Development and Acceptability of a Kidney Therapy Decision Aid for Patients Aged 75 Years and Older: A Design-Based Research Involving Patients, Caregivers, and a Multidisciplinary Team.

Rationale & Objective: Many older adults prefer quality of life over longevity, and some prefer conservative kidney management (CKM) over dialysis. There is a lack of patient-decision aids for adults aged 75 years or older facing kidney therapy decisions, which not only include information on dialysis and CKM but also encourage end-of-life planning. We iteratively developed a paper-based patient-decision aid for older people with low literacy and conducted surveys to assess its acceptability. Study Design: Design-based research. Setting and Participants: Informed by design-based research principles and theory of behavioral activation, a multidisciplinary team of experts created a first version of the patient-decision aid containing 2 components: (1) educational material about kidney therapy options such as CKM, and (2) a question prompt list relevant to kidney therapy and end-of-life decision making. On the basis of the acceptability input of patients and caregivers, separate qualitative interviews of 35 people receiving maintenance dialysis, and with the independent feedback of educated layperson, we further modified the patient-decision aid to create a second version. Analytical Approach: We used descriptive statistics to present the results of acceptability surveys and thematic content analyses for patients' qualitative interviews. Results: The mean age of patients (n=21) who tested the patient-decision aid was 80 years and the mean age of caregivers (n=9) was 70 years. All respondents held positive views about the educational component and would recommend the educational component to others (100% patients and caregivers). Most of the patients reported that the question prompt list helped them put concerns into words (80% patients and 88% caregivers) and would recommend the question prompt list to others (95% patients and 100% caregivers). Limitations: Single-center study. Conclusions: Both components of the patient-decision aid received high acceptability ratings. We plan to launch a larger effectiveness study to test the outcomes of a decision-supporting intervention combining the patient-decision aid with palliative care-based decision coaching.

Utilization of Low-Magnitude High-Frequency Vibration (LMHFV) as an Aid in Treating Peri-Implantitis: Case Presentations.

Peri-implantitis is an inflammatory process initiating in the soft tissue and then progressing to the hard tissue surrounding dental implants leading to loss of osseous support and potential loss of the implant if not identified early in the process. This process initiates in the soft tissue, which become inflamed spreading to the underlying bone leading to decreases in bone density with subsequent crestal resorption and thread exposure. In the absence of treatment of the peri-implantitis, the bone loss at the osseous implant interface progresses with inflammatory mediated decrease in the bone density that moves apically, eventually leading to mobility of the implant and its failure. Low-magnitude high-frequency vibration (LMHFV) has been shown to improve bone density, stimulate osteoblastic activity, and arrest progression of peri-implantitis with improvement of the bone or graft around the affected implant with or without surgery as part of the treatment. Two cases are presented using LMHFV to augment treatment.

The systemic oral health connection: Biofilms.

Frequently, periodontal health and it's associated oral biofilm has not been addressed in those patients who have systemic health issues, especially those who are not responding to medical treatment via their physician. Oral biofilm may be present in the periodontal sulcus in the absence of clinical disease of periodontal disease (bleeding on probing, gingival inflammation) and periodontal reaction is dependent on the patient's immune response to the associated bacterial and their byproducts. Increasing evidence has been emerging the past decade connecting oral biofilm with systemic conditions, either initiating them or complicating those medical conditions. The patient's health needs to be thought of as a whole-body system with connections that may originate in the oral cavity and have distant affects throughout the body. To maximize total health, a coordination in healthcare needs to be a symbiosis between the physician and dentist to eliminate the oral biofilm and aid in prevention of systemic disease or minimize those effects to improve the patient's overall health and quality of life. Various areas of systemic health have been associated with the bacteria and their byproducts in the oral biofilm. Those include cardiovascular disease, chronic kidney disease, diabetes, pulmonary disease, prostate cancer, colon cancer, pancreatic cancer, pre-term pregnancy, erectile dysfunction Alzheimer's disease and Rheumatoid arthritis. This article will discuss oral biofilm, its affects systemically and review the medical conditions associated with the oral systemic connection with an extensive review of the literature.

Reversal of Advanced Directives in Neurologic Emergencies.

