Initial Assessment of the Risk Assessment and Prediction Tool in a Heterogeneous Neurosurgical Patient Population.

BACKGROUND: Bundled care payments are increasingly being explored for neurosurgical interventions. In this setting, skilled nursing facility (SNF) is less desirable from a cost perspective than discharge to home, underscoring the need for better preoperative prediction of postoperative disposition. OBJECTIVE: To assess the capability of the Risk Assessment and Prediction Tool (RAPT) and other preoperative variables to determine expected disposition prior to surgery in a heterogeneous neurosurgical cohort, through observational study. METHODS: Patients aged 50 yr or more undergoing elective neurosurgery were enrolled from June 2016 to February 2017 (n = 623). Logistic regression was used to identify preoperative characteristics predictive of discharge disposition. Results from multivariate analysis were used to create novel grading scales for the prediction of discharge disposition that were subsequently compared to the RAPT Score using Receiver Operating Characteristic analysis. RESULTS: Higher RAPT Score significantly predicted home disposition (P < .001). Age 65 and greater, dichotomized RAPT walk score, and spinal surgery below L2 were independent predictors of SNF discharge in multivariate analysis. A grading scale utilizing these variables had superior discriminatory power between SNF and home/rehab discharge when compared with RAPT score alone (P = .004). CONCLUSION: Our analysis identified age, lower lumbar/lumbosacral surgery, and RAPT walk score as independent predictors of discharge to SNF, and demonstrated superior predictive power compared with the total RAPT Score when combined in a novel grading scale. These tools may identify patients who may benefit from expedited discharge to subacute care facilities and decrease inpatient hospital resource utilization following surgery.

Enhanced recovery after elective spinal and peripheral nerve surgery: pilot study from a single institution.

OBJECTIVEEnhanced recovery after surgery (ERAS) protocols address pre-, peri-, and postoperative factors of a patient's surgical journey. The authors sought to assess the effects of a novel ERAS protocol on clinical outcomes for patients undergoing elective spine or peripheral nerve surgery.METHODSThe authors conducted a prospective cohort analysis comparing clinical outcomes of patients undergoing elective spine or peripheral nerve surgery after implementation of the ERAS protocol compared to a historical control cohort in a tertiary care academic medical center. Patients in the historical cohort (September-December 2016) underwent traditional surgical care. Patients in the intervention group (April-June 2017) were enrolled in a unique ERAS protocol created by the Department of Neurosurgery at the University of Pennsylvania. Primary objectives were as follows: opioid and nonopioid pain medication consumption, need for opioid use at 1 month postoperatively, and patient-reported pain scores. Secondary objectives were as follows: mobilization and ambulation status, Foley catheter use, need for straight catheterization, length of stay, need for ICU admission, discharge status, and readmission within 30 days.RESULTSA total of 201 patients underwent surgical care via an ERAS protocol and were compared to a total of 74 patients undergoing traditional perioperative care (control group). The 2 groups were similar in baseline demographics. Intravenous opioid medications postoperatively via patient-controlled analgesia was nearly eliminated in the ERAS group (0.5% vs 54.1%, p < 0.001). This change was not associated with an increase in the average or daily pain scores in the ERAS group. At 1 month following surgery, a smaller proportion of patients in the ERAS group were using opioids (38.8% vs 52.7%, p = 0.041). The ERAS group demonstrated greater mobilization on postoperative day 0 (53.4% vs 17.1%, p < 0.001) and postoperative day 1 (84.1% vs 45.7%, p < 0.001) compared to the control group. Postoperative Foley use was decreased in the ERAS group (20.4% vs 47.3%, p < 0.001) without an increase in the rate of straight catheterization (8.1% vs 11.9%, p = 0.51).CONCLUSIONSImplementation of this novel ERAS pathway safely reduces patients' postoperative opioid requirements during hospitalization and 1 month postoperatively. ERAS results in improved postoperative mobilization and ambulation.

Assessing the utility of an IoS application in the perioperative care of spine surgery patients: the NeuroPath Pilot study.

BACKGROUND: In an attempt to improve care while decreasing costs and postoperative pain, we developed a novel IoS mobile health application, NeuroPath. The objective of this innovative app is to integrate enhanced recovery after surgery (ERAS) principles, patient education, and real-time pain and activity monitoring in a home setting with unencumbered two-way communication. METHODS: The NeuroPath application was built over 18 months, with support from Apple, Medable, the Department of Information-Technology and the Department of Neurosurgery. Target areas addressed by NeuroPath include patient prep for surgery, perioperative risk mitigation, activity monitoring, wound care, and opioid use management. These target areas are monitored through a provider app, which is downloaded to the care providers IPad Mini. The provider app permits real time viewing of wound healing (patient incision photographs), activity levels, pain levels, and narcotic usage. Participants are given a daily To-Do list, via the Care Card section of the interface. The To-Do list presents the patient with specific tasks for exercise, instructions to wash incision area, pre-operative instructions, directions for discussing medication with care team, among other patient specific recommendations. RESULTS: Of the 30 patients enrolled in the pilot study, there was a range of activity on the app. Patients with high involvement in the app logged in nearly every day from a week pre-op to >45 days post-op. Data for patients that utilized the app and uploaded regularly show trends of appropriately healing wounds, decreasing levels of pain, increasing step counts, and discontinuation of narcotics. CONCLUSIONS: This pilot study of the NeuroPath app demonstrates its potential utility for improving quality of patient care without increased costs. Participants who regularly used the app showed consistent improvement throughout the post-operative recovery period (increasing ambulation, decreasing pain and guided reduction in narcotic usage).

