Intestinal Flora Modulates Blood Pressure by Regulating the Synthesis of Intestinal-Derived Corticosterone in High Salt-Induced Hypertension.

RATIONALE: High-salt diet is one of the most important risk factors for hypertension. Intestinal flora has been reported to be associated with high salt-induced hypertension (hSIH). However, the detailed roles of intestinal flora in hSIH pathogenesis have not yet been fully elucidated. OBJECTIVE: To reveal the roles and mechanisms of intestinal flora in hSIH development. METHODS AND RESULTS: The abovementioned issues were investigated using various techniques including 16S rRNA gene sequencing, untargeted metabolomics, selective bacterial culture, and fecal microbiota transplantation. We found that high-salt diet induced hypertension in Wistar rats. The fecal microbiota of healthy rats could dramatically lower blood pressure (BP) of hypertensive rats, whereas the fecal microbiota of hSIH rats had opposite effects. The composition, metabolism, and interrelationship of intestinal flora in hSIH rats were considerably reshaped, including the increased corticosterone level and reduced Bacteroides and arachidonic acid levels, which tightly correlated with BP. The serum corticosterone level was also significantly increased in rats with hSIH. Furthermore, the above abnormalities were confirmed in patients with hypertension. The intestinal Bacteroides fragilis could inhibit the production of intestinal-derived corticosterone induced by high-salt diet through its metabolite arachidonic acid. CONCLUSIONS: hSIH could be transferred by fecal microbiota transplantation, indicating the pivotal roles of intestinal flora in hSIH development. High-salt diet reduced the levels of B fragilis and arachidonic acid in the intestine, which increased intestinal-derived corticosterone production and corticosterone levels in serum and intestine, thereby promoting BP elevation. This study revealed a novel mechanism different from inflammation/immunity by which intestinal flora regulated BP, namely intestinal flora could modulate BP by affecting steroid hormone levels. These findings enriched the understanding of the function of intestinal flora and its effects on hypertension.

A multi-institutional approach for decreasing narcotic prescriptions after laparoscopic appendectomy.

BACKGROUND: Appendicitis is a common indication for surgical hospital admission. Uncomplicated appendicitis is typically treated with surgical intervention, most commonly a laparoscopic appendectomy. As with many procedures, narcotic utilization is highly varied among surgeons for postoperative pain control. With the opioid epidemic and a demonstrated link between excessive narcotic prescriptions paving the way to dependence and addiction, it is more important than ever to decrease the circulation of these medications. We hypothesized that a perioperative, multimodal analgesia strategy coupled with monthly feedback reports comparing hospitals narcotic prescribing habits would decrease, and in some cases eliminate, the use of outpatient narcotics in adults after laparoscopic appendectomy. METHODS: A quality improvement project was initiated to provide monthly feedback to surgeons on narcotic prescribing habits after adult laparoscopic appendectomies. A multi-hospital database was created to include adult patients that were diagnosed with acute appendicitis, treated with laparoscopic appendectomy, and discharged within 48 h of surgery. The database provided information regarding the number of narcotic doses prescribed on discharge. Participating hospitals selected a site champion who distributed monthly prescribing reports. A protocol was created and distributed to participating sites that provided a guideline for preoperative and postoperative pain medication management. The intervention period was 10/1/2019-3/31/2020. We utilized the preceding year's data (October 1, 2018-September 30, 2019) as the pre-intervention control group. We also compared results between local and distant sites to see if personal connection to surgeons influenced the results. RESULTS: A total of 1785 appendectomies were performed during the study period at participating hospitals. The average number of prescribed narcotics decreased from 23.6 doses during the control period to 14.2 during the intervention (p < 0.001). There was no change in the number of total narcotic prescriptions (8.9 vs 7.9%, p = 0.52). Overall, the average number of narcotics prescribed decreased by 40% with similar decrease in average prescribed narcotics for local and distant hospitals, respectively (47.7% vs 42.1%). Average narcotic dose during the first 2 months of intervention at the local hospitals was 9.7 and 11.1 for the last 2 months of intervention (p = 0.69). Average narcotic dose during the first 2 months of intervention at the distant hospitals was 19.5 and 13.4 for the last 2 months of intervention (p = 0.005). CONCLUSION: A multimodal pain regimen combined with a monthly narcotic prescription report provided to prescribers decreases the average number of narcotic prescriptions after laparoscopic appendectomy. Local sites demonstrated immediate decrease in narcotic utilization compared to distant sites whose change occurred more gradually.

