Characterizing cardiac contractile motion for noninvasive radioablation of ventricular tachycardia.

Background: Respiratory motion management strategies are used to minimize the effects of breathing on the precision of stereotactic ablative radiotherapy for ventricular tachycardia, but the extent of cardiac contractile motion of the human heart has not been systematically explored. Objective: We aim to assess the magnitude of cardiac contractile motion between different directions and locations in the heart. Methods: Patients with intracardiac leads or valves who underwent 4-dimensional cardiac computed tomography (CT) prior to a catheter ablation procedure for atrial or ventricular arrhythmias at 2 medical centers were studied retrospectively. The displacement of transvenous right atrial appendage, right ventricular (RV) implantable cardioverter-defibrillator, coronary sinus lead tips, and prosthetic cardiac devices across the cardiac cycle were measured in orthogonal 3-dimensional views on a maximal-intensity projection CT reconstruction. Results: A total of 31 preablation cardiac 4-dimensional cardiac CT scans were analyzed. The LV lead tip had significantly greater motion compared with the RV lead in the anterior-posterior direction (6.0 ± 2.2 mm vs 3.8 ± 1.7 mm; P = .01) and superior-inferior direction (4.4 ± 2.9 mm vs 3.5 ± 2.0 mm; P = .049). The prosthetic aortic valves had the least movement of all fiducials, specifically compared with the RV lead tip in the left-right direction (3.2 ± 1.2 mm vs 6.1 ± 3.8 mm, P = .04) and the LV lead tip in the anterior-posterior direction (3.8 ± 1.7 mm vs 6.0 ± 2.2 mm, P = .03). Conclusion: The degree of cardiac contractile motion varies significantly (1 mm to 15.2 mm) across different locations in the heart. The effect of contractile motion on the precision of radiotherapy should be assessed on a patient-specific basis.

Sleep Apnea Combined with Pulmonary Hypertension in a Veteran Patient Population.

We have investigated the concurrence of sleep apnea and pulmonary hypertension in a Veteran population. We retrospectively reviewed 142 patients who underwent chest CT scans and had a dilated main pulmonary artery, defined as a width exceeding 29 mm on axial images. Approximately 40% of patients with pulmonary hypertension had associated sleep apnea. No significant difference in pulmonary artery diameters could be found between the group without sleep apnea and the group with sleep apnea (34.5 ± 4.2 mm vs. 34.7 ± 4.4 mm, p = 0.373).

Bovine Coronavirus Infects the Respiratory Tract of Cattle Challenged Intranasally.

Bovine Coronavirus (BCoV) is a member of a family of viruses associated with both enteric and respiratory diseases in a wide range of hosts. BCoV has been well-established as a causative agent of diarrhea in cattle, however, its role as a respiratory pathogen is controversial. In this study, fifteen calves were challenged intranasally with virulent BCoV in order to observe the clinical manifestation of the BCoV infection for up to 8 days after initial challenge, looking specifically for indication of symptoms, pathology, and presence of viral infection in the respiratory tract, as compared to six unchallenged control calves. Throughout the study, clinical signs of disease were recorded and nasal swabs were collected daily. Additionally, bronchoalveolar lavage (BAL) was performed at 4 days Post-challenge, and blood and tissue samples were collected from calves at 4, 6, or 8 days Post-challenge to be tested for the presence of BCoV and disease pathology. The data collected support that this BCoV challenge resulted in respiratory infections as evidenced by the isolation of BCoV in BAL fluids and positive qPCR, immunohistochemistry (IHC), and histopathologic lesions in the upper and lower respiratory tissues. This study can thus be added to a growing body of data supporting that BCoV is a respiratory pathogen and contributor to respiratory disease in cattle.

The value of supplemental prone imaging in low-dose CT lung cancer screening. A technical note.

This technical note presents our experience with the additional prone examination of patients during low dose CT lung cancer screening. The prone examination adds only a minor amount of radiation and time to the study and can reduce false positive findings that are gravity-dependent.

Ozone effects on blood biomarkers of systemic inflammation, oxidative stress, endothelial function, and thrombosis: The Multicenter Ozone Study in oldEr Subjects (MOSES).

