Is Insurance Payor Associated With Hospital Admission of Emergency Department Adult Patients With Odontogenic Infections?

BACKGROUND: Patients who present to the emergency department (ED) with severe odontogenic infections are often hospitalized for surgical drainage and medical management. However, inpatient management of these patients can be financially burdensome. While medical indications for hospital admission are well established, it remains unclear if patient insurance status is associated with admission. PURPOSE: The purpose of this study was to determine the nationally representative estimates of the incidence of hospital admission for patients with odontogenic infections and the association with insurance payor. STUDY DESIGN, SETTING, SAMPLE: This retrospective cohort study used the 2018 Nationwide Emergency Department Sample. Patients with odontogenic infections (based on International Classification of Diseases, 10th Revision codes) were included. Patients aged <18 years or who had missing data were excluded. PREDICTOR VARIABLE: The primary predictor variable was primary payor (private insurance, Medicare, Medicaid, self-pay, and other). MAIN OUTCOME VARIABLE: The primary outcome variable was hospital admission (yes/no). COVARIATES: Covariates included sociodemographic, medical, infection, and hospital variables. ANALYSES: Descriptive, bivariate, and multivariable logistic regression analyses were used to determine national estimates and predictors of admission. Odds ratios and 99% confidence intervals were computed. Discharge weights were accounted for in all analyses to provide nationally representative estimates. RESULTS: This study included 31,221 weighted ED encounters, of which 10,451 (33.5%) were admitted. In the study cohort, 7,687 (24.6%) had private insurance, 5,046 (16.2%) had Medicare, 10,070 (32.3%) had Medicaid, 7,436 (23.8%) were self-pay, and 982 (3.1%) had other. Bivariate analysis suggested that payor status was significantly associated with hospital admission (P < .01). The multivariable analysis showed that self-pay patients had significantly lower odds of hospital admission compared to those with private insurance (odds ratio, 0.54; 99% confidence interval, 0.42-0.70). Other independent predictors of hospital admission included infection in more than 1 location based on International Classification of Diseases, 10th Revision code, higher Charlson comorbidity index, and alcohol/substance use disorders. CONCLUSION AND RELEVANCE: Approximately one-third of patients presenting to the ED with odontogenic infections were admitted. Patients with no insurance were less likely to be admitted compared to those with private insurance. This finding may reflect multiple possibilities, including hospital financial incentives.

The influence of air masses on human mortality in the contiguous United States.

Temperature-related mortality is the leading cause of weather-related deaths in the United States. Herein, we explore the effect of air masses (AMs) - a relatively novel and holistic measure of environmental conditions - on human mortality across 61 cities in the United States. Geographic and seasonal differences in the effects of each AM on deseasonalized and detrended anomalous lagged mortality are examined using simple descriptive statistics, one-way analyses of variance, relative risks of excess mortality, and regression-based artificial neural network (ANN) models. Results show that AMs are significantly related to anomalous mortality in most US cities, and in most seasons. Of note, two of the three cool AMs (Cool and Dry-Cool) each show a strong, but delayed mortality response in all seasons, with peak mortality 2 to 4 days after they occur, with the Dry-Cool AM having nearly a 15% increased risk of excess mortality. Humid-Warm (HW) air masses are associated with increases in deaths in all seasons 0 to 1 days after they occur. In most seasons, these near-term mortality increases are offset by reduced mortality for 1-2 weeks afterwards; however, in summer, no such reduction is noted. The Warm and Dry-Warm AMs show slightly longer periods of increased mortality, albeit slightly less intensely as compared with HW, but with a similar lag structure by season. Meanwhile, the most seasonally consistent results are with transitional weather, whereby passing cold fronts are associated with a significant decrease in mortality 1 day after they occur, while warm fronts are associated with significant increases in mortality at that same lag time. Finally, ANN modeling reveals that AM-mortality relationships gleaned from a combined meta-analysis can actually lead to more skillful modeling of these relationships than models trained on some individual cities, especially in the cities where such relationships might be masked due to low average daily mortality.

Is Insurance Payer Associated With Hospital Admission of Emergency Department Patients With Mandible Fractures?