Psychosocial behavioral patterns for adolescents.

Among the many formative issues in adolescents, determinants for health behaviors are being shaped. The development of positive oral health behavior in adolescents is a complex process. Areas specifically related to oral health include self-concept and its relation-ship to oral health and compliance with orthodontic care; tobacco use; special considerations including anorexia, bulimia, and troubled youths; and health promotions. Knowledge is necessary, but there must also be shifts in attitudes and the development of health-related behaviors. Establishing these attitudes and behaviors in adolescence is crucial, because patterns of behavior developed in adolescence can form the basis for future health.

The congenitally missing maxillary lateral incisor. Part 1: esthetic judgment of treatment options.

AIM: To determine how general dentists, orthodontists, combined dental specialists, and laypeople judged the relative attractiveness of a series of photographs of teeth that included cases with congenitally missing incisors to compare the esthetic appeal of various treatment options. METHODS: The photographs included cases with Maryland bridges, dental implants, and orthodontic substitution of the lateral incisors with the canines. Cases with no missing teeth were included as controls. The subjects rated each photograph independently, assigning a number between 1 and 5 for each of a series of 7 bipolar adjectives. Each photograph was given an overall score from 7 (best) through 35 (worst) for use in statistical analysis (ANOVA). RESULTS: Results indicated that general dentists, orthodontists, combined dental specialists, and laypeople differed in their evaluations of the photographs, which represented multiple treatment options for congenitally missing maxillary lateral incisors. CONCLUSIONS: Including esthetics of the finished result as an advantage or disadvantage for either restoration or canine substitution of the lateral incisors could be misleading to the patient because the judgment of esthetics of a smile can vary from one person to another or from one dental professional to another, as indicated in this study.

The congenitally missing maxillary lateral incisor. Part 2: assessing dentists' preferences for treatment.

AIM: To (1) determine if there are different preferences among general dentists, a combined group of dental specialists, and orthodontists concerning whether a patient with congenitally missing lateral incisors should have the teeth restored or if the canines should be orthodontically moved into the position of the missing teeth; (2) determine the role that esthetics and function of the final result has on the respondents' treatment preferences; and (3) compare the respondents' opinions about treatment preferences to their rankings of esthetics reported in part 1. METHODS: The questionnaire accompanied the photographic evaluation in part 1. Percentages were computed and chi-squares were used to compare response patterns. RESULTS: Compared to orthodontists, a significantly greater percentage of general dentists and combined dental specialists would restore the lateral incisors and would do so primarily for esthetic reasons. Interestingly, for those dental professionals who responded that the missing teeth should be restored, many did not rank any photograph of a restorative option as the best option. CONCLUSIONS: Dental professionals should attempt to eliminate their personal opinions when recommending treatment options for a congenitally missing maxillary lateral incisor because discrepancies exist between the treatment result judged as most esthetic and the one most likely to be recommended.

The effect of irrigation with doxycycline or citric acid on leakage and osseous wound healing.

This study investigated the effect of doxycycline irrigation on wound healing and the apical seal of three filling materials. Part 1: 220 extracted teeth received root canal therapy followed by root resection (2 mm) and ultrasonic root end preparations (3 mm). Groups of 20 were irrigated with saline, citric acid, or doxycycline and filled with amalgam, Super EBA, or MTA. Leakage was measured (mm) after decalcification and clearing. Part 2: two defects were made on each side of the mandible of 10 New Zealand rabbits. On each side, one defect was irrigated with saline and one with either citric acid or doxycycline. The animals were killed in groups of five at 9 and 18 days. Sections of each defect were stained with hematoxylin and eosin for evaluation of healing and bone fill. Super EBA and MTA leaked significantly less than amalgam, regardless of irrigant. Leakage after irrigation with doxycycline compared to citric acid or saline was not significantly different for Super EBA or MTA but was lower for amalgam. There was no significant difference in healing or bone fill among irrigants at 9 or 18 days.

Prospective evaluation of implants connected to teeth.