Results of Lung Cancer Screening in the Community.

PURPOSE: To address doubts regarding National Lung Screening Trial (NLST) generalizability, we analyzed over 6,000 lung cancer screenings (LCSs) within a community health system. METHODS: Our LCS program included 10 sites, 7 hospitals (2 non-university tertiary care, 5 community) and 3 free-standing imaging centers. Primary care clinicians referred patients. Standard criteria determined eligibility. Dedicated radiologists interpreted all LCSs, assigning Lung Imaging Reporting and Data System (Lung-RADS) categories. All category 4 Lung-RADS scans underwent multidisciplinary review and management recommendations. Data was prospectively collected from November 2013 through December 2018 and retrospectively analyzed. RESULTS: Of 4,666 referrals, 1,264 individuals were excluded or declined, and 3,402 individuals underwent initial LCS. Second through eighth LCSs were performed on 2,758 patients, for a total of 6,161 LCSs. Intervention rate after LCS was 14.6% (500 individuals) and was most often additional imaging. Invasive interventions (n = 226) were performed, including 141 diagnostic procedures and 85 surgeries in 176 individuals (procedure rate 6.6%). Ninety-five lung cancers were diagnosed: 84 non-small cell (stage 1: 60; stage 2: 7; stage 3: 9; stage 4: 8), and 11 small cell lung cancers. The procedural adverse event rate was 23/226 (10.1%) in 21 patients (0.6% of all screened individuals). Pneumothorax (n = 10) was the most frequent, 6 requiring pleural drainage. There were 2 deaths among 85 surgeries or 2.3% surgical mortality. CONCLUSIONS: Our LCS experience in a community setting demonstrated lung cancer diagnosis, stage shift, intervention frequency, and adverse event rate similar to the NLST. This study confirms that LCS can be performed successfully, safely, and with equivalence to the NLST in a community health care setting.

Progress in the seasonal variations of blood lipids: a mini-review.

The seasonal variations of blood lipids have recently gained increasing interest in this field of lipid metabolism. Elucidating the seasonal patterns of blood lipids is particularly helpful for the prevention and treatment of cardiovascular and cerebrovascular diseases. However, the previous results remain controversial and the underlying mechanisms are still unclear. This mini-review is focused on summarizing the literature relevant to the seasonal variability of blood lipid parameters, as well as on discussing its significance in clinical diagnoses and management decisions.

Duodenal GI stromal tumors: Is radical resection necessary?

BACKGROUND AND OBJECTIVES: Duodenal gastrointestinal stromal tumors (GISTs) are rare tumors that pose a surgical challenge, and long-term outcomes after resection have not been detailed outside of small case series. This study uses the National Cancer Database (NCDB) to examine the determinants of radical resection for duodenal GISTs as well as the impact of local vs radical resection on overall survival (OS). METHODS: The NCDB was queried for nonmetastatic duodenal GISTs from 2004 to 2014. Predictors of radical resection were determined using multivariate logistic regression stratified by extent of tumor involvement. Factors associated with OS were identified with Cox proportional regression analysis. RESULTS: Treatment at an academic center, size >5 cm, and extra-duodenal extension were associated with radical resection. On multivariate analysis, radical resection was associated with decreased OS (HR, 1.93; P < .03). Systemic therapy, extra-duodenal extension, grade, stage, mitoses, and receipt of systemic therapy did not impact OS. CONCLUSION: Local resection of duodenal GISTs is associated with improved OS compared to radical resection after controlling for tumor factors and systemic treatment. Traditional indicators of tumor aggressiveness were associated with radical resection, but not OS. When feasible, local resection should be considered for resection of duodenal GISTs.

Early Weight Gain in Infants With Cleft Lip and Palate Treated With and Without Nasoalveolar Molding: A Retrospective Study.