Objective: Patients with advanced directives or Medical Orders for Life-Sustaining Treatment (MOLST), including "Do Not Resuscitate" (DNR) and/or "Do Not Intubate" (DNI), may be candidates for procedural interventions when presenting with acute neurologic emergencies. Such interventions may limit morbidity and mortality, but typically they require MOLST reversal. We investigated outcomes of patients with MOLST reversal for treatment of neurologic emergencies. Methods: We conducted a retrospective chart review from July 1, 2019 to April 30, 2021 of patients with MOLST reversal treated in our NeuroMedicine Intensive Care Unit. Variables collected include neurologic disease, MOLST reversal decision maker, procedural interventions, and outcomes. Results: Twenty-seven patients (18 female, median age 78 years (IQR 73-85 years), median baseline modified Rankin score 1 [IQR 0-2.5] were identified with MOLST reversal. The most common pre-procedural MOLST was DNR/DNI (n=22, 81%), and 93% (n=25) pre-procedural MOLSTs were completed by the patient. MOLSTs were reversed by surrogates in n=23 cases (85%). The median time from MOLST completion to MOLST reversal was 603 days (IQR 45 days to 4 years). The most common neurologic emergency was ischemic stroke (n=14, 52%). Most patients died (n=14, 52%), 26% (n=7) were discharged to skilled nursing, and 22% (n=6) returned to home or assisted living. Conclusions: In neurologic emergencies, urgent shared decision making is needed to ensure goal-concordant care, which may result in reversal of existing advanced directives. Outcomes of patients with MOLST reversal were heterogeneous, emphasizing the importance of deliberate patient-centered care weighing the risks and benefits of each intervention.

Increasing Lateral Ridge Width for Implant Placement Using Calcium Sulphate Bone Cement Technique.

Dental implant practitioners are often faced with a presentation of a narrow crest, making it difficult or impossible for implant placement and requiring modification of the ridge to allow implants to be utilized. Many different factors need to be considered when choosing the technique to expand the ridge laterally. Ideally, the technique should facilitate the goal of ridge width increase while reducing inflammation and postoperative pain for the patient. In this study, patients were treated for lateral ridge augmentation to improve ridge width using a calcium sulphate-based bone cement with a protocol that does not require membrane placement at the time of grafting. This minimally invasive, relatively economical surgical technique is aimed at improving postoperative comfort for patients while permitting widening of the lateral ridge.

Current State of Bone Replacement Grafting Materials for Dental Implants.

Contemporary dental implant therapy has flourished in recent years thanks in large part to advances made in bone augmentation capabilities. Bone grafts, which are often crucial to the success of implant restorations, are used mainly in three instances: at the time of extraction for delayed implant placement, when an immediate-socket implant is placed, and for ridge augmentation either laterally or vertically. Many bone grafting options are available to the surgeon depending on the site to be treated and the requirements in the area. Bone grafts and barriers come from different sources and are seen by the body's cell types in different manners. This yields a variety of biological outcomes, some of which have been published while others are in the process of being studied.

Socket Preparation for Delayed Implant Placement Using a Mineralized Cancellous Allograft.

Various materials have been used for extraction socket preservation in anticipation of implant placement or to limit resorption of socket walls. Materials have ranged from autogenous bone, allografts, and xenografts to synthetics. Ideally, the graft material being placed into the socket at the time of extraction should fully convert to host bone to yield vital bone that will permit implant osseointegration with as much contact between bone and the implant surface as possible. This article reviews different materials and presents two cases in which extraction of a molar was required and future implant placement planned.

Inhibition of osteoclast activities by SCPC bioceramic promotes osteoblast-mediated graft resorption and osteogenic differentiation.

Maximizing vital bone in a grafted site is dependent on a number of factors. These include resorption or turnover of the graft material, stimulation of bone formation pathway without a need for biological molecules added to the site and inhibition of cellular activities that compromise the mineralization of new bone matrix. In the present study, the dissolution profile of silica-calcium phosphate composite (SCPC) in physiological solution was measured and the data were fed to (ANN-NARX) prediction model to predict the time required for complete dissolution. The inductively coupled plasma-optical emission spectrometer ionic composition analysis of the culture medium incubated for 3 days with SCPC showed 57% decrease in Ca concentration and a significant increase in the concentration of Si (13.5 ± 1.8 µg/ml), P (249.4 ± 22 µg/ml), and Na (9.3 ± 0.52 µg/ml). In conjunction with the release of Si, P, and Na ions, the bone resorptive activity of osteoclasts was inhibited as indicated by the significant decrease in multinucleated tartrate resistant acidic phosphate stained cells and the volume of resorption pits on bone slices. In contrast, addition of SCPC to hBMSC cultured in conventional medium promoted higher Runt-related transcription factor 2 (p < .05), osteocalcin (p < .01), and bone sialo protein (p < .01) than that expressed by control cells grown in the absence of SCPC. The predicted dissolution time of 200 mg of porous SCPC particles in 10 ml phosphate buffered saline is 6.9 months. An important byproduct of the dissolution is inhibition of osteoclastic activity and promotion of osteoblastic differentiation and hence bone formation.

