Deep learning improves physician accuracy in the comprehensive detection of abnormalities on chest X-rays.

Chest X-rays are the most commonly performed medical imaging exam, yet they are often misinterpreted by physicians. Here, we present an FDA-cleared, artificial intelligence (AI) system which uses a deep learning algorithm to assist physicians in the comprehensive detection and localization of abnormalities on chest X-rays. We trained and tested the AI system on a large dataset, assessed generalizability on publicly available data, and evaluated radiologist and non-radiologist physician accuracy when unaided and aided by the AI system. The AI system accurately detected chest X-ray abnormalities (AUC: 0.976, 95% bootstrap CI: 0.975, 0.976) and generalized to a publicly available dataset (AUC: 0.975, 95% bootstrap CI: 0.971, 0.978). Physicians showed significant improvements in detecting abnormalities on chest X-rays when aided by the AI system compared to when unaided (difference in AUC: 0.101, p < 0.001). Non-radiologist physicians detected abnormalities on chest X-ray exams as accurately as radiologists when aided by the AI system and were faster at evaluating chest X-rays when aided compared to unaided. Together, these results show that the AI system is accurate and reduces physician errors in chest X-ray evaluation, which highlights the potential of AI systems to improve access to fast, high-quality radiograph interpretation.

Teledentistry adoption and applications: An American Dental Association Clinical Evaluators Panel survey.

BACKGROUND: The rise of teleworking technologies has affected various industries, including dentistry. Although some dentists have used it for some time, many are discovering the benefits of incorporating this technology to complement their existing patient care capabilities. METHODS: To assess how clinicians are using teledentistry in their practices, an electronic survey was developed and deployed to the American Dental Association Clinical Evaluators (ACE) Panel on February 27, 2023. The survey link remained open for 2 weeks. Nonrespondents received reminders after 1 week. RESULTS: Of the 244 respondents (24% response rate), 30% use teledentistry in their practices, with more than one-half of those using synchronous (53%) or asynchronous teledentistry (63%). The most common reasons for incorporating teledentistry were increased convenience for patients (53%), COVID-19 (50%), and increased accessibility to providers (39%). Teledentistry can help serve patients of all ages (the lowest represented age group [0-5 years] had 42% of dentists treating them) and distances, with 63% of teledentistry patients fewer than 20 miles away. Most users adopted teledentistry within the past 3 years and use it fewer than 5 hours per month. Benefits cited include a reduced number of in-person patient visits (63%) and increased access and quality of care (57%). Among nonusers, 60% felt there was no need, and 39% had concerns with reimbursement. CONCLUSIONS: Teledentistry has gained popularity in since the onset of the COVID-19 pandemic but may be underused, despite its potential to benefit a wider range of patients and applications than many believe. PRACTICAL IMPLICATIONS: Education on the capabilities and benefits of teledentistry may help increase adoption and improve patient care.

Anti-IL17A Halts the Onset of Diabetic Retinopathy in Type I and II Diabetic Mice.

There are ~463 million diabetics worldwide, and more than half have diabetic retinopathy. Yet, treatments are still lacking for non-proliferative diabetic retinopathy. We and others previously provided evidence that Interleukin-17A (IL-17A) plays a pivotal role in non-proliferative diabetic retinopathy. However, all murine studies used Type I diabetes models. Hence, it was the aim of this study to determine if IL-17A induces non-proliferative diabetic retinopathy in Type II diabetic mice, as identified for Type I diabetes. While examining the efficacy of anti-IL-17A as a potential therapeutic in a short-term Type I and a long-term Type II diabetes model; using different routes of administration of anti-IL-17A treatments. Retinal inflammation was significantly decreased (p < 0.05) after Type I-diabetic mice received 1 intravitreal injection, and Type II-diabetic mice received seven intraperitoneal injections of anti-IL-17A. Further, vascular tight junction protein Zonula Occludens-1 (ZO-1) was significantly decreased in both Type I and II diabetic mice, which was significantly increased when mice received anti-IL-17A injections (p < 0.05). Similarly, tight junction protein Occludin degradation was halted in Type II diabetic mice that received anti-IL-17A treatments. Finally, retinal capillary degeneration was halted 6 months after diabetes was confirmed in Type II-diabetic mice that received weekly intraperitoneal injections of anti-IL-17A. These findings provide evidence that IL-17A plays a pivotal role in non-proliferative diabetic retinopathy in Type II diabetic mice, and suggests that anti-IL-17A could be a good therapeutic candidate for non-proliferative diabetic retinopathy.