OBJECTIVE: To assess weight gain of infants with cleft lip and/or palate (CL ± P) treated with nasoalveolar molding (NAM). DESIGN: Retrospective, case-control chart review. SETTING: Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon. PATIENTS, PARTICIPANTS: Infants with nonsyndromic CL ± P and noncleft controls. INTERVENTIONS: Prior to primary lip surgery, NAM was either included (+NAM) or not included (-NAM) in the cleft treatment protocol. MAIN OUTCOME MEASURE(S): Weight gain and percentage weight gain relative to initial weight were compared among +NAM, -NAM, and control groups from birth to 7 months and from birth to 36 months. RESULTS: Comparing +NAM and -NAM groups, no significant difference in weight or percentage weight gain was found in either time window. Compared to controls, from birth to 7 months, both CL ± P groups weighed less (P < .001), while percentage weight gain was greater for the +NAM (P < .001) and did not differ for -NAM. From birth to 36 months relative to controls, weight for +NAM showed no significant difference and -NAM weighed less (P < .01), while percentage weight gain was greater for both CL ± P groups (P < .001). CONCLUSIONS: Comparisons of CL ± P infants treated with and without NAM showed that with the NAM appliance, despite its added complexity, there was no adverse impact on weight gain. Comparisons to noncleft, control infants suggests that NAM treatment may have a beneficial impact on weight gain.

Risk Factors Associated with Lifespan in Pet Dogs Evaluated in Primary Care Veterinary Hospitals.

The objective of this population-based retrospective cohort study was to identify factors associated with lifespan in pet dogs evaluated at primary care veterinary hospitals. Dogs ≥3 mo of age that visited any of 787 US hospitals at least twice from January 1, 2010, through December 31, 2012, were included. Survival curves were constructed for dogs by reproductive status, breed, body size, and purebreed (versus mixed-breed) status. Multivariate Cox proportional hazard regression was performed to identify factors associated with lifespan. There were 2,370,078 dogs included in the study, of whom 179,466 (7.6%) died during the study period. Mixed-breed dogs lived significantly longer than purebred dogs, and this difference was more pronounced as body size increased. Controlling for other factors, dogs of either sex had a greater hazard of death over the study follow-up period if sexually intact rather than gonadectomized. For dogs who lived to 2 yr of age, the hazard of death decreased with increasing frequency of dental scaling. Our findings support previous reports of the impact of body size and gonadectomy on lifespan and provide new evidence in support of ultrasonic dental scaling and mixed breeding.

A simplified pneumonia severity index (PSI) for clinical outcome prediction in COVID-19.

BACKGROUND: The Pneumonia Score Index (PSI) was developed to estimate the risk of dying within 30 days of presentation for community-acquired pneumonia patients and is a strong predictor of 30-day mortality after COVID-19. However, three of its required 20 variables (skilled nursing home, altered mental status and pleural effusion) are not discreetly available in the electronic medical record (EMR), resulting in manual chart review for these 3 factors. The goal of this study is to compare a simplified 17-factor version (PSI-17) to the original (denoted PSI-20) in terms of prediction of 30-day mortality in COVID-19. METHODS: In this retrospective cohort study, the hospitalized patients with confirmed SARS-CoV-2 infection between 2/28/20-5/28/20 were identified to compare the predictive performance between PSI-17 and PSI-20. Correlation was assessed between PSI-17 and PSI-20, and logistic regressions were performed for 30-day mortality. The predictive abilities were compared by discrimination, calibration, and overall performance. RESULTS: Based on 1,138 COVID-19 patients, the correlation between PSI-17 and PSI-20 was 0.95. Univariate logistic regression showed that PSI-17 had performance similar to PSI-20, based on AUC, ICI and Brier Score. After adjusting for confounding variables by multivariable logistic regression, PSI-17 and PSI-20 had AUCs (95% CI) of 0.85 (0.83-0.88) and 0.86 (0.84-0.89), respectively, indicating no significant difference in AUC at significance level of 0.05. CONCLUSION: PSI-17 and PSI-20 are equally effective predictors of 30-day mortality in terms of several performance metrics. PSI-17 can be obtained without the manual chart review, which allows for automated risk calculations within an EMR. PSI-17 can be easily obtained and may be a comparable alternative to PSI-20.

The CUSUM Slope Equals Observed Minus Expected Mortality and Can Be Visualized by a "Slope-Meter".

We present an additional advantage of the Risk-Adjusted CUSUM (RA-CUSUM), namely, that its slope can be quantified and is in fact equivalent to Observed (O) minus Expected (E) mortality. That is, the height of the RA-CUSUM is the O minus E deaths, which measures performance since the start of the series, and the slope of the RA-CUSUM is the O minus E mortality which measures performance during a chosen interval. We present a useful graphical tool (Slope-Meter) to allow approximation of this mortality difference by the viewer.