BACKGROUND: There is a lack of consensus on the optimal triage pathway for emergency department (ED) patients with mandibular fractures. It remains unclear if patient insurance payers predict hospital admission given potentially competing logistical and health system incentives. PURPOSE: To generate nationally representative estimates of the frequency of hospital admission and its association with primary insurance payers for ED patients with mandible fractures. METHODS: This retrospective cohort study used the 2018 Nationwide Emergency Department Sample, the largest all-payer database in the United States, to identify patients with mandible fractures. The database includes a stratified sample with discharge weights to generate nationally representative estimates. Patients with other facial fractures and/or concomitant injuries that independently warranted admission were excluded. PREDICTOR: The primary predictor variable was primary payer (public, private, self-pay, and other/no charge). OUTCOME VARIABLE: The primary outcome variable was hospital admission (yes/no). COVARIATES: Covariates included patient-, medical/injury-, and hospital-related variables. ANALYSES: Descriptive statistics, along with bivariate and multivariate logistic regression with Bonferroni correction, were used to produce national estimates and identify predictors of admission. P < .01 was considered significant. RESULTS: The cohort included 27,238 weighted encounters involving isolated mandible fractures, of which 5,345(20%) were admitted. The payers for admitted patients were 46% public, 25% private, 22% self-pay, and 7% no charge/other. In bivariate analyses, public insurance was associated with a higher likelihood of admission than private insurance (RR 1.24, 95% CI 1.06 to 1.45), though there was no association in the multivariate model (OR 1.03, 95% CI 0.83 to 1.28). In multivariate analysis, higher Charlson Comorbidity Index (OR 1.32, 95% CI 1.18 to 1.48), alcohol-related disorder (OR 3.47, 95% CI 2.74 to 4.39), substance-related disorder (OR 1.43, 95% CI 1.20 to 1.71), and more mandible fractures (OR 3.08, 95% CI 2.65 to 3.59) were associated with admission. Compared to body fractures, subcondylar (OR 3.83, 95% CI 2.39 to 6.14), angle (OR 3.53, 95% CI 2.84 to 6.09), and symphysis (OR 4.14, 95% CI 2.84 to 6.09) fractures had higher odds of admission. Finally, level I (OR 4.11, 95% CI 2.41 to 6.98) and level II (OR 3.16, 95% CI 1.85 to 5.39) trauma centers had higher odds of admission. CONCLUSIONS: In 2018, 20% of ED patients with isolated mandible fractures were admitted. Several patient and hospital characteristics were predictors of admission. Insurance status was not associated with admission.

Engineering self-propelled tumor-infiltrating CAR T cells using synthetic velocity receptors.

Chimeric antigen receptor (CAR) T cells express antigen-specific synthetic receptors, which upon binding to cancer cells, elicit T cell anti-tumor responses. CAR T cell therapy has enjoyed success in the clinic for hematological cancer indications, giving rise to decade-long remissions in some cases. However, CAR T therapy for patients with solid tumors has not seen similar success. Solid tumors constitute 90% of adult human cancers, representing an enormous unmet clinical need. Current approaches do not solve the central problem of limited ability of therapeutic cells to migrate through the stromal matrix. We discover that T cells at low and high density display low- and high-migration phenotypes, respectively. The highly migratory phenotype is mediated by a paracrine pathway from a group of self-produced cytokines that include IL5, TNFα, IFNγ, and IL8. We exploit this finding to "lock-in" a highly migratory phenotype by developing and expressing receptors, which we call velocity receptors (VRs). VRs target these cytokines and signal through these cytokines' cognate receptors to increase T cell motility and infiltrate lung, ovarian, and pancreatic tumors in large numbers and at doses for which control CAR T cells remain confined to the tumor periphery. In contrast to CAR therapy alone, VR-CAR T cells significantly attenuate tumor growth and extend overall survival. This work suggests that approaches to the design of immune cell receptors that focus on migration signaling will help current and future CAR cellular therapies to infiltrate deep into solid tumors.

Is hardware colonization associated with latent hardware complications and removal in maxillomandibular free flap reconstruction?