The evidence that exposure to ozone air pollution causes acute cardiovascular effects is mixed. We postulated that exposure to ambient levels of ozone would increase blood markers of systemic inflammation, prothrombotic state, oxidative stress, and vascular dysfunction in healthy older subjects, and that absence of the glutathione S-transferase Mu 1 (GSTM1) gene would confer increased susceptibility. This double-blind, randomized, crossover study of 87 healthy volunteers 55-70 years of age was conducted at three sites using a common protocol. Subjects were exposed for 3 h in random order to 0 parts per billion (ppb) (filtered air), 70 ppb, and 120 ppb ozone, alternating 15 min of moderate exercise and rest. Blood was obtained the day before, approximately 4 h after, and approximately 22 h after each exposure. Linear mixed effect and logistic regression models evaluated the impact of exposure to ozone on pre-specified primary and secondary outcomes. The definition of statistical significance was p<0.01. There were no effects of ozone on the three primary markers of systemic inflammation and a prothrombotic state: C-reactive protein, monocyte-platelet conjugates, and microparticle-associated tissue factor activity. However, among the secondary endpoints, endothelin-1, a potent vasoconstrictor, increased from pre- to post-exposure with ozone concentration (120 vs 0 ppb: 0.07 pg/mL, 95% confidence interval [CI] 0.01, 0.14; 70 vs 0 ppb: -0.03 pg/mL, CI -0.09, 0.04; p = 0.008). Nitrotyrosine, a marker of oxidative and nitrosative stress, decreased with increasing ozone concentrations, with marginal significance (120 vs 0 ppb: -41.5, CI -70.1, -12.8; 70 vs 0 ppb: -14.2, CI -42.7, 14.2; p = 0.017). GSTM1 status did not modify the effect of ozone exposure on any of the outcomes. These findings from healthy older adults fail to identify any mechanistic basis for the epidemiologically described cardiovascular effects of exposure to ozone. The findings, however, may not be applicable to adults with cardiovascular disease.

Comparison of microleakage between bulk-fill flowable and nanofilled resin-based composites.

AIM: The objective was to compare the marginal leakage (silver nitrate uptake) of nanohybrid resin-based composite (RBC) and two bulk-fill flowable RBCs with specific clinical protocols. METHODS: Four experimental groups of RBC were investigated including conventional composite Filtek™ Supreme in 2 mm increment (FS2), Filtek™ Supreme in 4 mm increment (FS4), Filtek™ Supreme Flowable (BFF), and SureFil® SDR® flow (SDR). Class II box preparation (4 × 4 × 3 mm) in extracted intact human molars was carried out and restored using the experimental groups, all according to the manufacturers' recommendations except FS4. Samples were aged by thermocycling (2,000 cycles). Microleakage was calculated by measuring dye penetration in sectioned teeth using a stereomicroscope. Level of significance was set at P < 0.05. RESULTS: BFF and FS2 exhibited the least dye penetration and microleakage measurement with no significant difference between the two groups, followed by SDR. FS4 showed the highest microleakage with significant difference in comparison with BFF and FS2. Gingival microleakage was found to be significantly higher than occlusal microleakage. CONCLUSION: The microleakage of the bulk-fill composites BFF and SDR are comparable with conventional composite FS2; however, it is more predictable to use FS2.

Cardiovascular function and ozone exposure: The Multicenter Ozone Study in oldEr Subjects (MOSES).

BACKGROUND: To date, there have been relatively few studies of acute cardiovascular responses to controlled ozone inhalation, although a number of observational studies have reported significant positive associations between both ambient ozone levels and acute cardiovascular events and long-term ozone exposure and cardiovascular mortality. OBJECTIVES: We hypothesized that short-term controlled exposure to low levels of ozone in filtered air would induce autonomic imbalance, repolarization abnormalities, arrhythmia, and vascular dysfunction. METHODS: This randomized crossover study of 87 healthy volunteers 55-70 years of age was conducted at three sites using a common protocol, from June 2012 to April 2015. Subjects were exposed for 3 h in random order to 0 ppb (filtered air), 70 ppb ozone, and 120 ppb ozone, alternating 15 min of moderate exercise with 15 min of rest. A suite of cardiovascular endpoints was measured the day before, the day of, and up to 22 h after each exposure. Mixed effect linear and logit models evaluated the impact of exposure to ozone on pre-specified primary and secondary outcomes. Site and time were included in the models. RESULTS: We found no significant effects of ozone exposure on any of the primary or secondary measures of autonomic function, repolarization, ST segment change, arrhythmia, or vascular function (systolic blood pressure and flow-mediated dilation). CONCLUSIONS: In this multicenter study of older healthy women and men, there was no convincing evidence for acute effects of 3-h, relatively low-level ozone exposures on cardiovascular function. However, we cannot exclude the possibility of effects with higher ozone concentrations, more prolonged exposure, or in subjects with underlying cardiovascular disease. Further, we cannot exclude the possibility that exposure to ambient ozone and other pollutants in the days before the experimental exposures obscured or blunted cardiovascular biomarker response to the controlled ozone exposures.