Calibration Factors for STS Risk Model Predictions: Why, How and When They Are Used.

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database is the world's premier adult cardiac surgery outcomes registry. This tutorial explains the following: how STS updates the risk models that are used to calculate the predicted risks of adverse events in the registry; why STS on a quarterly basis adjusts or "calibrates" the observed-to-expected ratios to equal 1 (O/E = 1), thereby effectively making the annual number of adverse events predicted by the model match the annual number of adverse events observed in the entire registry; the differences between the calibrated and uncalibrated O/E ratios; and how and when to use each.

CHEST Watch: A High School Outreach Program.

As the US population ages, health care workforce shortages are projected in surgery, medicine, and nursing. We describe an outreach program aimed at exposing high school students to health care as a career choice while emphasizing science courses and prevention of tobacco use. High school students were invited to participate in CHEST Watch, a structured educational program based on thoracic pathology. Before students attended the program, parental consent was collected. Students engaged in a discussion with multiple professionals (physicians, nurses, smoking cessation counselors, social workers, basic science researchers) who presented their personal motivation and information about the corresponding career. Participants then observed a lung cancer surgery. A strong anti-tobacco message was emphasized throughout. Before and after the event, the participants completed anonymous opinion surveys which queried their interest in science, health care careers, and tobacco use. The Cochran-Mantel-Haenszel test was used for trend analysis. A total of 4400 students from 84 schools attended CHEST Watch over 15 years. A significant increase in the students' interest in health care careers and science courses (P-value 0.0001) and a significant decrease in tobacco use interest (P-value 0.0001) were observed. Overall, feedback was strongly positive and very popular within the school systems. The CHEST Watch program is an innovative approach intended to recruit youth into health care careers to address projected future shortages in the workforce. Furthermore, the participants' experience resulted in an increasingly positive attitude towards personal health and a decreased interest in use of tobacco products.

Temporal trends and predictors of surgical ablation for atrial fibrillation across a multistate healthcare system.

BACKGROUND: Multiple class I and class IIa recommendations exist related to surgical ablation (SA) of atrial fibrillation (AF) in patients undergoing cardiac surgery. OBJECTIVE: Examine temporal trends and predictors of SA for AF in a large US healthcare system. METHODS: We retrospectively analyzed data from the Society for Thoracic Surgery (STS) Adult Cardiac Surgery Database for 21 hospitals in the Providence St. Joseph Health system. All patients with preoperative AF who underwent isolated coronary artery bypass graft (CABG) surgery, isolated aortic valve replacement (AVR), AVR with CABG surgery (AVR+CABG), isolated mitral valve repair or replacement (MVRr), and MVRr with CABG surgery (MVRr+CABG) from July 1, 2014, to March 31, 2020 were included. Temporal trends in SA were evaluated using the Cochran-Armitage trends test. A multilevel logistic regression model was used to examine patient-, hospital-, and surgeon-level predictors of SA. RESULTS: Among 3124 patients with preoperative AF, 910 (29.1%) underwent SA. This was performed most often in those undergoing isolated MVRr (n = 324, 44.8%) or MVRr+CABG (n = 75, 35.2%). Rates of SA increased over time and were highly variable between hospitals. Years since graduation from medical school for the primary operator was one of the few predictors of SA: odds ratio (95% confidence interval) = 0.71 (0.56-0.90) for every 10-year increase. Annual surgical (both hospital and operator) and AF catheter ablation volumes were not predictive of SA. CONCLUSION: Wide variability in rates of SA for AF exist, underscoring the need for greater preoperative collaboration between cardiologists, electrophysiologists, and cardiac surgeons.

Post operative pediatric appendicitis nurse-driven discharge: Patient outcomes and nursing perspectives.

BACKGROUND: Nurse-driven discharge pathways following pediatric appendectomies have proven effective in children's hospitals; studies in general hospital settings are lacking. Additionally, despite the central role of nursing in such pathways, nursing perspectives aren't investigated in the literature. METHODS: Data from all pediatric acute uncomplicated appendicitis patients who underwent laparoscopic appendectomy in the 12 months following institution of a nurse-driven discharge pathway (intervention, n = 67) were compared to those treated in the preceding year (control, n = 64). Surveys on the pathway were distributed to pediatric ward nurses. RESULTS: Postoperative length of stay (POLOS) decreased by 37% in the intervention group, about 6 h, (0.44 days ± 0.22 vs 0.7 days ± 0.27, p-value 0.0001), without a significant increase in related readmissions. Same day discharges increased from 10.9% to 46.3%, (P-value 0.0001). Nurse surveys revealed a high approval of the pathway (7-10/10) and yielded valuable feedback. CONCLUSION: A nurse-driven discharge pathway decreased POLOS without increasing readmission following pediatric laparoscopic appendectomy in a general hospital setting. Valuable insight into nursing perspectives on this pathway was acquired.