BACKGROUND: The relationship between hardware colonization, latent hardware complications, and hardware removal remains unclear following osteocutaneous free flap reconstruction of the jaws. METHODS: Retrospective cohort study of all patients undergoing free flap reconstruction of the maxilla or mandible from 2016 to 2021. RESULTS: A total of 240 subjects were included. Hardware colonization was associated with latent hardware complication in bivariate (p ≤ 0.001) and multivariate analysis (p ≤ 0.001). Time to latent hardware complication was 6.87 months earlier in colonized subjects (p ≤ 0.001). Of the 35 subjects undergoing hardware removal, 25 initiated but failed conservative therapy, and resolution of symptoms was achieved in 24 subjects after one operative intervention and 33 subjects after repeat intervention if indicated. CONCLUSIONS: Hardware colonization increases the risk and onset of latent hardware complication. Prompt hardware removal may improve outcomes by leading to faster resolution of symptoms without the burden and cost of conservative therapies.

Is Preoperative Serum Albumin Predictive of Adverse Outcomes in Head and Neck Cancer Surgery?

BACKGROUND: Patients with head and neck cancer are at increased risk of malnutrition due to tumor burden and surgical morbidity. PURPOSE: The purpose of this study was to evaluate the association between preoperative serum albumin and 30-day adverse outcomes in patients undergoing head and neck cancer surgery. STUDY DESIGN, SETTING, SAMPLE: This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database. Patients undergoing an ablative head and neck cancer procedure were included. Patients who had an unclear tumor location based on coding or missing outcome data were excluded. PREDICTOR VARIABLE: The primary predictor variable was preoperative albumin categorized as low (<3.4 g/dL), intermediate (3.4 to 3.9 g/dL), or high (>3.9 g/dL). OUTCOME VARIABLE: The primary outcome variable was intensive care unit (ICU)-level complications scored using the Clavien-Dindo classification system. This is a tool used to grade surgical complications, with grade IV and V complications defined as requiring ICU-level care. COVARIATES: Covariates were demographic (age, sex, body mass index), medical (smoking, functional status, weight loss), and perioperative (concurrent procedures, tumor location, reconstructive modality). ANALYSES: Descriptive, bivariate, and multiple logistic regression with bootstrap resampling statistics were used to evaluate the association between albumin and adverse outcomes. A significance level of P ≤ .05 was significant. RESULTS: A total of 4,491 subjects met inclusion criteria and had a documented albumin. There were 435 subjects with low albumin levels, 1,305 with intermediate levels, and 2,751 with high levels. In bivariate analysis, low albumin levels were associated with an increased risk of ICU-level complications, any complication, extended length of stay, and adverse discharge disposition (all P ≤ .001), while high levels were protective (all P ≤ .001). In bootstrapped multivariate analysis using intermediate albumin as the reference group and adjusting for demographics, tumor location, and reconstructive modality among others, low albumin levels were an independent predictor of ICU-level complications (P = .008, odds ratio, 1.64; 95% confidence interval, 1.14 to 2.40), while high levels were protective (P = .014, odds ratio, 0.689; 95% confidence interval, 0.521 to 0.923). CONCLUSIONS: Preoperative serum albumin was an independent predictor of adverse outcomes following ablative head and neck cancer procedures.

Circulation patterns associated with trends in summer temperature variability patterns in North America.

This study improves the understanding of circulation patterns associated with regional temperature trends by characterizing boreal summer temperature variability patterns in North America using rotated S-mode principal component analysis. We analyzed gridded observational 2-m temperature datasets and the ERA5 reanalysis temperature dataset to examine the climate patterns associated with long-term trends and inter-annual variability of temperature variability patterns in North America. Our analysis revealed significant trends among some classified temperature variability patterns from 1979 to 2022 summers, with inter-annual amplitudes (i.e., a departure from the mean state) signaling toward the warm regime. The anticyclonic circulation anomaly over the temperature coherent regions associated with Greenland/northeastern Canada, and Alaska, respectively, is linked to an increase in warm air advection and above-average temperatures, while cyclonic circulation over the northeast Pacific coast enhanced warm air advection and temperature increases in the coherent region comprising the northwestern portion of North America. The increase in global mean land and ocean temperatures is strongly associated with the long-term increase in the amplitude of atmospheric circulations associated with warm regimes in parts of North America. At the interannual time scale, temperature increase over Greenland/northeastern Canada is strongly associated with the negative phase of the Arctic Oscillation. These findings highlight the modulating effects of global temperature increase and warming of the western tropical Pacific Ocean on the increasing amplitude of circulations associated with warm regimes in North America. Our results further indicate that the enhancement of anticyclonic circulations over the Arctic contributes to nearly 68% of the observed reduction in sea ice extent.