Re-ACT: Remote Advanced Communication Training in a Time of Crisis.

BACKGROUND: We used a quality improvement framework to transform two-day and in-person advanced communication training (ACT) course into a remote ACT (Re-ACT) format to help clinicians improve serious illness conversation (SIC) skills. MEASURES: We assessed the reach, impact, and costs of Re-ACT and compared these measures to in-person ACT courses. INTERVENTIONS: About 45-60 minutes of synchronous, remote sessions consisting of a didactic introduction to SIC skills, tailored to the SARS-Cov-2 (COVID-19) crisis, and a live demonstration of SICs with patient-actors. OUTCOMES: The transition to Re-ACT sessions resulted in reaching a greater number of clinicians in less time, although depth of content and opportunities for skill practice decreased. Although both formats were well received, Re-ACT respondents felt less prepared than ACT respondents to use SIC skills. The costs of Re-ACT were significantly less than in-person ACT courses. CONCLUSIONS/LESSONS LEARNED: We provided effective and well-received SIC training during a time of crisis. Future work should further define the optimal mix of in-person and remote experiences to teach SIC skills.

Bone regeneration and graft material resorption in extraction sockets grafted with bioactive silica-calcium phosphate composite (SCPC) versus non-grafted sockets: clinical, radiographic, and histological findings.

PURPOSE: The purpose of the present study was to evaluate the effect of silica-calcium phosphate composite (SCPC) granules on bone regeneration in extraction sockets. METHODS: Ten patients were selected for a split-model study. In each patient, bone healing in SCPC-grafted and control ungrafted sockets was analyzed through clinical, radiographic, histomorphometric, and immunohistochemical assessments 6 months postoperatively. RESULTS: A radiographic assessment using cone-beam computed tomography showed minimal ridge dimension changes in SCPC-grafted sockets, with 0.39 mm and 1.79 mm decreases in height and width, respectively. Core bone biopsy samples were obtained 6 months post-extraction during implant placement and analyzed. The average percent areas occupied by mature bone, woven bone, and remnant particles in the SCPC-grafted sockets were 41.3%±12%, 20.1%±9.5%, and 5.3%±4.4%, respectively. The percent areas of mature bone and woven bone formed in the control ungrafted sockets at the same time point were 31%±14% and 24.1%±9.4%, respectively. Histochemical and immunohistochemical analyses showed dense mineralized bundles of type I collagen with high osteopontin expression intensity in the grafted sockets. The newly formed bone was well vascularized, with numerous active osteoblasts, Haversian systems, and osteocytes indicating maturation. In contrast, the new bone in the control ungrafted sockets was immature, rich in type III collagen, and had a low osteocyte density. CONCLUSIONS: The resorption of SCPC granules in 6 months was coordinated with better new bone formation than was observed in untreated sockets. SCPC is a resorbable bone graft material that enhances bone formation and maturation through its stimulatory effect on bone cell function. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03897010.

An Algorithmic Approach to Evaluation of an Ailing Implant.

With the incidence of failed and ailing dental implants increasing, the authors conducted research to evaluate and characterize all known criteria used in the assessment of implant health in the clinical setting. A review of articles found in electronic databases was performed. Once all parameters for implant assessment as supported by current literature were selected, implant assessment documents were created: a data acquisition form and a quantitative comprehensive evaluation. These documents provide the clinician an algorithm that yields a prognosis of survival for each implant. Diagnostic criteria were organized to offer a comprehensive assessment of risk factors related to implant health. Data acquisition prior to establishing the prognosis is necessary in accordance with the staging system developed. Parameters for diagnosis and staging include a thorough medical/social history of the patient, implant history, and clinical evaluation. The authors concluded that the establishment of parameters for comprehensive implant evaluation in the clinical setting is feasible. This assessment process enables an effective clinical approach to evaluate and treat ailing implants while facilitating a clinical diagnostic algorithm.