Evaluation and optimization of blanket production from recycled polyethylene terephthalate based on the coordination of environment, economy, and society.

The recycling of waste polyethylene terephthalate (PET) is widely regarded as an eco-friendly and cost-effective technology and has been gradually developed into an important direction for the utilization of solid waste resources. However, the integrated evaluation research on this technology from the environmental, economic, and social aspects are still not in place. Based on the theory of collaborative entropy, this study constructs an integrated evaluation and optimization methodology system for the environmental, economic, and social impacts of blanket production from recycled PET, using environmental life cycle assessment, life cycle cost assessment, social life cycle assessment, and sensitivity analysis. The study assessed the environmental load, economic cost, and social impact of blanket production from recycled PET, and then identified the key processes through sensitivity analysis. In addition, the graphical method and the principle of collaborative entropy model are applied to evaluate two of the environmental load, economic cost, and social impact in the blanket production from recycled PET. The results of the two methods are consistent, which indicates that to carry out multi-objective integrated evaluation with collaborative entropy model have good reliability. Moreover, the quantified results of collaborative entropy showed that the key processes that affected the coordinated development of the environment, economy, and society were organic chemicals usage process, electricity generation process, and direct air emission process. Based on the "Reduce-Reuse-Recycle" theory and the position of key processes in the system, feasible optimization suggestions were proposed. The establishment of this methodology system could provide theoretical and practical references for other waste utilization industry.

Outcome assessment of orthodontic clear aligner vs fixed appliance treatment in a teenage population with mild malocclusions.

OBJECTIVE: To assess the efficacy and efficiency of treatment in adolescents presenting with mild malocclusions, comparing outcomes using clear aligners to fixed appliances. MATERIALS AND METHODS: Patients identified retrospectively and consecutively from one private practice had been treated with either clear aligners (Invisalign, Align Technology, Santa Clara, Calif) or fixed appliances (0.022 Damon, Ormco, Orange, Calif; n = 26/group). Assessments of occlusion were made using the American Board of Orthodontics Discrepancy Index (DI) for initial records and Cast-Radiograph Evaluation (CRE) for final records. Number of appointments, number of emergency visits, and overall treatment time were determined from chart reviews. Data were analyzed using Pearson's correlation, Wilcoxon rank tests, unpaired t-tests, and Chi-square tests, with significance set to P ≤ .05. RESULTS: Pretreatment, the aligner and fixed groups showed no significant difference in overall severity (DI: 11.9 ± 5.3 vs 11.6 ± 4.8) or in any individual DI category. Posttreatment scores showed finishes for the aligner group had fewer discrepancies from ideal relative to the fixed appliance group (CRE: 30.1 ± 8.3 vs 37.0 ± 9.3; P < .01). Patients treated with aligners had fewer appointments (13.7 ± 4.4 vs 19.3 ± 3.6; P < .0001), fewer emergency visits (0.8 ± 1.0 vs 3.6 ± 2.5; P < .0001), and shorter overall treatment time (16.9 ± 5.7 vs 23.4 ± 4.4 months; P < .0001). CONCLUSIONS: Outcomes for treatment of mild malocclusions in adolescents showed equivalent effectiveness of clear aligners compared to fixed appliances, with significantly improved results for clear aligner treatment in terms of tooth alignment, occlusal relations, and overjet. Assessment of the number of appointments, number of emergency visits, and overall treatment time showed better outcomes for treatment with clear aligners.

Trends in Diagnosis Related Groups for Inpatient Admissions and Associated Changes in Payment From 2012 to 2016.