Are There Differences in Opioid Prescriptions to Urban and Rural Patients by Oral and Maxillofacial Surgeons in Massachusetts From 2011 to 2021?

PURPOSE: Oral-maxillofacial surgeons (OMSs) are frequent prescribers of opioid analgesics. It remains unclear if prescription patterns differ for urban versus rural patients, given potential differences in access to and delivery of care. This study aimed to characterize urban-rural differences in opioid analgesic prescriptions to patients in Massachusetts by OMSs from 2011 to 2021. METHODS: This retrospective cohort study used the Massachusetts Prescription Monitoring Program database to identify Schedule II and III opioid prescriptions by providers with specialty of oral and maxillofacial surgery from 2011 to 2021. The primary predictor variable was patient geography (urban/rural) and secondary predictor was year (2011-2021). The primary outcome variable was milligram morphine equivalent (MME) per prescription. Secondary outcome variables were days' supply per prescription and number of prescriptions received per patient. Descriptive and linear regression statistics were performed to analyze differences in prescriptions to urban and rural patients each year and throughout the study period. RESULTS: The study data, which includes OMS opioid prescriptions (n = 1,057,412) in Massachusetts from 2011 to 2021, ranged annually between 63,678 and 116,000 prescriptions to between 58,000 and 100,000 unique patients. The cohorts each year ranged between 48 and 56% female with mean ages between 37 and 44 years. There were no differences in the mean number of patients per provider in urban and rural populations in any year. The study sample had a large majority of urban patients (>98%). MME per prescription, days' supply per prescription, and prescriptions received per patient were all generally similar between urban and rural patients each year, with the largest MME per prescription difference in 2019 (87.3 for rural to 73.9 for urban patients, P < .01). From 2011 to 2021, all patients had a steady decrease in MME per prescription (ß = -6.64, 95% confidence interval: -6.81, -6.48; R2 = 0.39) and day's supply per prescription (ß = -0.1, 95% confidence interval: -0.1, -0.09; R2 = 0.37). CONCLUSION: In Massachusetts, there were similar opioid prescribing patterns by oral and maxillofacial surgeons to urban and rural patients from 2011 to 2021. There has also been a steady decrease in the duration and total dosage of opioid prescriptions to all patients. These results are consistent with multiple statewide policies over the last several years aimed at curbing opioid overprescribing.

Interfacility Emergency Department Transfer for Midface Fractures in the United States.

PURPOSE: Interfacility hospital transfer for isolated midfacial fractures is common but rarely clinically necessary. The purpose of this study was to generate nationally representative estimates regarding the incidence, risk factors, and cost of transfer for isolated midface fractures. METHODS: This was a retrospective cohort study using the Nationwide Emergency Department Sample 2018 to identify patients with isolated midface fractures. The primary predictor variable was hospital trauma center designation (Level I, Level II, Level III, and nontrauma center). The primary outcome variable was hospital transfer. Total emergency department (ED) charges were also assessed. Covariates were demographic, medical, injury-related, and hospital characteristics. Descriptive, bivariate, and multiple logistic regression statistics were used to evaluate the incidence and predictors of interfacility transfer. RESULTS: During the study period, there were 161,022 ED encounters with a midface fracture as primary diagnosis, of which 5,680 were transferred (3.53%). In an unadjusted analysis, evaluation at a nontrauma center, level III trauma center, nonteaching hospital, and numerous demographic, medical, and injury-related variables were associated with transfer (P ≤ .001). In the adjusted model, the strongest independent predictors for hospital transfer were evaluation at a nontrauma center (odds ratio [OR] = 16.2, 95% confidence interval [CI] = 13.6-19.4), level III trauma center (OR = 13.4, 95% CI = 11.1-16.1) or level II trauma center (OR = 3.25, 95% CI = 2.66-3.98), any Le Fort fracture (OR = 12.0, 95% CI = 10.4-14.0), orbital floor fracture (OR = 3.73, 95% CI = 3.48-4.00), history of cerebrovascular event (OR = 2.74, 95% CI = 2.18-3.45), and cervical spine injury (OR = 5.87, 95% CI = 4.79-7.20) (P ≤ .001). The average ED charge per encounter was $7,206 ± 9,294 for a total nationwide charge of approximately 1.16 billion dollars. Transferred subjects had total ED charges of $97 million, not including additional charges at the recipient hospital. CONCLUSION: Isolated midface fractures are transferred infrequently, but given the high incidence have substantial healthcare costs. Predictors of transfer were mixed rather than clustered within one variable type, although it is likely that transfers are driven in part by lack of access to maxillofacial specialists given the predominance of hospital covariates. Programs evaluating necessity of transfer and facilitating specialist evaluation in the outpatient setting may reduce healthcare expenditures for these injuries.

