Comparing the Salzmann Index to automatic qualifying conditions when selecting medically necessary orthodontic patients.

INTRODUCTION: This study compared the Salzmann Index (SI) to the American Association of Orthodontists-proposed Automatic Qualifying Conditions (AQC) list in determining eligibility for medically necessary orthodontic care (MNOC). In Pennsylvania, The SI must reflect a score of ≥25, whereas the AQCs are considered binary indicators of a treatment need-the presence of any AQC qualifies a patient for treatment under Medicaid. This study was designed to determine whether the same patients are selected as eligible for MNOC regardless of which selection method is used. METHODS: The orthodontic records of 139 participants aged 10-17 years were used to calculate SI scores and identify any AQCs present. McNemar's test of agreement was used to compare patients selected for treatment needs on the basis of SI to those selected on the basis of the presence of an AQC. RESULTS: The mean SI score was 14.7. Twelve patients (8.6%) were selected for treatment needs because of an SI of ≥25, whereas 44 patients (31.7%) were deemed to have at least 1 AQC present. Of the 44 patients with AQCs, only 11 had SI scores of ≥25. McNemar's test of agreement found that SI score and AQC presence did not select patients similarly (P <0.001). CONCLUSIONS: The SI and AQCs do not appear to select the same patients for MNOC, suggesting that replacing the SI with a list of AQCs would significantly impact which patients are selected for Medicaid-funded orthodontic care in Pennsylvania.

Relationship of 3 indexes of orthodontic treatment need used by Medicaid and oral health-related quality of life.

INTRODUCTION: This study aimed to assess the relationship between 3 indexes of orthodontic treatment need that are used by Medicaid, namely the Salzmann Index (SI), the handicapping labiolingual deviation (HLD) Index, and the HLD California Modification Index, and oral health-related quality of life (OHRQOL). METHODS: The orthodontic records of 100 participants aged 11-14 years were used to calculate occlusal index scores. The condition-specific oral impacts on daily performances (OIDP) index questionnaire was used to quantify OHRQOL and to identify detriments attributable to malocclusion-related conditions (MRCs). The relationship between occlusal index scores and OHRQOL was analyzed using descriptive statistics, Spearman rank-order and biserial correlations, and logistic regression. RESULTS: The mean index scores were: SI, 15.4; HLD, 13.2; and HLD California Modification, 15.8. Ninety percent of participants did not have normative orthodontic treatment need according to current index criteria. OIDP scores were not normally distributed, and the mean score was 3.1. Of those participants who reported an impact, 83% attributed at least 1 of those impacts to MRCs; however, 90% of these were of mild or moderate intensity. Smiling was the performance most impacted by MRCs. The only statistically significant correlation between an occlusal index and OIDP scores was for the SI, though this association was weak (r = 0.27). None of the variables used in the logistic regression model (age, sex, 3 index scores) were significant predictors of OHRQOL. CONCLUSIONS: No meaningful association exists between the 3 indexes studied and OHRQOL. These findings challenge the validity of current systems for the allocation of Medicaid-funded orthodontic treatment.

Influence of maxillary lateral incisor width ratio on perception of smile esthetics among orthodontists and laypersons.

OBJECTIVE: This study aimed to analyze the impact of different maxillary lateral incisor width ratios on the perception of smile esthetics among orthodontists and laypersons. METHODS: A smile photograph of a male subject showing the lips and gingival margins was selected. The smile was standardized for maxillary central incisor width proportions and ideally perceived smile esthetics. The maxillary lateral incisor width was symmetrically modified in increments of ratios of the central incisor from a ratio of 4:10 to a ratio of 8:10. The images were analyzed by 283 laypersons and 83 orthodontists who ranked the level of attractiveness using a visual analog scale. RESULTS: There were significant differences between the esthetic perception of the five different width ratios, and between the orthodontists and laypersons in their evaluations of esthetics (P < 0.0004). There were no significant differences in esthetic evaluations between genders. CONCLUSIONS: For orthodontists, the most attractive width ratio was 5.7:10, while the highest ranked ratio among laypersons was 8:10, although laypersons ranked all ratios very similarly. Both groups ranked the width ratio of 4:10 the lowest. Orthodontists were more critical in their assessment of esthetics. CLINICAL SIGNIFICANCE: To what proportions or protocol should a peg-shaped maxillary lateral incisor or missing lateral, that is, to be replaced with an implant/crown be restored? This is an important clinical question that is often encountered by the orthodontist and the restoring dentist. The literature suggests that orthodontists and laypeople have different perceptions of smile esthetics, and it is important to have patient centered goals when treatment planning. Further research is necessary to identify the width ratio of which the lateral incisor is perceived to be esthetic as well as the ideal ratio to consider when restoring lateral incisors. This research assessed and compared the perception that orthodontists and laypeople have on smile esthetics regarding different width ratios of lateral incisors.

