Microbiology Alloplastic Total Joint Infections: A 20-Year Retrospective Study.

PURPOSE: Prosthetic joint infection (PJI) is a rare complication of temporomandibular joint replacement (TJR). This study evaluated TJR PJIs at the authors' institution over a 20-year period, including micro-organisms cultured, antibiotic resistance patterns, and intraoperative protocols of TJR. PATIENTS AND METHODS: Patients were identified using Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes and surgical logs from January 1995 through 2015. Inclusion criteria were adults older than 18 years with previous alloplastic TJR and the presence of infection of the prosthesis at explantation. Exclusion criteria were patients younger than 18 years and who received hemiarthroplasty. Primary outcomes included culture data and antibiotic selection for PJI. Secondary outcomes included intraoperative duration and in vivo duration. RESULTS: Eleven patients were identified and 15 joints were explanted. Average length in vivo was 232 months (standard deviation, 478.9 months). Six percent (n = 1) were identified as early PJI (0 to 3 months), 46% (n = 7) were intermediate PJI (3 months to 2 yr), and 33% (n = 5) were late PJI (>2 yr). One patient could not be classified as early, intermediate, or late. Staphylococcus aureus was present in 53% of patients and was the predominant organism isolated. Propionibacterium acnes was isolated in 33% of patients. Penicillin was the antibiotic with the greatest organism resistance (46%). CONCLUSION: In the present study, the most commonly cultured organism was S aureus (53%), a finding consistent with current literature. The prevalence of P acnes colonization was noted in 33% of cases. Although the relevance of P acnes and its contribution to PJI requires further investigation, it is associated with PJI and biofilm formation. Based on this study, consideration could be given to the use of vancomycin and first-generation cephalosporins as perioperative antibiotic coverage.

Oral and Maxillofacial Surgery Foundation Research and Fellowship Awards: A 26-Year Review at Massachusetts General Hospital and Harvard School of Dental Medicine.

PURPOSE: The purpose of this study was to review outcomes of the Oral and Maxillofacial Surgery (OMS) Foundation's funding awards to members of the OMS department at Massachusetts General Hospital (MGH) in terms of projects completed, abstracts presented, peer-reviewed publications, and career trajectories of recipients. MATERIALS AND METHODS: Data were collected from MGH and OMS Foundation records and interviews with award recipients. Primary outcome variables included 1) number of awards and award types, 2) funding amount, 3) project completion, 4) number of presented abstracts, 5) conversion from abstracts to publications, 6) number of peer-reviewed publications, 7) career trajectories of awardees, and 8) additional extramural funding. RESULTS: Eleven Student Research Training Awards provided $135,000 for 39 projects conducted by 37 students. Of these, 34 (87.2%) were completed. There were 30 student abstracts presented, 21 peer-reviewed publications, and a publication conversion rate of 58.8%. Faculty research awards comprised $1,510,970 for 22 research projects by 12 faculty members and two research fellows. Of the 22 funded projects, 21 (95.5%) were completed. There were 110 faculty and research fellow abstracts presented and 113 peer-reviewed publications, for a publication conversion rate of 93.8%. In the student group, 17 of 37 (45.9%) are enrolled in or are applying for OMS residencies. Of the 10 students who have completed OMS training, 3 (30%) are in full-time academic positions. Of the 12 faculty recipients, 9 (75%) remain in OMS academic practice. During this time period, the department received $9.9 million of extramural foundation or National Institutes of Health funding directly or indirectly related to the OMS Foundation grants. CONCLUSIONS: The results of this study indicate that 90.2% of projects funded by the OMS Foundation have been completed. Most projects resulted in abstracts and publications in peer-reviewed journals. These grants encouraged students to pursue OMS careers and aided OMS faculty in developing their research programs.

Anesthesia Complications of Diazepam Use for Adolescents Receiving Extraction of Third Molars.