Importance: Hospitals are reimbursed based on Diagnosis Related Groups (DRGs), which are defined, in part, by patients having 1 or more complications or comorbidities within a given DRG family. Hospitals have made substantial investment in efforts to document these complications and comorbidities. Objective: To examine temporal trends in DRGs with a major complication or comorbidity, compare these findings with 2 alternative measures of disease severity, and estimate associated changes in payment. Design, Setting, and Participants: This retrospective cohort study used data from the all-payer National Inpatient Sample for admissions assigned to 1 of the top 20 reimbursed DRG families at US acute care hospitals from January 1, 2012, to December 31, 2016. Data were analyzed from July 10, 2018, to May 29, 2019. Exposures: Quarter year of hospitalization. Main Outcomes and Measures: The primary outcome was the proportion of DRGs with a major complication or comorbidity. Secondary outcomes were comorbidity scores, risk-adjusted mortality rates, and estimated payment. Changes in assigned DRGs, comorbidity scores, and risk-adjusted mortality rates were analyzed by linear regression. Payment changes were estimated for each DRG by calculating the Centers for Medicare & Medicaid Services weighted payment using 2012 and 2016 case mix and hospitalization counts. Results: Between 2012 and 2016, there were 62 167 976 hospitalizations for the 20 highest-reimbursed DRG families; the sample was 32.9% male and 66.8% White, with a median age of 57 years (interquartile range, 31-73 years). Within 15 of these DRG families (75%), the proportion of DRGs with a major complication or comorbidity increased significantly over time. Over the same period, comorbidity scores were largely stable, with a decrease in 6 DRG families (30%), no change in 10 (50%), and an increase in 4 (20%). Among 19 DRG families with a calculable mortality rate, the risk-adjusted mortality rate significantly decreased in 8 (42%), did not change in 9 (47%), and increased in 2 (11%). The observed DRG shifts were associated with at least $1.2 billion in increased payment. Conclusions and Relevance: In this cohort study, between 2012 and 2016, the proportion of admissions assigned to a DRG with major complication or comorbidity increased for 15 of the top 20 reimbursed DRG families. This change was not accompanied by commensurate increases in disease severity but was associated with increased payment.

Comprehensive Glycomic Analysis Reveals That Human Serum Albumin Glycation Specifically Affects the Pharmacokinetics and Efficacy of Different Anticoagulant Drugs in Diabetes.

Long-term hyperglycemia in patients with diabetes leads to human serum albumin (HSA) glycation, which may impair HSA function as a transport protein and affect the therapeutic efficacy of anticoagulants in patients with diabetes. In this study, a novel mass spectrometry approach was developed to reveal the differences in the profiles of HSA glycation sites between patients with diabetes and healthy subjects. K199 was the glycation site most significantly changed in patients with diabetes, contributing to different interactions of glycated HSA and normal HSA with two types of anticoagulant drugs, heparin and warfarin. An in vitro experiment showed that the binding affinity to warfarin became stronger when HSA was glycated, while HSA binding to heparin was not significantly influenced by glycation. A pharmacokinetic study showed a decreased level of free warfarin in the plasma of diabetic rats. A preliminary retrospective clinical study also revealed that there was a statistically significant difference in the anticoagulant efficacy between patients with diabetes and patients without diabetes who had been treated with warfarin. Our work suggests that larger studies are needed to provide additional specific guidance for patients with diabetes when they are administered anticoagulant drugs or drugs for treating other chronic diseases.

Definition and implications of novel pharyngo-glottal reflex in human infants using concurrent manometry ultrasonography.

OBJECTIVES: Glottal relationships during swallowing dominate the etiology of dysphagia. We investigated the pharyngo-glottal relationships during basal and adaptive swallowing. METHODS: Temporal changes in glottal closure kinetics (frequency, response latency, and duration) with spontaneous and adaptive pharyngeal swallows were defined in 12 infants using concurrent pharyngoesophageal manometry and ultrasonography of the glottis. RESULTS: Frequency, response latency, and duration of glottal closure with spontaneous swallows (n=53) were 100%, 0.27+/-0.1 s, and 1+/-0.22 s, respectively. The glottis adducted earlier (P<0.0001 vs. upper esophageal sphincter relaxation) within the same respiratory phase as swallow (P=0.03). With pharyngeal provocations (n=41), glottal adduction (pharyngo-glottal closure reflex (PGCR)) was noted first and then again with pharyngeal reflexive swallow (PRS). The frequency, response latency, and duration of glottal closure with PGCR were 100%, 0.56+/-0.13 s, and 0.52+/-0.1 s, respectively. Response latency to PRS was 3.24+/-0.33 s; the glottis adducted 97% within 0.36+/-0.08 s in the same respiratory phase (P=0.03), and remained adducted for 3.08+/-0.71 s. Glottal adduction was the quickest with spontaneous swallow (P=0.04 vs. PGCR), and the duration was the longest during PRS (P<0.005 vs. PGCR or spontaneous swallow). CONCLUSIONS: Glottal adduction during basal or adaptive swallowing reflexes occurs in either respiratory phase, thus ensuring airway protection against pre-deglutitive or deglutitive aspiration. The independent existence and magnitude (duration of adduction) of PGCR suggests a hypervigilant state of the glottis in preventing aspiration during swallowing or during high gastroesophageal reflux events. Investigation of pharyngeal-glottal relationships with the use of noninvasive methods may be more acceptable across the age spectrum.