The Salzmann Index and discrepancy index correlation: Determining a threshold discrepancy index score for Medicaid approval.

INTRODUCTION: This study aimed to compare patients' Salzmann Index scores for those who applied for Medicaid orthodontic coverage in Pennsylvania with their corresponding American Board of Orthodontics discrepancy index (DI) scores to assess if there is a correlation between Salzmann and DI scores. In addition, a threshold DI score was calculated that would correspond to Medicaid coverage approval. The study intended to answer the following questions: is there a correlation of 0.7 or greater between a patient's Salzmann Index and their DI? If so, is there a particular DI score that can be used as the minimum score for approving Medicaid orthodontic coverage in the state of Pennsylvania? METHODS: Salzmann Index scores, DI scores, and approval and disapproval results for Medicaid orthodontic coverage were obtained from 104 subjects aged between 10 and 17 years. A linear regression model was generated to assess if there was a correlation between the Salzmann scores and DI scores. If a correlation coefficient of 0.7 or greater were found, a threshold Salzmann Index score would be determined for subjects who were approved for Medicaid orthodontic coverage. The threshold Salzmann score would be used in the linear regression formula to find the corresponding DI score, which would be designated as the threshold DI score for approval for Medicaid orthodontic coverage in the state of Pennsylvania. RESULTS: A Pearson correlation of 0.453 was calculated between the 104 Salzmann scores and DI scores, demonstrating a moderate correlation. With the correlation coefficient being lower than 0.7, binary logistic regressions were calculated to assess the predictability between a given Salzmann score and approval and disapproval for Medicaid orthodontic coverage. The Salzmann score had an overall 68.3% success in predicting Medicaid orthodontic coverage approval/disapproval. Of the 58 subjects that were approved for Medicaid orthodontic coverage, 46.6% had Salzmann scores equal to or greater than 25. Of the 46 subjects that were disapproved for Medicaid orthodontic coverage, 78.3% had Salzmann scores equal to or less than 24. CONCLUSIONS: With the lack of high prediction rates seen from the results of the regression models, the current system of Medicaid does not appear to show consistency for assessing the need for orthodontic treatment coverage. Multiple insurance companies that participate under Medicaid require a Salzmann score of 25 or greater for approval; however, the results show the Salzmann score is arbitrary in terms of approval and disapproval. There appear to be underlying factors apart from the Salzmann score that the Pennsylvania Medicaid system uses to justify whether a patient was approved or denied for coverage.

Effects of a video guided T'ai Chi group intervention on center of balance and falls efficacy: a pilot study.

This pilot study evaluated effects of a video-guided T'ai Chi group intervention on center of balance (COB) and falls efficacy, using a one arm, pre/post design. Thirty-two participants began the study, 17 completed pre- and post-testing and 15 were lost to follow-up. Outcomes were compared for the 17 participants who completed pre- and post-testing and subgroups based on session attendance. Irrespective of session attendance, participant COB scores improved. There was a significant negative correlation between number of sessions attended and pre and post scores on the fall efficacy (fear of falling) measure, indicating those with higher fear of falling were less likely to complete the study. Older participants were also less likely to continue participation. Findings indicate potential benefits of T'ai Chi in improving COB (a fall risk factor) among community-dwelling older adults. However, those with greater potential benefit (higher fear scores, older participants) were less likely to continue participation.

