an alveolar cleft width of 11–12 mm in three cases, an extraction of a decayed deciduous tooth 17 months after bone grafting in one case and a traumatic transplant loss in another case. The non-existence of a lateral incisor and a broad cleft are related to poor results. Conclusion Based on the results presented, primary bone grafting using calvarial bone seems to be a promising alternative in bridging narrow alveolar defects. This method allows early intervention at an age in which children do not recognize themselves as cleft patients. The preservation of the deciduous teeth is equally important regarding their functional stimulus for bone development.

This work introduces two new curves that are multivariate generalizations of the “classical” Lorenz curve. All data of d-variate distributions can be visualized by drawing these curves in the plane, whereas Koshevoy’s and Mosler’s generalization by a lift zonoid in ℝd+1 can only be drawn for d = 2. The generalizations of the Lorenz curve induce partial orderings of d-variate distributions. Furthermore, two inequality or heterogeneity measures that are consistent with the induced rankings are proposed. They can be considered as new generalizations of the univariate Gini coefficient. For deciding which of the two measures is more appropriate for measuring a sort of convergence concerning different countries of an union or of regions of a country, we establish systems of axioms. Although these systems are reflecting natural properties, several of the axioms are new. Moreover, by means of these axioms well- known inequality measures are tested, too.

Kommunikation, Massenkommunikation oder computervermittelte Kommunikation - was es mit diesen Begriffen auf sich hat, wird in diesem Buch kompakt und verständlich erklärt. Der Kommunikation in sozialen Netzwerken und mittels dieser Netzwerke ist ein eigener Abschnitt gewidmet.

As already described in previous studies, neural crest stem cells (NCSCs) can be found in adult human dental pulp. The present study investigated the methodology for enrichment and differentiation-induction of the above mentioned cells.Dental pulp was extracted from human wisdom teeth of four patients and subsequently cultured as explants on fibronectin-coated plates in neurobasal medium supplemented with B27, basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), insulin, l-glutamine and neuregulin-β1. The cells were then characterized by immunofluorescence, while their differentiation-potential was tested by the attempt to induce cells into different lineages, i.e. osteogenic, melanocytic and glial.The enriched cell population expressed nestin, CD271 and SOX10, which are well-known markers for NCSCs. Consequently, the cells were successfully induced to differentiate into osteoblasts, melanocytes and Schwann cells, expressing the corresponding differentiation markers.Human adult dental pulp contains a population of stem cells with neural crest ontogeny, which can thus be recruited for multiple regenerative therapies.

The purpose of this study was to assess the risk of postoperative bleeding complications after oral procedures performed under continued mono or dual anticoagulation therapy with rivaroxaban (and aspirin). This retrospective single-center observational study included 52 oral procedures performed under continued oral anticoagulant therapy with rivaroxaban (20 mg/day). Among them, two procedures were performed under continued dual therapy with aspirin (100 mg/day) added to the regimen. Postoperative bleeding events were compared with 285 oral procedures in patients without any anticoagulation/antiplatelet therapy. Postoperative bleeding complications after oral surgery occurred significantly more often in patients under continued rivaroxaban therapy (11.5 %) than in the control cases without anticoagulation/antiplatelet medication (0.7 %). All of the bleeding events were manageable: Two of them were treated with local compression, three by applying new fibrin glue with (one case) or without (two cases) secondary sutures, one occurred during a weekend and was therefore treated under inpatient conditions with suture replacement. All postoperative bleeding episodes occurred during the first postoperative week. According to our data, continued anticoagulation therapy with rivaroxaban significantly increases postoperative bleeding risk for oral surgical procedures, although the bleeding events were manageable. Oral surgeons, cardiologists, general physicians, and patients should be aware of the increased bleeding risk after oral surgical procedures. Close observation up to 1 week postoperatively is advisable to prevent excessive bleeding.

Object.To determine the incidence of postoperative bleeding for oral osteotomy carried out under continued monoantiplatelet therapy with clopidogrel and dual therapy with clopidogrel/aspirin.Design.Retrospective single center observatory study of two study groups and a control group.Methods.A total of 64 and 60 oral osteotomy procedures carried out under continued monoclopidogrel therapy and dual clopidogrel/aspirin therapy, respectively, were followed for two weeks for postoperative bleeding. Another 281 similar procedures were also followed as a control group. All oral osteotomy procedures were carried out on an outpatient basis.Results.We observed postoperative bleeding in 2/281 (0.7%) cases in the control group, in 1/64 (1.6%) cases in the clopidogrel group, and in 2/60 (3.3%) cases in the dual clopidogrel/aspirin group. The corresponding 95% confidence intervals are 0–1.7%, 0–4.7%, and 0–7.8%, respectively, and the incidences did not differ significantly among the three groups (P>0.09). Postoperative hemorrhage was treated successfully in all cases with local measures. No changes of antiplatelet medication, transfusion, nor hospitalisation were necessary. No major cardiovascular events were recorded.Conclusions.Our results indicate that minor oral surgery can be performed safely under continued monoantiplatelet medication with clopidogrel or dual antiplatelet medication with clopidogrel/aspirin.