Interfacility Emergency Department Transfer for Mandibular Fractures in the United States.

PURPOSE: Interfacility hospital transfer for isolated mandibular fractures is common but rarely clinically necessary. The purpose of this study was to generate nationally representative estimates regarding the incidence, risk factors, and cost of transfer for isolated mandibular fractures. METHODS: This was a retrospective cohort study using the Nationwide Emergency Department Sample 2018 to identify patients with isolated mandibular fractures. The primary predictor variable was hospital trauma center designation (Level I, Level II, Level III, and nontrauma center). The primary outcome variable was hospital transfer. Total emergency department (ED) charges were also assessed. Covariates were demographic, medical, injury-related, and hospital characteristics. Descriptive, bivariate, and multiple logistic regression statistics were used to evaluate the incidence and predictors of interfacility transfer. RESULTS: A total of 28,357 encounters with mandibular fracture as the primary diagnosis were included. Within this cohort there were 2,893 hospital transfers (10.2%). In unadjusted analysis, evaluation at a nontrauma center, level III trauma center, metropolitan nonteaching hospital, nonmetropolitan nonteaching hospital, micropolitan region, and history of cerebrovascular event was associated with hospital transfer (P ≤ .001). In the adjusted model, independent predictors (risk factors) for hospital transfer were evaluation at a nontrauma center (P ≤ .001, odds ratio [OR] = 12.8, 95% confidence interval [CI] = 6.43 to 25.4), level III trauma center (P ≤ .001, OR = 10.7, 95% CI = 5.25 to 21.7), nonmetropolitan nonteaching hospital (P ≤ .001, OR = 2.45, 95% CI = 1.73 to 3.46), metropolitan nonteaching hospital (P ≤ .001, OR = 1.57, 95% CI = 1.20 to 2.06), cervical spine injury (P = .002, OR = 3.53, 95% CI = 1.61 to 7.75), fractures of the mandibular body (P = .007, OR = 1.33, 95% CI = 1.08 to 1.64), and unspecified mandibular fractures (P = .006, OR = 1.49, 95% CI = 1.12 to 1.99). The average ED charge per encounter was $7,482 ± 565 for a total nationwide charge of $212,172,264. Transferred subjects had total ED charges of $25,632,974, not including additional charges incurred at the recipient hospital. CONCLUSION: Isolated mandibular fractures are common injuries that are frequently transferred and cost the healthcare system millions of dollars annually. Hospital characteristics rather than medical or injury-related variables were the strongest predictors of transfer, suggesting that transfers are primarily driven by need to access maxillofacial surgical services. Programs evaluating necessity of transfer and facilitating specialist evaluation in the outpatient setting may reduce healthcare expenditures for this injury.

Females Have Worse Overall and Disease-Specific Survival in Human Papillomavirus-Negative Oropharyngeal Squamous Cell Carcinoma.