Perceptions of midline deviations among different facial types.

INTRODUCTION: The correction of a deviated midline can involve complicated mechanics and a protracted treatment. The threshold below which midline deviations are considered acceptable might depend on multiple factors. The objective of this study was to evaluate the effect of facial type on laypersons' perceptions of various degrees of midline deviation. METHODS: Smiling photographs of male and female subjects were altered to create 3 facial type variations (euryprosopic, mesoprosopic, and leptoprosopic) and deviations in the midline ranging from 0.0 to 4.0 mm. Evaluators rated the overall attractiveness and acceptability of each photograph. RESULTS: Data were collected from 160 raters. The overall threshold for the acceptability of a midline deviation was 2.92 ± 1.10 mm, with the threshold for the male subject significantly lower than that for the female subject. The euryprosopic facial type showed no decrease in mean attractiveness until the deviations were 2 mm or more. All other facial types were rated as decreasingly attractive from 1 mm onward. Among all facial types, the attractiveness of the male subject was only affected at deviations of 2 mm or greater; for the female subject, the attractiveness scores were significantly decreased at 1 mm. The mesoprosopic facial type was most attractive for the male subject but was the least attractive for the female subject. CONCLUSIONS: Facial type and sex may affect the thresholds at which a midline deviation is detected and above which a midline deviation is considered unacceptable. Both the euryprosopic facial type and male sex were associated with higher levels of attractiveness at relatively small levels of deviations.

Critical thinking skills in nursing students: comparison of simulation-based performance with metrics.

AIM: This paper is a report of an examination of the relationship between metrics of critical thinking skills and performance in simulated clinical scenarios. BACKGROUND: Paper and pencil assessments are commonly used to assess critical thinking but may not reflect simulated performance. METHODS: In 2007, a convenience sample of 36 nursing students participated in measurement of critical thinking skills and simulation-based performance using videotaped vignettes, high-fidelity human simulation, the California Critical Thinking Disposition Inventory and California Critical Thinking Skills Test. Simulation-based performance was rated as 'meeting' or 'not meeting' overall expectations. Test scores were categorized as strong, average, or weak. RESULTS: Most (75.0%) students did not meet overall performance expectations using videotaped vignettes or high-fidelity human simulation; most difficulty related to problem recognition and reporting findings to the physician. There was no difference between overall performance based on method of assessment (P = 0.277). More students met subcategory expectations for initiating nursing interventions (P ≤ 0.001) using high-fidelity human simulation. The relationship between videotaped vignette performance and critical thinking disposition or skills scores was not statistically significant, except for problem recognition and overall critical thinking skills scores (Cramer's V = 0.444, P = 0.029). There was a statistically significant relationship between overall high-fidelity human simulation performance and overall critical thinking disposition scores (Cramer's V = 0.413, P = 0.047). CONCLUSION: Students' performance reflected difficulty meeting expectations in simulated clinical scenarios. High-fidelity human simulation performance appeared to approximate scores on metrics of critical thinking best. Further research is needed to determine if simulation-based performance correlates with critical thinking skills in the clinical setting.

Critical thinking ability of new graduate and experienced nurses.

AIM: This paper is a report of a study to identify critical thinking learning needs of new and experienced nurses. BACKGROUND: Concern for patient safety has grown worldwide as high rates of error and injury continue to be reported. In order to improve patient safety, nurses must be able to recognize changes in patient condition, perform independent nursing interventions, anticipate orders and prioritize. METHODS: In 2004-2006, a consecutive sample of 2144 newly hired nurses in a university-affiliated healthcare system completed the Performance Based Development System Assessment consisting of 10 videotaped vignettes depicting change in patient status. Results were reported as meeting or not meeting expectations. For nurses not meeting expectations, learning needs were identified in one of six subcategories. RESULTS: Overall, 74.9% met assessment expectations. Learning needs identified for nurses not meeting expectations included initiating independent nursing interventions (97.2%), differentiation of urgency (67%), reporting essential clinical data (65.4%), anticipating relevant medical orders (62.8%), providing relevant rationale to support decisions (62.6%) and problem recognition (57.1%). Controlling for level of preparation, associate (P=0.007) and baccalaureate (P<0.0001) nurses were more likely to meet expectations as years of experience increased; a similar trend was not seen for diploma nurses (P=0.10). Controlling for years of experience, new graduates were less likely to meet expectations compared with nurses with >or=10 years experience (P=0.046). CONCLUSION: Patient safety may be compromised if a nurse cannot provide clinically competent care. Assessments such as the Performance Based Development System can provide information about learning needs and facilitate individualized orientation targeted to increase performance level.