Transplant-Free Survival and Interventions at 6 Years in the SVR Trial.

BACKGROUND: In the SVR trial (Single Ventricle Reconstruction), 1-year transplant-free survival was better for the Norwood procedure with right ventricle-to-pulmonary artery shunt (RVPAS) compared with a modified Blalock-Taussig shunt in patients with hypoplastic left heart and related syndromes. At 6 years, we compared transplant-free survival and other outcomes between the groups. METHODS: Medical history was collected annually using medical record review, telephone interviews, and the death index. The cohort included 549 patients randomized and treated in the SVR trial. RESULTS: Transplant-free survival for the RVPAS versus modified Blalock-Taussig shunt groups did not differ at 6 years (64% versus 59%, P=0.25) or with all available follow-up of 7.1±1.6 years (log-rank P=0.13). The RVPAS versus modified Blalock-Taussig shunt treatment effect had nonproportional hazards (P=0.009); the hazard ratio (HR) for death or transplant favored the RVPAS before stage II surgery (HR, 0.66; 95% confidence interval, 0.48-0.92). The effect of shunt type on death or transplant was not statistically significant between stage II to Fontan surgery (HR, 1.36; 95% confidence interval, 0.86-2.17; P=0.17) or after the Fontan procedure (HR, 0.76; 95% confidence interval, 0.33-1.74; P=0.52). By 6 years, patients with RVPAS had a higher incidence of catheter interventions (0.38 versus 0.23/patient-year, P<0.001), primarily because of more interventions between the stage II and Fontan procedures (HR, 1.72; 95% confidence interval, 1.00-3.03). Complications did not differ by shunt type; by 6 years, 1 in 5 patients had had a thrombotic event, and 1 in 6 had had seizures. CONCLUSIONS: By 6 years, the hazards of death or transplant and catheter interventions were not different between the RVPAS versus modified Blalock-Taussig shunt groups. Children assigned to the RVPAS group had 5% higher transplant-free survival, but the difference did not reach statistical significance, and they required more catheter interventions. Both treatment groups have accrued important complications. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00115934.

Respiratory Responses to Ozone Exposure. MOSES (The Multicenter Ozone Study in Older Subjects).

RATIONALE: Acute respiratory effects of low-level ozone exposure are not well defined in older adults. OBJECTIVES: MOSES (The Multicenter Ozone Study in Older Subjects), although primarily focused on acute cardiovascular effects, provided an opportunity to assess respiratory responses to low concentrations of ozone in older healthy adults. METHODS: We performed a randomized crossover, controlled exposure study of 87 healthy adults (59.9 ± 4.5 yr old; 60% female) to 0, 70, and 120 ppb ozone for 3 hours with intermittent exercise. Outcome measures included spirometry, sputum markers of airway inflammation, and plasma club cell protein-16 (CC16), a marker of airway epithelial injury. The effects of ozone exposure on these outcomes were evaluated with mixed-effect linear models. A P value less than 0.01 was chosen a priori to define statistical significance. MEASUREMENTS AND MAIN RESULTS: The mean (95% confidence interval) FEV1 and FVC increased from preexposure values by 2.7% (2.0-3.4) and 2.1% (1.3-2.9), respectively, 15 minutes after exposure to filtered air (0 ppb). Exposure to ozone reduced these increases in a concentration-dependent manner. After 120-ppb exposure, FEV1 and FVC decreased by 1.7% (1.1-2.3) and 0.8% (0.3-1.3), respectively. A similar concentration-dependent pattern was still discernible 22 hours after exposure. At 4 hours after exposure, plasma CC16 increased from preexposure levels in an ozone concentration-dependent manner. Sputum neutrophils obtained 22 hours after exposure showed a marginally significant increase in a concentration-dependent manner (P = 0.012), but proinflammatory cytokines (IL-6, IL-8, and tumor necrosis factor-α) were not significantly affected. CONCLUSIONS: Exposure to ozone at near ambient levels induced lung function effects, airway injury, and airway inflammation in older healthy adults. Clinical trial registered with www.clinicaltrials.gov (NCT01487005).