PURPOSE: To evaluate the safety of midazolam and diazepam for adolescents during third molar extraction and whether any differences in perioperative complications exist when using the 2 benzodiazepines alone or in combination. MATERIALS AND METHODS: A prospective study was performed in adolescents (<21 yr old) who underwent at least 1 third molar extraction by an oral and maxillofacial surgeon in the ambulatory setting from January 2001 through December 2010 using the Oral and Maxillofacial Surgery Outcomes System. The primary predictor variable was type of benzodiazepine used, divided into the total number of patients who received diazepam with or without midazolam. The outcome of interest was adverse complications resulting from anesthesia. Multivariable logistic regression was applied to measure the association between benzodiazepine type and adverse complications. RESULTS: Patients in the diazepam group (n = 4,213) and in the combination group (n = 426) had a complication rate of 1.4%, whereas those in the midazolam group (n = 13,451) had a complication rate of 1.0% (P = .027). Multiple logistic regression analysis showed a 50% increased odds of adverse complications in patients receiving diazepam (adjusted odds ratio = 1.50; 95% confidence interval, 1.05 to 2.16; P = .027). CONCLUSIONS: Adolescent patients who received intravenous diazepam during third molar procedures had an increased odds of anesthesia-related complications compared with those given midazolam.

Complications of Moderate Sedation Versus Deep Sedation/General Anesthesia for Adolescent Patients Undergoing Third Molar Extraction.

PURPOSE: To examine the complications resulting from moderate sedation versus deep sedation/general anesthesia for adolescent patients undergoing third molar extraction and determine whether any differences in complication risks exist between the 2 levels of sedation. MATERIALS AND METHODS: We performed a prospective study of the Oral and Maxillofacial Surgery Outcomes System from January 2001 to December 2010. The primary predictor variable was the level of sedation, divided into 2 groups: moderate sedation versus deep sedation/general anesthesia. The primary outcome was the incidence of adverse complications resulting from the sedation level. Differences in the cohort characteristics were analyzed using the independent samples t test, χ(2) test, and analysis of variance, as appropriate. Multivariable logistic regression was used to measure the effect the level of sedation had on the adverse complication rate. RESULTS: Patients in the moderate sedation group had a complication rate of 0.5%, and patients in the deep sedation/general anesthesia group had a complication rate of 0.9%. Compared with moderate sedation, deep sedation/general anesthesia did not pose a significantly increased risk of adverse anesthesia complications (adjusted odds ratio 1.63, 95% confidence interval 0.95 to 2.81; P = .077). CONCLUSIONS: The results of our study have shown that the risk of adverse anesthesia complications is not increased when choosing between moderate and deep sedation/general anesthesia for adolescent patients undergoing third molar extraction.

Is There a Difference in Cost Between Standard and Virtual Surgical Planning for Orthognathic Surgery?

PURPOSE: Virtual surgical planning (VSP) and 3-dimensional printing of surgical splints are becoming the standard of care for orthognathic surgery, but costs have not been thoroughly evaluated. The purpose of this study was to compare the cost of VSP and 3-dimensional printing of splints ("VSP") versus that of 2-dimensional cephalometric evaluation, model surgery, and manual splint fabrication ("standard planning"). MATERIALS AND METHODS: This is a retrospective cohort study including patients planned for bimaxillary surgery from January 2014 to January 2015 at Massachusetts General Hospital. Patients were divided into 3 groups by case type: symmetric, nonsegmental (group 1); asymmetric (group 2); and segmental (group 3). All cases underwent both VSP and standard planning with times for all activities recorded. The primary and secondary predictor variables were method of treatment planning and case type, respectively. Time-driven activity-based micro-costing analysis was used to quantify the differences in cost. Results were analyzed using a paired t test and analysis of variance. RESULTS: The sample included 43 patients (19 in group 1, 17 in group 2, and 7 in group 3). The average times and costs were 194 ± 14.1 minutes and $2,765.94, respectively, for VSP and 540.9 ± 99.5 minutes and $3,519.18, respectively, for standard planning. For the symmetric, nonsegmental group, the average times and costs were 188 ± 17.8 minutes and $2,700.52, respectively, for VSP and 524.4 ± 86.1 minutes and $3,380.17, respectively, for standard planning. For the asymmetric group, the average times and costs were 187.4 ± 10.9 minutes and $2,713.69, respectively, for VSP and 556.1 ± 94.1 minutes and $3,640.00, respectively, for standard planning. For the segmental group, the average times and costs were 208.8 ± 13.5 minutes and $2,883.62, respectively, for VSP and 542.3 ± 118.4 minutes and $3,537.37, respectively, for standard planning. All time and cost differences were statistically significant (P < .001). CONCLUSIONS: The results of this study indicate that VSP for bimaxillary orthognathic surgery takes significantly less time and is less expensive than standard planning for the 3 types of cases analyzed.