IL-17A Enhances Retinal Neovascularization.

Retinal neovascularization occurs in proliferative diabetic retinopathy, neovascular glaucoma, and age-related macular degeneration. This type of retinal pathology normally occurs in the later stages of these ocular diseases and is a prevalent cause of vision loss. Previously, we determined that Interleukin (IL)-17A plays a pivotal role in the onset and progression of non-proliferative diabetic retinopathy in diabetic mice. Unfortunately, none of our diabetic murine models progress to proliferative diabetic retinopathy. Hence, the role of IL-17A in vascular angiogenesis, neovascularization, and the onset of proliferative diabetic retinopathy was unclear. In the current study, we determined that diabetes-mediated IL-17A enhances vascular endothelial growth factor (VEGF) production in the retina, Muller glia, and retinal endothelial cells. Further, we determined that IL-17A can initiate retinal endothelial cell proliferation and can enhance VEGF-dependent vascular angiogenesis. Finally, by utilizing the oxygen induced retinopathy model, we determined that IL-17A enhances retinal neovascularization. Collectively, the results of this study provide evidence that IL-17A plays a pivotal role in vascular proliferation in the retina. Hence, IL-17A could be a potentially novel therapeutic target for retinal neovascularization, which can cause blindness in multiple ocular diseases.

Quantification of Utilization Management Barriers for Patients Initiating Therapy to Lower Lipid Levels.

This cohort study quantifies the rejections that patients with new-to-class claims face when attempting to initiate therapy with PCSK9 inhibitors and explores the association of rejection with subsequent behavior.

Inhibition of CD40-TRAF6-dependent inflammatory activity halts the onset of diabetic retinopathy in streptozotocin-diabetic mice.

Diabetes initiates inflammation that can impair the retinal vasculature, and lead to diabetic retinopathy; one of the leading causes of blindness. Inflammatory pathways have been examined as potential therapeutic targets for diabetic retinopathy, but there is still a need for early-stage treatments. We hypothesized that the CD40-TNF Receptor Associated Factor 6 (TRAF6) axis plays a pivotal role in the onset of diabetic retinopathy, and that the CD40-TRAF6 axis would be a prime therapeutic target for early-stage non-proliferative diabetic retinopathy. The CD40-TRAF6 complex can initiate NFκB activation, inflammation, and tissue damage. Further, CD40 and TRAF6 are constitutively expressed on Muller glia, and upregulated in the diabetic retina. Yet the role of the CD40-TRAF6 complex in the onset of diabetic retinopathy is still unclear. In the current study, we examined the CD40-TRAF6 axis in diabetic retinopathy using a small molecule inhibitor (SMI-6877002) on streptozotocin-induced diabetic mice. When CD40-TRAF6-dependent inflammation was inhibited, retinal vascular leakage and capillary degeneration was ameliorated in diabetic mice. Collectively, these data suggest that the CD40-TRAF6 axis plays a pivotal role in the onset of diabetic retinopathy, and could be a novel therapeutic target for early diabetic retinopathy.

Physician perceptions of drug utilization management: Results of a national survey.

The use of drug utilization management techniques such as formulary exclusions, prior authorizations, and step edits has risen sharply during the last decade, contributing to the growing burden on physicians and patients. Limited quantitative data exist, however, on physician perceptions of drug utilization management. A national survey was conducted between February 9 and March 30, 2021, targeting office-based physicians working in the United States to assess their perceptions on drug utilization management in their practice. Of the 742 physicians that participated in the study, over 80% reported deciding against prescribing certain treatments in anticipation of drug utilization management at least sometimes (>50% of the time). Despite utilization management having an impact on prescribing decisions, about half of physicians said that the utilization management policies they encounter rarely or never (0-25% of the time) align with clinical evidence.

Out-of-Pocket Costs and Prescription Filling Behavior of Commercially Insured Individuals With Chronic Obstructive Pulmonary Disease.

This cohort study uses a longitudinal access and adjudication data set to evaluate prescription out-of-pocket costs and filling behaviors of commercially insured individuals with chronic obstructive pulmonary disease (COPD).

The Physician and Administrator-Reported Cost of Drug Utilization Management to Physician Practices: A Cross-Sectional Survey.