Successful treatment of Aureobasidium pullulans central catheter-related fungemia and septic pulmonary emboli.

INTRODUCTION: Aureobasidium pullulans is a saprophytic fungus that is widely distributed in the environment, and in the right host can be an opportunistic human pathogen. PRESENTATION OF CASE: A 66-year-old man with Crohn's disease with a single kidney, and requiring total parenteral nutrition via a Hickman catheter, was admitted with a 10-week history of progressive shortness of breath, fevers and weight loss. Chest imaging demonstrated new multifocal lung parenchymal opacities compatible with septic pulmonary emboli. Blood culture grew a yeast-like organism that transformed into a black mold on subculture, eventually identified as A. pullulans. Due to triazole resistance, the patient was treated with liposomal amphotericin and micafungin. Serum (1,3)-ß-d-glucan level was used to monitor therapy, initially measured at >500 pg/mL and decreasing to 66 pg/mL after one year of therapy. DISCUSSION: We describe the successful treatment of a case of catheter related fungemia and septic pulmonary emboli due A. pullulans. While initially appearing as an oval yeast on blood culture, subsequent growth as a black mold led to identification of the fungus as A. pullulans. The infection was cured with a combination of antifungal agents, even though the foreign body could not be safely removed. Nephrotoxicity required dosing adjustment of the amphotericin to biweekly during the maintenance phase of treatment. The serum (1,3)-ß-d-glucan level proved to be useful in monitoring response to therapy. CONCLUSION: We report here successful treatment of a disseminated A. pullulans infection with an induction and maintenance approach to liposomal amphotericin dosing, and monitoring response to therapy with serum (1,3)-ß-d-glucan levels.

Massive Transfusion in Cardiac Surgery: The Impact of Blood Component Ratios on Clinical Outcomes and Survival.

BACKGROUND: Cardiac surgery is the most common setting for massive transfusion in medically advanced countries. Studies of massive transfusion after injury suggest that the ratios of administered plasma and platelets (PLT) to red blood cells (RBCs) affect mortality. Data from the Red Cell Storage Duration Study (RECESS), a large randomized trial of the effect of RBC storage duration in patients undergoing complex cardiac surgery, were analyzed retrospectively to investigate the association between blood component ratios used in massively transfused patients and subsequent clinical outcomes. METHODS: Massive transfusion was defined as those who had ≥6 RBC units or ≥8 total blood components. For plasma, high ratio was defined as ≥1 plasma unit:1 RBC unit. For PLT transfusion, high ratio was defined as ≥0.2 PLT doses:1 RBC unit; PLT dose was defined as 1 apheresis PLT or 5 whole blood PLT equivalents. The clinical outcomes analyzed were mortality and the change in the Multiple Organ Dysfunction Score (ΔMODS) comparing the preoperative score with the highest composite score through the earliest of death, discharge, or day 7. Outcomes were compared between patients transfused with high and low ratios. Linear and Cox regression were used to explore relationships between predictors and continuous outcomes and time to event outcomes. RESULTS: A total of 324 subjects met the definition of massive transfusion. In those receiving high plasma:RBC ratio, the mean (SE) 7- and 28-day ΔMODS was 1.24 (0.45) and 1.26 (0.56) points lower, (P = .007 and P = .024), respectively, than in patients receiving lower ratios. In patients receiving high PLT:RBC ratio, the mean (SE) 7- and 28-day ΔMODS were 1.55 (0.53) and 1.49 (0.65) points lower (P = .004 and P = .022), respectively. Subjects who received low-ratio plasma:RBC transfusion had excess 7-day mortality compared with those who received high ratio (7.2% vs 1.7%, respectively, P = .0318), which remained significant at 28 days (P = .035). The ratio of PLT:RBCs was not associated with differences in mortality. CONCLUSIONS: This analysis found that in complex cardiac surgery patients who received massive transfusion, there was an association between the composition of blood products used and clinical outcomes. Specifically, there was less organ dysfunction in those who received high-ratio transfusions (plasma:RBCs and PLT:RBCs), and lower mortality in those who received high-ratio plasma:RBC transfusions.