Sulcular Modified Internal Labial Enhancement (SMILE) Technique for Gingival Augmentation.

The concept of periodontal root coverage has evolved over many years. To achieve high predictability a minimally invasive approach that reduces morbidity and can provide root coverage for multiple teeth in the same surgery is needed. This article describes a novel approach that represents a progression of the latest tunneling techniques in root coverage. The somewhat unique method utilizes fewer instruments than other similar techniques and incorporates the use of platelet-rich fibrin.

Symptom burden among individuals with Parkinson disease: A national survey.

OBJECTIVE: To explore disease burden in Parkinson disease (PD) by evaluating the prevalence of symptoms and key disease milestones (critical events, e.g., hospitalization or frequent falls) and their association with quality of life (QOL) in those with PD. METHODS: We created and pretested an online needs assessment survey to evaluate the clinical characteristics, QOL, symptom prevalence, and critical event frequency among those with PD. We recruited individuals with self-reported Hoehn and Yahr stage II-V PD through online postings and email through the Davis Phinney Foundation. We used logistic regression to evaluate the association between a large number of uncontrolled symptoms and events on QOL. RESULTS: A total of 612 individuals (mean age 70.1 years, 49.8% women) completed the survey. Among respondents, 13.6% reported poor QOL. Nearly 20% of respondents reported >3 falls, and 15% of respondents had been hospitalized over the previous 6 months. Participants had an average of 5.1 uncontrolled symptoms, with 86.1% of respondents reporting at least 1 uncontrolled symptom; more than 10% of respondents reported >10 uncontrolled symptoms. Depression, confusion, pain, and bothersome hallucinations were associated with poor QOL among the cohort. CONCLUSIONS: In this national survey of individuals with PD, we identified poor QOL, frequent critical events, and numerous uncontrolled symptoms among a substantial proportion of respondents. Although motor symptoms were common, only nonmotor symptoms were associated with poor QOL. Many of these symptoms and events are treatable or preventable, highlighting the need for better identification and management to improve QOL among those with PD.

Autogenous Dentin Grafting of Osseous Defects Distal to Mandibular Second Molars After Extraction of Impacted Third Molars.

Bone loss at the distal aspect of mandibular second molars frequently is reported after extraction of impacted third molars. Typically, osseous grafting of the extraction site is not routinely performed. This study examined osseous healing following guided bone regeneration treatment of osseous defects distal to mandibular second molars after surgical removal of impacted mesioangularly or horizontally inclined third molars using the processed third molar as the graft material. For the study, 13 patients who required impacted third molar extractions were selected based on angulation of impaction. Patients requiring bilateral extractions were designated for a split-mouth study, while others were selected based on impaction angulation as a random study group. After surgical extraction of the third molars, the extracted teeth were stripped of any soft tissue, including the periodontal ligament, then ground and disinfected using a dentin grinding protocol to produce an autogenous dentin graft (ADG). This graft was then placed into the extraction socket and covered with a hemostatic sponge prior to site closure. Patients in the control group underwent the same procedure as those in the study group except that no ADG was placed in the socket and only a hemostatic sponge was placed prior to wound closure. Clinical and radiological examinations were performed, including panoramic radiographs and probing depths at 3 months and 12 months postoperatively. The alveolar bone level distal to the second molar was established by both probing depths and radiographic evaluation, which were compared between the two groups. At 12 months postoperative the study group showed probing distal to the second molar with a mean depth of 1.15 mm, whereas the control group showed probing with a mean depth of 4.45 mm. The authors conclude that autogenous dentin grafting is a viable option for use in the treatment of osseous defects distal to mandibular second molars following extraction of impacted third molars.

Healing Dynamics Following Alveolar Ridge Preservation with Autologous Tooth Structure.

The objective of this clinical study was to assess the outcomes of autologous tooth structure in alveolar ridge preservation procedures. Extraction sites were grafted with autologous tooth structure prepared from the extracted teeth, and histologic samples were obtained at varying intervals to allow observation of bone-healing dynamics over time. Grafted areas were occupied by dentin particles that had begun to connect via bridges of woven bone at 3 months posthealing, and vital bone was in direct contact with residual particles with no inflammatory infiltrate. Further clinical investigation is warranted on the comparative effectiveness of autologous tooth structure against established bone-substitute biomaterials.