Comparing the plaque-removal ability of a triple-headed toothbrush versus a conventional manual toothbrush in adolescents with fixed orthodontic appliances: A single-center, randomized controlled clinical trial.

OBJECTIVE: The objective of this trial was to compare the plaque removal ability of a triple-headed toothbrush to a conventional manual toothbrush in adolescents with fixed orthodontic appliances. MATERIALS AND METHODS: Sixty adolescent patients undergoing orthodontic treatment were randomly assigned to brush one time with either a conventional manual toothbrush or a triple-headed toothbrush. The main outcome was the post-brushing plaque index as measured by the Silness-Löe plaque index. RESULTS: Sixty patients (mean age, 14.2; standard deviation, 1.65) were randomized in a 1:1 ratio to either a manual toothbrush group or a triple-headed toothbrush group. Baseline characteristics were similar between the two groups. There were no dropouts. The mean post-brushing plaque index was 0.84 (95% CI, 0.67-1.02; SD, 0.60) for the conventional manual toothbrush group, and 0.31 (95% CI, 0.13-0.49; SD, 0.48) for the triple-headed toothbrush group. There was a statistically significant difference in the mean plaque index of 0.53 (95% CI, 0.28-0.78; P<0.001) between the two groups after brushing. No harms were observed. CONCLUSION: The results of this study indicate strong evidence that the triple-headed toothbrush leads to a significantly lower plaque index compared to the conventional manual toothbrush post-brushing.

Long-term dental and skeletal effects of mandibular advancement devices in adults with obstructive sleep apnoea: A systematic review.

OBJECTIVE: This systematic review aimed to clarify whether there are any significant long-term sequelae to wearing mandibular advancement devices focusing on dental and skeletal effects in adults with OSA. MATERIALS AND METHODS: Databases, including PubMed, Medline, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and SAGE Journals. Hand searches and grey literature were also used. A piloted data collection form was used to extract the appropriate data. RESULTS: Twenty-three reports of 19 studies were included. Five had serious risk of bias while 18 had moderate risk of bias. Meta-analysis revealed a significant change in overbite and overjet. I-squared analysis showed a high level of statistical heterogeneity. A moderate correlation was found between wear time and amount of change. CONCLUSION: Mandibular advancement devices will cause a small but statistically significant change in the dentition of long-term wearers. Skeletal changes are generally secondary to dental changes.

Can nurses impact patient outcomes using a patient-centered care model?

OBJECTIVE: The aim of this study was to determine if nurses, using patient-centered care (PCC), affect patient satisfaction, perceptions of nursing care, and quality outcomes. BACKGROUND: The Institute of Medicine proposed PCC as 1 of 6 national quality aims, whereas the Centers for Medicare and Medicaid Services highlighted integration of PCC as 1 of 12 actions for quality improvement. METHODS: A total of 116 patients were randomized into an intervention (PCC) or control group. Patients who were to receive PCC were called before admission and cared for by nurses who trained to administer/practice PCC. Control patients received usual care. Both groups completed questionnaires and received postdischarge calls. Length of stay, falls, infections, and adverse events were measured to assess quality of care. RESULTS: No significant differences were found between groups for length of stay, infection, falls, postoperative complications, quality of care, satisfaction level, or perceptions of nursing care. CONCLUSIONS: Patient-centered care did not affect patient's level of satisfaction or quality of care. However, findings yielded clinically relevant results regarding patient/staff responses.