Diagnostic Utility of Chest Radiography in Predicting Long-Standing Systemic Arterial Hypertension.

PURPOSE: To investigate the association between aortic arch width on frontal chest radiography and systemic hypertension. METHODS: A total of 200 consecutive patients were included. Relationships between aortic arch width measurement on chest radiography and blood pressure measurement were investigated using Student's t -tests and Fisher's exact tests. RESULTS: Twenty-five patients were normotensive (< 130/90 mmHg), and 175 were hypertensive. Using cut-off values, 136 patients had an aortic arch width ≥ 3.5 cm, and 65 had an aortic arch width ≥ 4 cm. We found a significant relationship between aortic arch width and hypertension (p < 0.001) as well between aortic arch width cut-off values of 3.5 cm and 4 cm and hypertension (p < 0.001 and p < 0.005, respectively). An aortic arch width ≥ 3.5 cm was associated with a positive likelihood ratio (LR) of 2.3, negative LR of 0.39, sensitivity of 73, specificity of 68, positive predictive value of 94, negative predictive value of 26.6, pretest odds of 7, posttest odds of 16, and posttest probability of 94%. An aortic arch width ≥ 4 cm was associated with a positive LR of 4.50, negative LR of 0.70, sensitivity of 36, specificity of 92, positive predictive value of 97, negative predictive value of 17, pretest odds of 7, posttest odds of 31.5, and posttest probability of 97%. CONCLUSIONS: Aortic arch width measurement on chest radiography can be used to predict the presence of long-standing systemic arterial hypertension.

Utilizing a Collaborative Learning Model to Promote Early Extubation Following Infant Heart Surgery.

OBJECTIVE: To determine whether a collaborative learning strategy-derived clinical practice guideline can reduce the duration of endotracheal intubation following infant heart surgery. DESIGN: Prospective and retrospective data collected from the Pediatric Heart Network in the 12 months pre- and post-clinical practice guideline implementation at the four sites participating in the collaborative (active sites) compared with data from five Pediatric Heart Network centers not participating in collaborative learning (control sites). SETTING: Ten children's hospitals. PATIENTS: Data were collected for infants following two-index operations: 1) repair of isolated coarctation of the aorta (birth to 365 d) and 2) repair of tetralogy of Fallot (29-365 d). There were 240 subjects eligible for the clinical practice guideline at active sites and 259 subjects at control sites. INTERVENTIONS: Development and application of early extubation clinical practice guideline. MEASUREMENTS AND MAIN RESULTS: After clinical practice guideline implementation, the rate of early extubation at active sites increased significantly from 11.7% to 66.9% (p < 0.001) with no increase in reintubation rate. The median duration of postoperative intubation among active sites decreased from 21.2 to 4.5 hours (p < 0.001). No statistically significant change in early extubation rates was found in the control sites 11.7% to 13.7% (p = 0.63). At active sites, clinical practice guideline implementation had no statistically significant impact on median ICU length of stay (71.9 hr pre- vs 69.2 hr postimplementation; p = 0.29) for the entire cohort. There was a trend toward shorter ICU length of stay in the tetralogy of Fallot subgroup (71.6 hr pre- vs 54.2 hr postimplementation, p = 0.068). CONCLUSIONS: A collaborative learning strategy designed clinical practice guideline significantly increased the rate of early extubation with no change in the rate of reintubation. The early extubation clinical practice guideline did not significantly change postoperative ICU length of stay.

Prospective Clinical and Radiographic Study of Alveolar Ridge Preservation Combining Freeze-Dried Bone Allograft With Two Xenogeneic Collagen Matrices.