BACKGROUND: The use of drug utilization management techniques such as formulary exclusions, prior authorizations, and step edits has risen sharply during the last decade, contributing to growing administrative costs for physician practices. However, limited data exist on the extent of these administrative costs, with previous studies relying on data from over a decade ago. OBJECTIVE: The aim of this study was to assess physician and practice administrator experiences with drug utilization management. METHODS: A national survey was conducted between 9 February and 30 March 2021, targeting 925 physicians and administrators working at medical practices in the US. Time spent by physicians and their staff on tasks related to drug utilization management for prescription medications was collected and used to calculate the dollar value of that time. RESULTS: We estimated that physicians spent a median of 4.0 h per week on drug utilization management, while nurses spent 15.0 h and other staff spent between 3.6 and 10.0 h on drug utilization management per physician per week. This time was associated with a calculated median dollar value of $75,927 per physician per year. Extrapolating this estimate to a national scale suggests that time spent annually by physician practices on drug utilization management could be valued at more than $43 billion. CONCLUSIONS: Drug utilization management results in significant time spent by US physician practices, which in turn, results in meaningful costs to these practices. As the prevalence of drug utilization management continues to grow, the impact on physician practices will remain an important topic.

Teledentistry for Patient-centered Screening and Assessment.

Teledentistry is a powerful tool for connecting oral health providers with patients who cannot easily visit a dental office, such as patients with special health care needs. Teledentistry is a skill that must be learned and this article will review key concepts that will allow providers to be better prepared to use it within their practices. These concepts include considerations for data collection and information that is necessary for a successful teledentistry visit. The authors also provide different examples of teledentistry in action, such as guided oral hygiene or dental screenings. Lastly, the authors review some unique challenges related to teledentistry and recommendations for overcoming those challenges.

Interprofessional clinical training based in a federally qualified health center: a short report.

A.T. Still University and HealthPoint, a federally qualified health center, worked together to develop novel interprofessional educational clinical experiences for dental and medical students. This short report is focused on evaluating outcomes related to student and patient experiences. Dental and medical faculty designed the program to be as hands on as possible while minimizing disruption to clinic flow. Second-year medical and fourth-year dental students worked together to assess the physical and oral health of the patients. One hundred forty-eight students participated. Of 429 total patients assessed, 83 were referred from the medical clinic to the dental clinic. Caries was present in 24.9% of patients. Overwhelmingly, the patients enjoyed having teams of students care for them. These types of clinical interprofessional experiences give students valuable opportunities to learn with, from, and about each other while providing hands-on care to patients.

Dental Anesthesia for Medical Providers: A Novel Interprofessional Course.

PURPOSE: To limit the use of opioids for nontraumatic dental conditions in emergency settings, the physician assistant (PA) and dental faculty at A.T. Still University designed a course that teaches PA students to administer dental anesthesia. METHODS: Dental faculty and teacher assistants taught PA students proper dental anesthesia. The course consisted of a recorded, prelaboratory lecture and in-person lab. During the laboratory, students rotated through 3 stations where they reviewed dental anatomy, practiced injections on dental anesthesia manikins, and simulated injections on student volunteers using the Safe-D-Needle. Students completed verbal and hands-on assessments. RESULTS: Ninety-seven percent of students passed the assessments on their first attempt. Course evaluations suggested the course had a positive effect on students' attitudes toward oral pain management. CONCLUSION: This educational model allowed PAs to expand their emergency medicine toolbox. In the future, this model should be adapted to incorporate other healthcare professionals as well.

Advanced Glycation End Products Associated With Cardiometabolic Biomarkers in Treated Human Immunodeficiency Virus Infection.

BACKGROUND: Despite advances in antiretroviral therapy (ART), people living with human immunodeficiency virus (HIV) continue to be at increased risk of cardiometabolic complications compared to HIV-uninfected individuals. Advanced glycation end products (AGEs) are implicated in the development and progression of cardiometabolic complications in the general population. Their role in HIV remains unclear. METHODS: ACTG A5260s is a prospective open-label randomized trial in which ART-naive people living with HIV were randomized to tenofovir disoproxil fumarate /emtricitabine plus atazanavir/ritonavir, darunavir/ritonavir, or raltegravir over 96 weeks. Changes in circulating AGEs with ART initiation were assessed, and linear regression was used to examine the associations between serum AGEs with carotid intima-media thickness (cIMT), visceral and subcutaneous adipose tissue, total fat, lean mass, body mass index, insulin resistance, leptin, and adiponectin. RESULTS: Overall, 214 participants were included. Ninety percent were male, 48% were White, the median age was 36 years, median HIV-1 RNA was 4.58 log10 copies/mL, and median CD4 count was 338 cells/µL. Most AGEs remained relatively unchanged following 96 weeks of ART initiation, except for methylglyoxal-derived hydroimidazolone 1 (MG-H1), which increased following 96 weeks of ART (mean fold change, 1.15 [95% confidence interval, 1.02-1.30]). No differences were detected across ART regimens. Increases in AGE levels over time were associated with worsening body fat composition measures, insulin resistance, and cIMT, even after adjusting for clinically relevant factors. CONCLUSIONS: AGE levels did not decrease following ART initiation. Most AGE levels remained stable, except for MG-H1, which increased. In people with HIV on ART, the accumulation of circulating AGEs over time appears to be independently associated with worsening cardiometabolic biomarkers.Summary: Antiretroviral therapy (ART) does not appear to be effective in reducing advanced glycation end product (AGE) levels. On the contrary, AGE levels seem to increase following ART initiation. Accumulation of AGEs was found to be independently associated with cardiometabolic complications in treated people living with HIV.