Effect of patient-centered care on patient satisfaction and quality of care.

A clinical randomized study (posttest design) was conducted to examine whether patient-centered care (PCC) impacts patient satisfaction, perception of nursing care, and quality of care. Differences were seen in 2 of 3 subscales within the Baker and Taylor Measurement Scale. The PCC group rated satisfaction (P = .04) and quality of services (P = .03) higher than controls. PCC may impact patients' perception of the level of satisfaction and quality of care received.

Comparison of 2 models for managing tracheotomized patients in a subacute medical intensive care unit.

OBJECTIVE: To compare 2 models for managing patients admitted to a subacute medical intensive care unit (MICU) who required prolonged mechanical ventilation (> or = 7 d). METHODS: The subjects were 192 consecutive patients (mean +/- SD age 61.5 +/- 16.1 y, 52% male, 86% white) managed during alternating 7-month blocks of time by an attending physician in collaboration with an acute care nurse practitioner (ACNP) (n = 98 patients) or by an attending physician in collaboration with critical care/pulmonary fellows (n = 94 patients). The total observation time was 28 months (14 mo per team). RESULTS: At unit entry, there were no significant differences in age, sex, race, comorbidity, Acute Physiology and Chronic Health Evaluation III score, or time of tracheostomy between the patients managed by the 2 teams. Patients managed by the ACNP team were more likely to have required mechanical ventilation due to an acute pulmonary problem (p = 0.005). At subacute MICU discharge, the groups were not significantly different in regard to subacute MICU length of stay, days on mechanical ventilation, or discharge weaning status (p > 0.05). The number of readmissions to the MICU was similar for the ACNP team (n = 7) and fellows team (n = 8), as were readmissions to the subacute MICU < or = 72 h after discharge (ACNP = 2, fellows = 1). Each team had 2 deaths without treatment limitation. CONCLUSION: As hypothesized, management of patients who required prolonged mechanical ventilation with tracheostomy had equivalent outcomes with the ACNP team or the fellows team.

Enhancing Nurses' Pain Assessment to Improve Patient Satisfaction.

Patient satisfaction with pain management has increasing importance with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores tied to reimbursement. Previous studies indicate patient satisfaction is influenced by staff interactions. This single-group pre/post design study aimed to improve satisfaction with pain management in older adults undergoing total joint replacement. This was a single-group pre-/posttest design. Nurse (knowledge assessment) and patient (American Pain Society Patient Outcomes Questionnaire Revised [APS-POQ-R], HCAHPS) responses evaluated pre- and postimplementation of the online educational program. Nurse focus group followed intervention. Nurses' knowledge improved significantly (p < .006) postintervention. HCAHPS scores (3-month average) for items reflecting patient satisfaction improved from 70.2 ± 9.5 to 73.9 ± 6.0. APS-POQ-R scores did not change. Focus group comments indicated need for education regarding linkages between pain management and patient satisfaction. Education on linkages between patient satisfaction and pain management can improve outcomes; education on strategies to further improve practice may enhance ability to achieve benchmarks.

Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit.

BACKGROUND: Many academic medical centers employ nurse practitioners as substitutes to provide care normally supplied by house staff. OBJECTIVE: To compare outcomes in a subacute medical intensive care unit of patients managed by a team consisting of either an acute care nurse practitioner and an attending physician or an attending physician and critical care/pulmonary fellows. METHODS: During a 31-month period, in 7-month blocks of time, 526 consecutive patients admitted to the unit for more than 24 hours were managed by one or the other of the teams. Patients managed by the 2 teams were compared for a variety of outcomes. RESULTS: Patients managed by the 2 teams did not differ significantly for any workload, demographic, or medical condition variable. The patients also did not differ in readmission to the high acuity unit (P = .25) or subacute unit (P = .44) within 72 hours of discharge or in mortality with (P = .25) or without (P = .89) treatment limitations. Among patients who had multiple weaning trials, patients managed by the 2 teams did not differ in length of stay in the subacute unit (P = .42), duration of mechanical ventilation (P = .18), weaning status at time of discharge from the unit (P = .80), or disposition (P = .28). Acute Physiology Scores were significantly different over time (P = .046). Patients managed by the fellows had more reintubations (P=.02). CONCLUSIONS: In a subacute intensive care unit, management by the 2 teams produced equivalent outcomes.