BACKGROUND: Tooth extractions are followed by significant dimensional changes in the alveolar crest that may preclude implant placement. This randomized, controlled, prospective compares the preservation of soft and hard tissue dimensional changes after alveolar ridge preservation (ARP) using two membranes consisting of collagen matrix (CM) or extracellular matrix (ECM) as barriers over freeze-dried bone allograft (FDBA). METHODS: Standardized clinical and radiographic measurements of soft and hard tissues were recorded by means of a stent before and 4 months after ARP. The surgery entailed sulcular incisions with minimal flap elevation and repositioning without advancement. RESULTS: Of 11 patients in the CM group and 12 in the ECM group who completed the study, gingival thickness (GT) increased from 0.1 to 0.2 mm for both groups along with a 0.5-mm decrease in the width of keratinized tissue after healing. Reductions in ridge width were most pronounced on the coronal aspect, 1.8 mm for CM and 2.0 mm for ECM, whereas vertical reduction was most pronounced on the buccal aspect, 0.7 to 1.0 mm. Differences between groups were not statistically significant. However, significant correlation for changes in GT (P = 0.001) and crestal bone width (P = 0.002) with preoperative buccal plate thickness (BPT) was observed. CONCLUSIONS: Both xenogeneic collagen matrices combined with FDBA were effective in maintaining soft tissues and minimizing ridge resorption in all dimensions after ARP. BPT was an important determinant for amount of change in crestal GT and ridge width.

Microbiologic Findings in Relation to Risk Assessment for Periodontal Disease: A Cross-Sectional Study.

BACKGROUND: In this study, an association between a computerized risk calculator and microbiologic testing is examined in patients with periodontitis. METHODS: Seventy-four patients with moderate and severe periodontitis were selected from patients receiving treatment at Tufts University School of Dental Medicine. Their periodontal risk was analyzed with a periodontitis risk assessment tool, and microbiologic testing was performed. Periodontitis risk assessment and microbiologic testing were examined for a possible association. The data were evaluated by the χ(2) test at P <0.05 levels. RESULTS: Forty-six patients scored as having a "very high" risk of periodontitis and 22 patients scored as having a "high" risk of periodontitis by the risk assessment tool. Patients with a risk score of very high risk showed a higher detection of each bacterium except Capnocytophaga species than the rest of the study population. Treponema denticola and Prevotella intermedia (P = 0.01 and P = 0.02, respectively) were two bacteria that showed a statistically significant difference between patients at very high risk and those at high risk. CONCLUSIONS: Patients with periodontitis were identified as high risk and very high risk compared with the rest of the risk categories by the risk assessment tool. The study population, categorized mostly as very high risk, showed high detection of putative periodontal bacteria.

Using a Simulated Infobutton Linked to an Evidence-Based Resource to Research Drug-Drug Interactions: A Pilot Study with Third-Year Dental Students.

Many health professions students and clinicians are using evidence-based databases that allow for quicker and more accurate clinical decisions. The aims of this pilot study were to compare third-year dental students' speed and accuracy in researching questions about drug-drug interactions (DDI) when using two different methods: a simulated infobutton linked to the evidence-based clinical decision support resource UpToDate versus traditional Internet resources accessed through a computer or smart device. Students researched two simulated cases during two sessions. In the first session, half the students used the infobutton, while the other half used traditional electronic tools only. In the second session, ten days later, a cross-over took place. The sessions were timed, and after researching the case, students answered three questions on the use of antibiotics, analgesics, and local anesthetics. Of the 50 students who volunteered for the study, two were excluded, and 44 participated in both sessions and the exam. The results showed that the students took a similar amount of time to identify DDI whether they used the infobutton (mean=286.5 seconds) or traditional tools (265.2 seconds); the difference was not statistically significant (p=0.429). Their scores using the two research methods were similar in all three content areas: antibiotics (p=0.797), analgesics (p=0.850), and local anesthetics (p=0.850). In a post-intervention survey, students were generally favorable about infobutton and UpToDate, reporting the tool was easy to use (62.5%), provided the answer they were looking for (53.1%), was fast (50%), and they would use it again (68.8%). This pilot study found that the time and accuracy of these students conducting DDI research with the infobutton and UpToDate were about the same as using traditional Internet resources.