Population-based return on investment of deploying transient elastography.

OBJECTIVES: To evaluate the cost savings outcomes, from the payer's perspective, of deploying vibration-controlled transient elastography/controlled attenuation parameter (VCTE/CAP) machines for detecting and monitoring fatty liver disease (FLD). STUDY DESIGN: We modeled disease transitions and costs under the current observed pathway and under an alternative pathway in which VCTE/CAP devices are adopted. Marginal savings (or costs) due to implementing the device are derived by comparing the aggregate costs between the 2 pathways. Sources of potential savings are 2-fold. First, VCTE/CAP tests result in early identification of patients with FLD (the majority are currently undiagnosed), allowing for proactive intervention and behavior change to slow the progression of disease in these patients. Second, VCTE/CAP tests can reduce the aggregate volume of some current diagnosis methods, such as liver biopsy, imaging, and laboratory work. METHODS: Our model relied on administrative claims data consisting of 5 million commercial members and 3 million Medicare members to inform baseline statistics on disease prevalence, health care cost and utilization, and disease progression associated with different severities of liver disease. We consulted expert clinical opinion and medical literature to inform our assumptions related to device adoption and use. RESULTS: Scenario testing demonstrated positive net savings within 2 to 3 years after device deployment. Across a 5-year time span, we estimate net savings up to $2.64 per member per month (PMPM) for Medicare payers and up to $1.91 PMPM for commercial payers. CONCLUSIONS: We conclude that deploying VCTE/CAP devices is a financially advantageous solution to address the epidemic of FLD.

Quantifying The Economic Burden Of Drug Utilization Management On Payers, Manufacturers, Physicians, And Patients.

The continuing launch of innovative but high-price drugs has intensified efforts by payers to manage use and spending and by pharmaceutical manufacturers to support patient access and sales. Payers are restricting drug formularies, requiring more stringent prior authorizations, and raising patient cost-sharing requirements. Manufacturers are investing in programs that help patients and physician practices navigate administrative controls and help patients meet cost-sharing obligations. Based on a compilation and analysis of the existing peer-reviewed and professional literature, this article estimates that payers, manufacturers, physicians, and patients together incur approximately $93.3 billion in costs annually on implementing, contesting, and navigating utilization management. Payers spend approximately $6.0 billion annually administering drug utilization management, and manufacturers spend approximately $24.8 billion supporting patient access in response. Physicians devote approximately $26.7 billion in time spent navigating utilization management, whereas patients spend approximately $35.8 billion annually in drug cost sharing, even after taking advantage of manufacturer and philanthropic sources of financial support. All stakeholders in the US pharmaceutical system would benefit from a deescalation of utilization management, combining lower drug prices with lower barriers to patient access.

Retinal Inflammation, Oxidative Stress, and Vascular Impairment Is Ablated in Diabetic Mice Receiving XMD8-92 Treatment.