Instrument Selection and Application Used to Probe Dental Implants.

PURPOSE: The purpose of this study is to survey clinicians' choice of peri-implant instrument selection and the application used to probe dental implants as well as to evaluate peri-implant probing force and pressure applied as compared to that reported in current literature. MATERIALS AND METHODS: 48 clinicians (16 periodontists/periodontal residents, 16 restorative dentists and 16 hygienists) participated in the study. A questionnaire to determine the frequency and method of probing dental implants was provided and subject to the Chi-square test. Each participant was given a choice of three periodontal probes (Marquis, UNC15, Plastic) to use on the typodont and probing force was recorded blindly. Probing force and pressure data were analyzed with ANOVA among subject groups as well as probe types per site; where statistical differences (p < .05) were detected, Tukey's posthoc test was applied. RESULTS: The questionnaire resulted in a variety of answers although the majority demonstrated an agreement on probing implants in everyday practice. There was no significant difference among provider groups in regard to instrument selection, probing forces and pressure in both maxilla and mandible although the mean probing forces and pressures in all provider groups were higher than the suggested value reported in the literature. CONCLUSION: This study indicates that there are variations among clinical provider groups with regard to peri-implant probe instrument type used and forces applied, though these are not statistically significant. Probe tip diameter should be considered to avoid BOP false positives when probing dental implants especially as the forces generally used by the clinicians may be higher than advised.

An In Vivo and Cone Beam Computed Tomography Investigation of the Accuracy in Measuring Alveolar Bone Height and Detecting Dehiscence and Fenestration Defects.

PURPOSE: To investigate cone beam computed tomography (CBCT) accuracy in measuring facial bone height and detecting dehiscence and fenestration defects around teeth. MATERIALS AND METHODS: Patients who were treatment planned for periodontal flap or dental implant surgeries were enrolled (n = 25). CBCT imaging (Carestream CS 9300) was obtained at 0.09-mm voxels (n = 10 patients, 23 teeth) and at 0.18-mm voxels (n = 15 patients, 33 teeth). Facial bone height measurements, from cusp tip to crest of bone height along the long axis of the tooth, and presence or absence of dehiscence or fenestration defects were recorded from CBCT images in triplicates independently by two examiners. The corresponding clinical measurements were made at the time of surgery. Comparisons of CBCT and clinical measurements were made using paired t tests for teeth: anterior and posterior, maxillary and mandibular, with or without restorations, or root canal therapy. Level of agreement between investigators was assessed by concordance correlation coefficients (CCC), Pearson's correlation coefficient (PCC), and Cohen's Kappa. RESULTS: Comparing mean CBCT and clinical measurements, statistically significant differences were noted for 0.09-mm and 0.18-mm voxel sizes, for anterior and posterior teeth, for maxillary and mandibular teeth, for teeth with or without restorations, and for teeth without root canal therapy (P < .05). Clinical and CBCT measurements were similar for teeth with crowns and with root canal therapy (P > .05). CBCT measurements underestimated mean facial bone height from 0.33 ± 0.78 to 0.88 ± 1.14 mm (mean ± SD) and absolute facial bone height values from 0.56 ± 0.35 to 1.08 ± 0.92 mm. Intraexaminer and interexaminer reliability for measuring facial bone height ranged from poor to substantial (PCC = 0.78 to 0.97 and CCC = 0.63 to 0.96, respectively). Interexaminer reliability for detection of dehiscence and fenestration defects ranged from poor to moderate (Cohen's Kappa = -0.09 to 0.66). CONCLUSION: CBCT imaging underestimated facial bone height and overestimated the presence of dehiscence and fenestration defects.