PURPOSE: Although sex (male vs female) has been identified as an independent prognostic factor in human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC), the role of sex in HPV-negative OPSCC is less understood. The purpose of this study is to measure the association between sex and HPV-negative OPSCC disease-specific survival (DSS) and overall survival (OS). METHODS: This longitudinal, retrospective study examined cases of HPV-negative OPSCC diagnosed in the United States between 2013 and 2016 from the Surveillance, Epidemiology, and End Results database. Patients with primary OPSCC and known HPV-negative status were included. Those with HPV-positive or unknown status and primary lesions located outside the oropharynx were excluded. The primary predictor variable was patient sex (male vs female). Primary outcome variables of interest included DSS and OS. The following patient-level covariates were also assessed: age, race, insurance status, primary anatomical site and histological type of lesion, histologic grade and stage, and disease outcome. A survival analysis was conducted using univariate and multivariate analyses via a cox proportional hazard regression model. An α value less than 0.05 was considered statistically significant. RESULTS: The study sample consisted of 2,565 cases (25.1% female) of HPV-negative OPSCC. Females presented with lower histologic grade (P = .015) and earlier stage (P = .003). Females demonstrated worse DSS (P < .001) and OS (P < .001). After multivariate adjustment, female sex (hazard ratio [HR] = 1.38; 95% confidence interval [CI], 1.13 to 1.67; P = .002), advanced age (HR = 1.672; 95% CI, 1.07 to 2.60; P = .023), advanced overall stage (HR = 4.69; 95% CI, 1.54 to 14.267; P = .006), TNM stage (T4: HR = 5.74; 95% CI, 3.86 to 8.55, P < .001, N3: HR = 3.48; 95% CI, 2.17 to 5.58; P < .001, and M1: HR = 2.80; 95% CI, 2.09 to 3.74; P < .001), subjects residing in counties with the highest rates of smoking (HR = 1.29; 95% CI, 1.01 to 1.65; P = .044), and the lack of surgical treatment in patients treated with radiation and/or chemotherapy (HR = 1.44; 95% CI, 1.08 to 1.91; P = .012) were correlated with poorer DSS and OS. CONCLUSION: Females with HPV-negative OPSCC demonstrated worse DSS and OS despite better typical prognostic signs such as histologic grade and clinical stage.

Evaluation of Accessibility and Content of Oral and Maxillofacial Surgery Fellowship Program Websites.

PURPOSE: Opportunities for graduating oral and maxillofacial surgery residents to pursue fellowship training are expanding. However, there is a paucity of information in the literature for prospective applicants in our specialty. The purpose of this study was to evaluate the accessibility and content of oral and maxillofacial surgery fellowship program websites (FPWs). METHODS: The authors designed a cross-sectional study including oral and maxillofacial surgery fellowship programs in North America listed on 4 major websites: 1) The American Association of Oral and Maxillofacial Surgeons, 2) The American Academy of Craniomaxillofacial Surgeons Match, 3) The American Dental Association, and 4) The American Academy of Cosmetic Surgery. The existence and accessibility of stand-alone FPWs from these listings were assessed. Content scores were generated based on the presence or absence of 23 content variables related to program characteristics, fellow recruitment, and fellow education on listings and available webpages. Descriptive and bivariate statistics were used to evaluate the relationship between predictor variables and content scores. RESULTS: A total of 44 fellowship programs were included. Of these fellowships, 26 (59.1%) had a stand-alone FPW. The mean content score was 10.8 ± 4.82 out of a maximum of 23. Content scores were significantly greater for head and neck oncology fellowships (P ≤ .001), programs with a stand-alone FPW (P ≤ .001), and Commission on Dental Accreditation-accredited programs (P = .046). Programs with a stand-alone FPW had content scores 1.87 times greater than those without and was the predictor variable with the greatest mean difference between groups. There was no significant difference in content scores with respect to geographic region. CONCLUSIONS: Oral and maxillofacial surgery FPWs demonstrate deficiencies in content areas relevant to prospective applicants. Optimizing the content of FPWs may represent an opportunity to better inform and recruit graduating residents into fellowship programs.

Mandibular Fracture Repair in Older Adults: Is Age Associated With Adverse Outcomes?