PURPOSE: This prospective clinical trial examined the effect on teeth and implants when rigidly or non-rigidly connected in a cross-arch model. MATERIALS AND METHODS: Thirty patients received 2 implants, 1 on each side of the mandible, and were restored with 3-unit fixed partial dentures connected either rigidly or non-rigidly to an abutment tooth. Patients were followed for at least 5 years post-restoration. RESULTS: Repeated-measures analysis revealed no significant difference in crestal bone loss at implants (rigid versus non-rigid methods). An overall significant difference (P < .001) was found comparing methods for teeth. Paired t tests revealed no significant differences in crestal bone levels for implants or teeth at the 5-year recall. Kaplan-Meier methods and the Cox proportional hazards model showed no differences between attachment methods with regard to success based on survival and bone loss criteria. During the 5-year recall period, 1 implant (rigid side) was removed. Four implants developed bone loss greater than 2 mm during the course of this trial. One tooth on the rigid side and 2 teeth on the non-rigid side had greater than 2 mm of crestal bone loss and were removed secondary to fractures. In all, 5 abutment teeth were removed, all of which had been treated with root canal therapy and fractured at the interface of the post within the tooth. There was no clear relationship of tooth fracture to attachment. Repeated-measures analysis of mobility values revealed no significant changes over the time course of this study, and paired t tests revealed no statistically significant differences between implants for mobility. Repeated-measures analysis and paired t tests for probing depth revealed no significant changes over the time course of this study. There were no significant differences in soft tissue indices for either attachment method. The percentage of patients who had measurable intrusion was 66% for the non-rigid group, and 44% for the rigid group; 25% of the non-rigid teeth had greater than 0.5 mm intrusion, compared with 12.5% for the rigid group. For the 2 time periods evaluated, there was no significant increase in intrusion over time. The non-rigid-side implant required more nonscheduled visits to treat problems than the rigid implant and the teeth. DISCUSSION: Most patients were treated successfully with rigid or non-rigid attachment of implants to teeth. CONCLUSION: The high incidence of intrusion and non-scheduled patient visits suggest that alternative treatments without connecting implants to teeth may be indicated.

Evaluation of compressed air used in the dental operatory.

BACKGROUND: The authors report the findings obtained when they quantitatively examined compressed air samples from air-water syringes located in different dental operatories at the Louisiana State University School of Dentistry fo r the presence of microbial contaminants. METHODS: Streams of air of 30 seconds' duration from air-water syringes were forced through sterile modified stainless steel membrane filter holders (Millipore, Millipore Corp., Bedford, Mass.), each containing a membrane filter (average pore diameter = 0.45 micrometers). Each filter was aseptically removed, placed onto the surface of a Petri dish containing sheep blood agar and incubated under increased carbon dioxide tension at 37 C for 48 hours. The authors performed a count of the resultant microbial colonies, after which they microscopically examined the gram-stained organisms. RESULTS: Bacteria were detected in 24 percent of the samples. The number of colonies observed on the filters varied among the dental units. The air from only one of the dental units sampled repeatedly was found to be free of bacterial contaminants. This contrasted with other units for which one or more samples were found to be positive for microorganisms. The majority of colonies observed were pigmented. Microscopic examination of organisms from representative colonies revealed that most were either gram-positive cocci or gram-negative diplococci and tetrads. The results of the one-sample t test were found to be significant (t = 5.6, df = 98, P = .0001). The 95 percent confidence interval was 0.15 to 0.32. CONCLUSION: The results suggest that, at least statistically, a percentage of air lines will have bacteria present.

Determination of subepithelial connective tissue graft thickness in the dog.

PURPOSE: In this study, we determined the tissue thickness of healed subepithelial connective tissue grafts, the type of tissue present after healing, and the percentage of shrinkage of subepithelial connective tissue grafts over time in the facial aspect of the canine maxilla. MATERIALS AND METHODS: Four dogs each received 2 single-thickness subepithelial connective tissue grafts, 2 double-thickness grafts, and 2 sham-operated sites in the facial aspect of the maxilla bilaterally. The subepithelial connective tissue graft was harvested from the palate and included the periosteum. After the creation of a pouch on the facial aspect of the maxilla, the grafts were sutured directly to the maxillary periosteum and additional sutures were placed to secure the overlying mucosal flap to the graft. Thickness measures of the grafts before placement and after surgery with the grafts in place were made biweekly with a calibrated probe using known reference points on the teeth. Thickness measures were analyzed using a random-effects mixed model. All dogs were killed at 12 weeks, and the tissues were fixed, serially sectioned, and stained with hematoxylin and eosin for microscopic examination. RESULTS: Initial measurements of the sites demonstrated a thickness of 1.5 +/- 0.6 mm. Immediate postoperative measures were 7.1 mm (single thickness), 7.0 mm (double thickness), and 4.8 mm (sham operated). Week 6 measures were 3.9 mm (single thickness), 3.6 mm (double thickness), and 2.7 mm (sham operated), and week 12 measures were 3.9 mm (single thickness), 3.4 mm (double thickness), and 2.9 mm (sham operated). The difference between single- and double-thickness grafts was not significant (P =.34). The differences between single thickness and sham operated (P =.0036) and between double thickness and sham operated (P =.0049) were significant. Microscopic evaluation demonstrated that the grafts were indistinguishable from the adjacent subcutaneous tissues of the maxilla. The submucosal graft region contained fat, small blood vessels, nerves, and fibrous connective tissue. CONCLUSIONS: Based on this study in dogs, shrinkage of subepithelial grafts can be expected. The grafts become incorporate into the host tissues and appear similar to the normal connective tissue.