Perception of facial attractiveness following modification of the nose and teeth.

OBJECTIVE: We investigated how laypeople perceive persons with straight teeth and nose, mild to moderate modification of the nose, and mild to moderate modification of the teeth. The objectives were to determine: (1) how modification of the nose or teeth affects others' perceptions of target persons' facial attractiveness, (2) whether these evaluations are affected by the target persons' or raters' gender, (3) whether the frontal view or three-quarter view has any effect on the ratings. MATERIALS AND METHODS: Survey data were collected from 226 college students at Seton Hill University (49% male, 51% female; age range, 18-25 years) who rated, on a 100mm VAS, photos of subjects with straight teeth and nose (control), mild to moderate modification of the nose, and mild to moderate modification of the teeth from the frontal and three-quarter views. RESULTS: Male and female target photos with teeth modification were considered the least attractive. Both male and female target photos showed that female raters evaluated both control and nose modification conditions more positively than did male raters. For male and female target photos, the frontal view was less esthetically pleasing under teeth modification. CONCLUSIONS: Both male and female evaluators judged teeth modification as the least attractive compared to nose modification. It is recommended for rhinoplasty patients with malaligned teeth that it may be beneficial for cosmetic surgeons to establish an interdisciplinary approach working with orthodontists.

The influence of text messaging on oral hygiene effectiveness.

OBJECTIVE: To investigate whether text message reminders regarding oral hygiene have an effect on plaque removal in orthodontic patients. MATERIALS AND METHODS: In this randomized, controlled clinical trial, 50 orthodontic patients were assigned to either a text message or control group. Patients in the text message group received 12 text messages over the course of 4 weeks and one text message for 8 weeks thereafter. Photos were taken at baseline (T0), at 4 weeks after baseline (T1), and at 12 weeks after baseline (T2). For each subject, photos of eight teeth were taken and then the area of the tooth and amount of plaque were measured using planimetry. RESULTS: There was a statistically significant difference in plaque coverage between baseline and both T1 and T2 in the text message group as measured using planimetry. This was demonstrated by comparing the average measurements of the control group and the treatment group. CONCLUSION: This study demonstrated that the use of automated text message reminders sent from an orthodontic office was effective in improving oral hygiene compliance in orthodontic patients.

Postthoracotomy Pain Syndrome Following Surgery for Lung Cancer: Symptoms and Impact on Quality of Life.

Postthoracotomy pain syndrome (PTPS) is a common complication following thoracic surgery. Most studies examining the influence of PTPS on patient-reported symptoms include few patients managed using a minimally invasive approach. Associated sensory changes, potentially neuropathic in origin, are not well described. We therefore examined the symptoms and quality of life (QOL) of patients with and without PTPS who underwent a standard thoracotomy (n = 43) or minimally invasive surgery (n = 54). Patients in this prospective, cross-sectional study completed questionnaires to assess pain (McGill Pain Questionnaire), neuropathic symptoms (Neuropathic Symptom Questionnaire), symptom distress (Symptom Distress Scale), anxiety and depression (Hospital Anxiety and Depression Scale), and QOL (Functional Assessment Cancer Therapy-Lung). Excepting younger age (p = .009), no demographic or surgical characteristic differentiated patients with and without PTPS. Patients with PTPS described discomfort as pain only (15.1%), neuropathic symptoms only (30.2%) or pain and neuropathic symptoms (54.7%). Scores differed between patients with and without PTPS for symptom distress (p < .001), anxiety and depression (p < .001), and QOL (p = .009), with higher distress associated with PTPS. Despite new surgical techniques, PTPS remains common and results in considerable distress. A focused assessment is needed to identify all experiencing this condition, with referral to pain management specialists if symptoms persist.