PURPOSE: The purpose of this study was to measure the association between age and adverse outcomes in patients undergoing open reduction internal fixation (ORIF) of mandibular fractures. METHODS: This was a retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program databases (2011 to 2019) to identify patients with mandibular fractures treated with ORIF. The primary predictor variable was age (<45 years, 45 to 54 years, 55 to 64 years, 65 to 74 years, and ≥75 years). The primary outcome variable was surgical complications. Secondary outcome variables included any complication, extended length of stay (LOS ≥95th percentile), and adverse discharge destination. Covariates included demographic, medical, and perioperative covariates. Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the association between age and adverse outcomes. RESULTS: During the study period, 2,843 patients underwent ORIF of a mandibular fracture, and 2,168 subjects were included. There were 1,673 subjects aged <45 years (77.2%), 240 subjects aged 45 to 54 years (11.1%), 155 subjects aged 55 to 64 years (7.10%), 53 subjects aged 65 to 74 years (2.40%), and 47 subjects aged ≥75 years (2.20%). A total of 148 subjects (6.83%) experienced a surgical complication; the incidence of surgical complications increased in a step-wise fashion with each decade of life (P ≤ .001). In bivariate analysis, subjects aged 65 to 74 years were more likely to experience extended LOS (P = .004), whereas subjects aged ≥75 years were more likely to have an extended LOS (P ≤ .001) and an adverse discharge destination (P ≤ .001). In multivariate analysis, age 65 to 74 years was an independent predictor of any complication (P = .032, 95% confidence interval [CI] = 1.08 to 5.37), extended LOS (P = .001, 95% CI = 1.72 to 8.79), and adverse discharge destination (P = .050, 95% CI = 1.00 to 14.4), whereas age ≥75 years was an independent predictor of surgical complications (P = .043, 95% CI = 1.03 to 6.68), any complication (P = .018, 95% CI = 1.20 to 6.75), extended LOS (P = .001, 95% CI = 2.35 to 12.3), and an adverse discharge destination (P ≤ .001, 95% CI = 3.01 to 33.2). CONCLUSIONS: The elderly are at increased risk of adverse outcomes with step-wise increases in the odds of select outcomes with increasing age.

Orthognathic Surgery in Older Patients: Is Age Associated With Perioperative Complications?

PURPOSE: The incidence of older patients undergoing orthognathic surgery is increasing. The purpose of this study is to evaluate the association between age and perioperative adverse outcomes in patients undergoing orthognathic surgery. METHODS: This is a retrospective cohort study of patients undergoing orthognathic surgery in the 2011 to 2019 American College of Surgeons National Surgical Quality Improvement Program databases. The primary predictor variable was age group (≥40 or <40 years). The primary outcome variable was adverse outcomes occurring within 30 days of the index operation. Descriptive, bivariate, and Firth logistic regression statistics were utilized to evaluate association between age and adverse outcomes. RESULTS: During the study period, 1,226 patients underwent an orthognathic procedure and 835 subjects were included. Of these subjects, 145 were 40 years or older (17.4%) and 690 were less than 40 years (82.6%). Subjects 40 years or older were more likely to be American Society of Anesthesiologists (ASA) classification II (P ≤ .001), ASA III (P ≤ .001), or diagnosed with obstructive sleep apnea (P ≤ .001). A total of 34 subjects experienced an adverse outcome (4.07%), though there was no significant difference in the incidence of adverse outcomes between age groups (P = .152). In bivariate analysis, hypertension on medication (P = .037), procedure type (P = .001), and segmented Le Fort I osteotomies (P = .039) were associated with adverse outcomes. After controlling for age, hypertension on medication, segmented Le Fort I osteotomies, and diagnosis of obstructive sleep apnea, isolated mandibular osteotomies were the only independent predictors of adverse outcomes (odds ratio 2.64; 95% confidence interval, 1.06 to 7.24; P = .038). Length of stay was 1.38 ± 1.43 days for the 40 years or older group compared to 1.06 ± 1.18 in the <40 group (P = .012). CONCLUSIONS: Despite higher ASA classifications, older patients did not have a significantly greater incidence of perioperative adverse outcomes including airway complications, nor was increased age associated with adverse outcomes in bivariate or multivariate analysis.

What factors differentiate dentigerous cysts from other pericoronal lesions?

OBJECTIVE: To evaluate the histopathologic outcomes of pericoronal radiolucencies and identify factors predictive of diagnosis. STUDY DESIGN: A retrospective cohort study of 258 patients with 280 radiolucent pericoronal lesions undergoing treatment at our institution between 2005 and 2019. The primary predictor variable was lesion size (≥2 cm and <2 cm). The primary outcome variable was histopathologic diagnosis (dentigerous cyst vs other pathologic entity). Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between clinical and radiographic variables and histopathologic diagnosis. RESULTS: The study sample was composed of 258 patients with 280 histopathologic specimens. There were 218 dentigerous cysts (77.9%) and 62 other pathologic entities (22.1%). Lesions ≥2 cm were 3.20 times more likely to be diagnosed as a nondentigerous cyst pathologic entity (P ≤ .001). After adjusting for jaw (maxilla vs mandible), pain, history of infection, cortical perforation, expansion, and multiple lesions, younger age (P ≤ .001, odds ratio [OR] = 0.950, 95% confidence interval [CI] = 0.929-0.972) and lesion size as a continuous variable (P = .007, OR = 1.06, 95% CI = 1.02-1.11) were independent predictors of other pathologic entities. CONCLUSIONS: The majority of pericoronal radiolucent lesions were dentigerous cysts. Younger age and larger lesions were independent predictors of other pathologic entities.