The global number of diabetics continues to rise annually. As diabetes progresses, almost all of Type I and more than half of Type II diabetics develop diabetic retinopathy. Diabetic retinopathy is a microvascular disease of the retina, and is the leading cause of blindness in the working-age population worldwide. With such a significant health impact, new drugs are required to halt the blinding threat posed by this visual disorder. The cause of diabetic retinopathy is multifactorial, and an optimal therapeutic would halt inflammation, cease photoreceptor cell dysfunction, and ablate vascular impairment. XMD8-92 is a small molecule inhibitor that blocks inflammatory activity downstream of ERK5 (extracellular signal-related kinase 5) and BRD4 (bromodomain 4). ERK5 elicits inflammation, is increased in Type II diabetics, and plays a pathologic role in diabetic nephropathy, while BRD4 induces retinal inflammation and plays a role in retinal degeneration. Further, we provide evidence that suggests both pERK5 and BRD4 expression are increased in the retinas of our STZ (streptozotocin)-induced diabetic mice. Taken together, we hypothesized that XMD8-92 would be a good therapeutic candidate for diabetic retinopathy, and tested XMD8-92 in a murine model of diabetic retinopathy. In the current study, we developed an in vivo treatment regimen by administering one 100 µL subcutaneous injection of saline containing 20 µM of XMD8-92 weekly, to STZ-induced diabetic mice. XMD8-92 treatments significantly decreased diabetes-mediated retinal inflammation, VEGF production, and oxidative stress. Further, XMD8-92 halted the degradation of ZO-1 (zonula occludens-1), which is a tight junction protein associated with vascular permeability in the retina. Finally, XMD8-92 treatment ablated diabetes-mediated vascular leakage and capillary degeneration, which are the clinical hallmarks of non-proliferative diabetic retinopathy. Taken together, this study provides strong evidence that XMD8-92 could be a potentially novel therapeutic for diabetic retinopathy.

Aryl Hydrocarbon Receptor Agonist VAF347 Impedes Retinal Pathogenesis in Diabetic Mice.

Diabetic retinopathy is the leading cause of blindness in the working-age population worldwide. Although the cause of diabetic retinopathy is multifactorial, IL-17A is a prevalent inflammatory cytokine involved in the promotion of diabetes-mediated retinal inflammation and the progression of diabetic retinopathy. The primary source of IL-17A is Th17 cells, which are T helper cells that have been differentiated by dendritic cells in a proinflammatory cytokine environment. Aryl hydrocarbon receptor (AhR) is a ligand-dependent transcription factor that can manipulate dendritic cell maturation, halt the production of IL-6 (a proinflammatory cytokine), and suppress Th17 cell differentiation. In the current study, we examined the efficacy of an AhR agonist, VAF347, as a potential therapeutic for the onset of non-proliferative diabetic retinopathy in streptozotocin (STZ)-induced diabetic C57BL/6 mice. We determined that diabetes-mediated leukostasis, oxidative stress, and inflammation in the retina of STZ-diabetic mice were all significantly lower when treated with the AhR agonist VAF347. Furthermore, when VAF347 was subcutaneously injected into STZ-diabetic mice, retinal capillary degeneration was ameliorated, which is the hallmark of non-proliferative diabetic retinopathy in this diabetes murine model. Collectively, these findings provide evidence that the AhR agonist VAF347 could be a potentially novel therapeutic for non-proliferative diabetic retinopathy.

Implementation of teledentistry for orthodontic practices.

Recent advances in technology, growing patient demand, and the need for social distancing due to Coronavirus Disease 2019 has expedited adoption of teledentistry in orthodontics as a means of consulting and monitoring a patient without an in-office visit. However, a lack of computer literacy and knowledge of software choices, and concerns regarding patient safety and potential infringement of regulations can make venturing into this new technology intimidating. In this article, various types of teledentistry systems for orthodontic practices, implementation guidelines, and important regulatory considerations on the use of teledentistry for orthodontic purposes are discussed. A thorough evaluation of the intended use of the software should precede commitment to a service. Selected service should be Health Insurance Portability and Accountability Act compliant at minimum and a Business Associate Agreement should be in place for protection of privacy. Ensuring the compatibility of the designated clinic computer with the system's requirements and installation of all safeguards must follow. Appointments should be documented in the same manner as in-office visits and teledentistry patients must be located within the clinician's statutory license boundary. Informed consent forms should include teledentistry or a supplemental teledentistry consent form should be used. Malpractice insurance covers everything usual and customary under the provider's license but the need for cyber liability insurance increases with teledentistry.

Teledentistry Platforms for Orthodontics.

Technology has transformed almost every aspect of our lives. Smartphones enable patients to request, receive, and transmit information irrespective of the time and place. The global pandemic has forced healthcare providers to employ technology to aid in 'flattening the curve. The Novel Coronavirus, which is responsible for COVID-19, is transmitted primarily through person-to-person contact but may also be spread through aerosol generating procedures, so many clinics have severely limited interpersonal interactions. The purpose of this article is to provide helpful information for those orthodontists considering some form of remote practice. Various HIPAA-compliant telecommunication or teledentistry systems that can be used for orthodontic treatment are introduced and discussed. Detailed information about each platform that can potentially be used for orthodontics is provided in Figure 1. The authors do not endorse any of the products listed and the included software is not all inclusive but instead is a glimpse into the options available.