Bone Healing in Rabbit Calvaria Defects Using a Synthetic Bone Substitute: A Histological and Micro-CT Comparative Study.

Bioactive alloplastic materials, like beta-tricalcium phosphate (ß-TCP) and calcium sulfate (CS), have been extensively researched and are currently used in orthopedic and dental bone regenerative procedures. The purpose of this study was to compare the performance of EthOss versus a bovine xenograft and spontaneous healing. The grafting materials were implanted in standardized 8 mm circular bicortical bone defects in rabbit calvariae. A third similar defect in each animal was left empty for natural healing. Six male rabbits were used. After eight weeks of healing, the animals were euthanized and the bone tissue was analyzed using histology and micro-computed tomography (micro-CT). Defects treated with ß-TCP/CS showed the greatest bone regeneration and graft resorption, although differences between groups were not statistically significant. At sites that healed spontaneously, the trabecular number was lower (p < 0.05) and trabecular separation was higher (p < 0.05), compared to sites treated with ß-TCP/CS or xenograft. Trabecular thickness was higher at sites treated with the bovine xenograft (p < 0.05) compared to sites filled with ß-TCP/CS or sites that healed spontaneously. In conclusion, the novel ß-TCP/CS grafting material performed well as a bioactive and biomimetic alloplastic bone substitute when used in cranial defects in this animal model.

Evaluation of an In Situ Hardening ß-Tricalcium Phosphate Graft Material for Alveolar Ridge Preservation. A Histomorphometric Animal Study in Pigs.

The purpose of this study was to investigate the effectiveness of a resorbable alloplastic in situ hardening bone grafting material for alveolar ridge preservation in a swine model. Seven Landrace pigs were used. In each animal, the maxillary left and right deciduous second molars were extracted, and extraction sites were either grafted with a resorbable alloplastic in situ hardening bone substitute, composed of beta-tricalcium phosphate (ß-TCP) granules coated with poly(lactic-co-glycolic) acid (PLGA), or left unfilled to heal spontaneously. Animals were euthanized after 12 weeks, and the bone tissue was analyzed histologically and histomorphometrically. Linear changes of ridge width were also clinically measured and analyzed. Pronounced bone regeneration was found in both experimental and control sites, with no statistically significant differences. At the experimental sites, most of the alloplastic grafting material was resorbed and remnants of the graft particles were severely decreased in size. Moreover, experimental sites showed, in a statistically nonsignificant way, less mean horizontal dimensional reduction of the alveolar ridge (7.69%) compared to the control sites (8.86%). In conclusion, the ß-TCP/PLGA biomaterial performed well as a biocompatible resorbable in situ hardening bone substitute when placed in intact extraction sockets in this animal model.

An Integrated, Developmental Four-Year Medical School Curriculum in Palliative Care: A Longitudinal Content Evaluation Based on National Competency Standards.

BACKGROUND: While palliative care (PC) competencies for medical school graduates have been defined, the lack of established curriculum models and assessment tools hampers curricular evaluation. OBJECTIVE: To describe the scope and content of the University of Rochester's longitudinal, integrated four-year PC curriculum after 17 years of implementation, review student evaluative responses, and compare the curriculum to national competency standards. DESIGN AND SETTING: Combining and reorganizing a published PC curriculum assessment tool and a list of medical school PC competencies, we created a novel nine-topic framework to assess the content coverage of our curriculum. We queried our electronic medical school curriculum database and surveyed course and clerkship directors, as well as PC, pain, ethics, and humanities faculty, to locate where and when PC topics are taught and to collate student responses to these experiences. RESULTS: We present a comprehensive list of PC curricular activities over a four-year medical school experience. The curriculum covers all nine PC topics longitudinally in multiple formats. Five in-depth activities cover multiple PC topics in a format that integrates biological, psychological, and social dimensions; these activities have survived and evolved over 17 years in our setting. A majority of year 3 University of Rochester students feel "well" or "extremely well" trained in PC. CONCLUSIONS: Our four-year PC curriculum provides robust and developmentally appropriate training that addresses all nine evidence-based core topics for PC education. Medical student feedback and their Association of American Medical Colleges (AAMC) survey responses suggest that they find their PC learning experiences rewarding. This curriculum could serve as a model for other schools.