Is Preoperative Serum Albumin Predictive of Adverse Surgical Outcomes in Maxillofacial Fracture Repair?

PURPOSE: Malnutrition has been recognized as a predictor of postoperative adverse outcomes across many surgical subspecialties. The purpose of this study was to evaluate the relationship between serum albumin and adverse outcomes in patients undergoing operative repair of maxillofacial fractures. METHODS: The authors utilized the 2011 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases to identify patients with facial fractures undergoing operative repair. The primary predictor variable was preoperative serum albumin level. Outcome variables included complications and other adverse outcomes occurring within 30 days of the index operation. Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the relationship between serum albumin and adverse outcomes. RESULTS: During the study period 1211 subjects underwent operative repair of a facial fracture and had a documented serum albumin level. Of these subjects, 1037 (85.6%) had normal albumin levels and 174 (14.4%) had hypoalbuminemia. A total of 90 subjects experienced a complication (7.43%), although albumin level was not associated with surgical complications or any complication. In bivariate analysis, subjects with hypoalbuminemia were significantly more likely to have an extended length of stay (P ≤ .001), adverse discharge disposition (P ≤ .001), and be readmitted (P = .002). In multivariate analysis, hypoalbuminemia was an independent predictor of an extended length of stay (P ≤ .001, 95% CI 2.50 to 7.62), adverse discharge disposition (P = .048, 95% CI 1.01 to 3.75), and readmission (P = .041, 95% CI 1.03 to 3.47). CONCLUSIONS: Serum albumin was not an independent predictor of complications after maxillofacial trauma repair. However, it was an independent predictor of other adverse outcomes including extended length of stay, adverse discharge disposition, and readmission. Targeted nutritional optimization may represent an opportunity to improve outcomes in this demographic.

Does the Modified Frailty Index (mFI-5) Predict Adverse Outcomes in Maxillofacial Fracture Repair?

PURPOSE: Frailty has been recognized as a predictor of postoperative adverse outcomes in many surgical subspecialties. The purpose of this study was to evaluate the relationship between frailty and complications in patients undergoing operative repair of facial fractures. METHODS: The authors utilized the 2011 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases to identify patients with facial fractures undergoing operative repair. The primary predictor variable was frailty as measured by the 5-Factor Modified Frailty Index (mFI-5). The primary outcome variable was the postoperative complication rate. Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the relationship between frailty and complications. RESULTS: During the study period, 4,290 subjects underwent operative repair of a facial fracture. Of these subjects, 4,086 (83.0%) were classified as nonfrail, 626 (12.7%) as moderately frail, and 208 (4.20%) as severely frail. A total of 237 subjects experienced a complication (4.82%), and the incidence of complications increased in a stepwise manner with increasing frailty (P ≤ .001). In multivariate regression, age (P = .050, 95% CI = 1.00 to 1.02), Native Hawaiian/Pacific Islander race (P = .018, 95% CI = 1.23 to 8.63), classification as moderately frail (P = .010, 95% CI = 1.15 to 2.66), classification as severely frail (P = .032, 95% CI = 1.06 to 3.70), mandibular fractures (P = .004, 95% CI = 1.24 to 2.98), and wound classification as contaminated (P ≤ .001, 95% CI = 1.53 to 4.57) or dirty/infected (P = .020, 95% CI = 1.16 to 5.55) were independent predictors of complications. Severely frail subjects also had greater length of hospital admission (P ≤ .001) and higher 30-day readmission rates (P ≤ .001). CONCLUSIONS: Frailty is an independent predictor of complications following facial fracture repair and is associated with greater length of hospital admission and 30-day readmission rates.