At-home oral care for adults with developmental disabilities: a survey of caregivers.

BACKGROUND: Little is known about effective at-home oral care methods for people with developmental disabilities (DDs) who are unable to perform personal preventive practices themselves and rely on caregivers for assistance. METHODS: A convenience sample of 808 caregivers (84.5 percent paid, 15.5 percent family members) who accompanied adults with DDs (20 years or older) to appointments at a specialized statewide dental care system completed computer-assisted personal interview surveys. The authors used these data to investigate caregivers' at-home oral care experiences and to explore differences between caregivers who were paid and those who were family members. RESULTS: Caregivers reported that a high proportion (85 percent) of dentate adults with DDs received assistance with tooth cleaning. They also reported a high prevalence of dental problems, and low adherence to brushing (79 percent) and flossing (22 percent) recommendations. More caregivers reported that they felt confident assisting with brushing than with flossing (85 percent versus 54 percent). Family members and paid caregivers differed with respect to confidence and training. CONCLUSIONS: At-home oral care, particularly flossing, presents substantial challenges for adults with DDs. Solutions must be tailored to address the different experiences and distinct needs of the family members and paid caregivers who assist these adults. PRACTICAL IMPLICATIONS: Caregivers play an important role in providing at-home oral care, and they must be included in efforts to improve oral health outcomes for people with DDs.

Patient-specific modeling of ventricular activation pattern using surface ECG-derived vectorcardiogram in bundle branch block.

Patient-specific computational models have promise to improve cardiac disease diagnosis and therapy planning. Here a new method is described to simulate left-bundle branch block (LBBB) and RV-paced ventricular activation patterns in three dimensions from non-invasive, routine clinical measurements. Activation patterns were estimated in three patients using vectorcardiograms (VCG) derived from standard 12-lead electrocardiograms (ECG). Parameters of a monodomain model of biventricular electrophysiology were optimized to minimize differences between the measured and computed VCG. Electroanatomic maps of local activation times measured on the LV and RV endocardial surfaces of the same patients were used to validate the simulated activation patterns. For all patients, the optimal estimated model parameters predicted a time-averaged mean activation dipole orientation within 6.7 ± 0.6° of the derived VCG. The predicted local activation times agreed within 11.5 ± 0.8 ms of the measured electroanatomic maps, on the order of the measurement accuracy.

Saudi and U.S. dental student attitudes toward treating individuals with developmental disabilities.

This study was conducted to compare the attitudes of senior dental students at the Faculty of Dentistry at King Abdulaziz University (KAU) in Jeddah, Saudi Arabia, and at Tufts University School of Dental Medicine (TUSDM) in Boston, Massachusetts, about providing dental care to individuals with developmental disabilities (DD). Two subsequent classes of senior dental students at both universities were surveyed using a pretested, validated, online questionnaire. The students' demographic and educational data were collected, along with information about their experience, training, and attitudes toward this population. Two hundred and fourteen students responded to the online survey, for a response rate of 35 percent (51 percent for KAU students and 21 percent for TUSDM students). Students at TUSDM had more training, more experience, and more positive attitudes toward individuals with DD compared to KAU students (p<0.05). Students who reported having previous experience with individuals with DD had more positive attitudes than students who reported no experience with these individuals (p<0.05). Students who reported being prepared to treat individuals with DD had more positive attitudes than students who reported not being prepared (p<0.05). These findings suggest an association between predoctoral education in the treatment of individuals with special needs and having positive attitudes toward providing oral health care to individuals with DD.

BigMouth: a multi-institutional dental data repository.

Few oral health databases are available for research and the advancement of evidence-based dentistry. In this work we developed a centralized data repository derived from electronic health records (EHRs) at four dental schools participating in the Consortium of Oral Health Research and Informatics. A multi-stakeholder committee developed a data governance framework that encouraged data sharing while allowing control of contributed data. We adopted the i2b2 data warehousing platform and mapped data from each institution to a common reference terminology. We realized that dental EHRs urgently need to adopt common terminologies. While all used the same treatment code set, only three of the four sites used a common diagnostic terminology, and there were wide discrepancies in how medical and dental histories were documented. BigMouth was successfully launched in August 2012 with data on 1.1 million patients, and made available to users at the contributing institutions.