The present study aimed to find bone substitutes to enhance osteogenic differentiation of mesenchymal stem cells in three-dimensional scaffolds in the absence of dexamethasone.Seven commercial bone substitutes were added to a three-dimensional fibrin-matrix containing rat mesenchymal stem cells in a biocompatible poly-L-lactic-acid mesh. Cell viability, cytotoxicity and alkaline phosphatase activity were followed for three weeks. Expression of bone markers was examined by qualitative evaluation of corresponding transcripts.Six out of the seven bone derivatives exhibited an osteogenic-enhancing effect.The osteogenic-enhancing effect of the evaluated bone substitutes suggests their potential clinical application for preparation of autologous bone replacement material in three-dimensional carriers.

Purpose Her2 (ErbB2) transforms cells when overexpressed and is an important therapeutic target in breast cancer. Contrary to breast cancer, studies on Her2 overexpression and gene amplification in squamous cell carcinomas of the head and neck region described largely different results. This study was undertaken to learn more on the prevalence and clinical significance of HER2 amplification and overexpression in squamous cell carcinomas of the head and neck. Materials and methods Her2 expression and gene amplification was analyzed by immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) on two tissue microarrays composed of 427 squamous cell carcinomas of the head and neck region and 222 oral squamous cell carcinomas. Results were compared with clinicopathological features. Results Her2 expression and gene amplification was rarely detectable in squamous cell carcinomas of the head and neck region and unrelated to tumor phenotype or survival of the patients with oral squamous carcinoma. Discussion Our results demonstrate that Her2 protein and gene amplification was only detectable in a small subset of squamous cell carcinomas of the head and neck region as well as oral squamous cell carcinomas. However, it can be speculated that those few patients with Her2 overexpressing and gene amplificated tumors may possibly benefit from an anti-Her2 therapy.

This article deals with inequality measures on income distributions. These measures are assumed to fulfil common axioms like the Principle of Progressive Transfers, Normalization, and Symmetry. Strict Monotonicity will be defined and is included in the basic set of axioms. If the measures are especially based on bilateral comparisons and if two additional conditions are fulfilled the bilateral inequality measure must be proportional to the absolute distance of the two incomes involved. It is remarkable that all these conditions do not give an answer whether an inequality measure for two incomes should be a quasi-convex or a quasi-concave function. This question is controversely discussed in economic research. Our surprising answer, however, is given by use of RAO's statistic concept defining the diversity of a population.

For the further development of robot-assisted endoscope guidance in functional endoscopic sinus surgery (FESS), ground data about the workspaces and endoscope movements in conventional FESS are needed.Applying a self-developed marker-based tracking system, we collected the pose data (position and orientation) of the endoscope and all other instruments used in five real sinus surgeries.The automated segmentation of the endoscope poses shows the shape of a hourglass, with a pivot region or pivot point at the 'waistline' of the hourglass, close to the nasal entrance in the nasal dome.We were able to identify a pivot point at the waistline of the segmented endoscope poses. The size of the pivot point corresponds with the diameter of the 4 mm endoscope. Because of the reduction to four degrees of freedom for endoscope motions (three rotations and one translation), easier and safer robot-assisted endoscope guidance becomes feasible.

Hybrid tumours of the salivary glands are rare neoplasms. They are composed of at least two different tumour entities located in the same topographic area and account for only 0.1% of all salivary gland tumours. The most common component is an adenoid cystic carcinoma. There are several possible forms of hybrid tumours, which are most commonly located in the parotid gland.We report on a 59-year-old female, who presented with a lesion of the caruncula of the left sublingual gland. The biopsy showed an adenoid cystic carcinoma in combination with a salivary duct carcinoma. Treatment consisted of tumour resection, bilateral selective neck dissection and adjuvant radiotherapy. Histopathologically, at least 30% of the tumour mass was composed of a salivary duct carcinoma and 70% of an adenoid cystic carcinoma. At 58 months after treatment, the patient is alive without evidence of recurrent disease.To our knowledge, the presented case is the first description of a hybrid tumour of the sublingual gland. Furthermore, the post-therapeutic course is encouraging, as hybrid tumours of the salivary glands usually have a poor prognosis.

Cutaneous surgery in the head and neck carries an intermediate risk of bleeding, so many surgeons stop anticoagulant treatment perioperatively despite the risk of cardiovascular events. We reviewed many procedures done in patients who were taking aspirin, and we did not find evidence of significantly increased postoperative bleeding compared with procedures in patients who were not taking aspirin (10/259=4% compared with 6/209=3%, p=0.6). Our results suggest that cutaneous surgery in the head and neck is safe for patients taking aspirin.

Objectives To study immunohistochemical expression of the epithelial growth factor receptor (EGFR) in oral carcinomas and the head and neck region to examine possible associations with various features of the tumors and survival of the patients. Materials and methods Sections were made from two tissue arrays composed of 206 oral squamous cell carcinomas and 427 squamous cell carcinomas of the head and neck region, respectively, and examined for EGFR expression and Ki-67 labeling index by means of immunohistochemistry, and for EGFR gene amplification by means of fluorescence in situ hybridization. Correlation between resulting parameters and with clinical features was evaluated using chi-square test and Kaplan–Meyer analysis. Results A statistically significant association was observed for strong EGFR immunohistochemical (IHC) expression with advanced lymph node involvement (P = 0.02). EGFR immunohistochemical expression did not significantly correlate with patient disease specific (DS) or overall survival (OS). EGFR gene amplification was not correlated with any of the tumor features nor to survival of the patients (DS and OS). Discussion Epithelial growth factor receptor IHC expression and gene amplification might be suitable to predict locoregional control in oral squamous cell carcinoma patients but an inappropriate predictor for patients survival.