Health Insurance Affects Head and Neck Cancer Treatment Patterns and Outcomes.

PURPOSE: The purpose of this study is to examine the effect of insurance coverage on stage of presentation, treatment, and survival of head and neck cancer (HNC). MATERIALS AND METHODS: A retrospective study was conducted using the Surveillance, Epidemiology, and End Results (SEER) program to identify patients diagnosed with HNC. The primary variable of interest was insurance analyzed as a dichotomous variable: Patients were considered uninsured if they were classified as "uninsured" by SEER, whereas patients were considered insured if they were defined by SEER as "any Medicaid," "insured," or "insured/no specifics." The outcomes of interest were cancer stage at presentation (M0 vs M1), receipt of definitive treatment, and HNC-specific mortality (HNCSM). Multivariable logistic regression modeled the association between insurance status and stage at presentation, as well as between insurance status and receipt of definitive treatment, whereas HNCSM was modeled using Fine and Gray competing risks. Sensitivity logistic regression analysis was used to determine whether observed interactions remained significant by insurance type (privately insured, Medicaid, and uninsured). RESULTS: Patients without medical insurance were more likely to present with metastatic cancer (adjusted odds ratio, 1.60; P < .001), were more likely to not receive definitive treatment (adjusted odds ratio, 1.64; P < .001), and had a higher risk of HNCSM (adjusted hazard ratio, 1.20; P = .002). Sensitivity analyses showed that when results were stratified by insurance type, significant interactions remained for uninsured patients and patients with Medicaid. CONCLUSIONS: Uninsured patients and patients with Medicaid are more likely to present with metastatic disease, are more likely to not be treated definitively, and are at a higher risk of HNCSM. The treatment gap between Medicaid and private insurance observed in this study should serve as an immediate policy target for health care reform.

Components of Patient Satisfaction After Orthognathic Surgery.

The purpose of this study was to compare overall patient satisfaction after orthognathic surgery with the following specific categories: appearance, functional ability, general health, sociability, and patient-clinician communication. A 16-question survey was developed and administered to include patients at either 6 or 12 months after orthognathic surgery between June 2013 and June 2014 at the University of Pennsylvania and Massachusetts General Hospital. The predictor variables included age, sex, type of procedure, medical comorbidities, intra- or postoperative complications, and presence of paresthesia. The outcome variable was patient satisfaction overall and in each category based on a Likert scale (0: not satisfied at all to 5: very satisfied).A total of 37 patients completed the survey and had a high overall rate of satisfaction (100% of responses were 4 or 5 on Likert scale). Overall satisfaction had the highest correlation with appearance (ρ=0.52, P=0.0009) followed by sociability (ρ=0.47, P=0.004), patient-clinician communication (ρ=0.38, P=0.02) functionality (ρ=0.19, P=0.26), and general health (ρ = -0.11, P = 0.51). Patients had high satisfaction scores for orthognathic surgery. Satisfaction with postoperative appearance had the strongest correlation with overall satisfaction.

Marital status and head and neck cancer outcomes.

BACKGROUND: The objective of this study was to examine the effects of marital status on stage at presentation, receipt of treatment, and survival in patients with head and neck cancer (HNC). METHODS: The Surveillance, Epidemiology, and End Results database was used to analyze 51,272 patients who were diagnosed with HNC from 2007 to 2010. The impact of marital status on cancer stage at presentation, receipt of definitive treatment, and HNC-specific mortality (HNCSM) was determined using multivariable logistic and Fine and Gray competing-risks regression models, as appropriate. RESULTS: Marriage had a protective effect against metastatic presentation of oral and laryngeal cancers (oral cancer: adjusted odds ratio [AOR], 0.72; 95% confidence interval [CI], 0.60-0.87; P < .001; laryngeal cancer: AOR, 0.53; 95% CI, 0.42-0.67; P < .001) but not against oropharyngeal, hypopharyngeal, or nasopharyngeal cancers. Among patients with nonmetastatic disease, married patients were more likely to receive definitive treatment (overall AOR, 1.77; 95% CI, 1.60-1.95; P < .001) and had a lower risk of HNCSM (overall adjusted hazard ratio, 0.72; 95% CI, 0.68-0.77; P < .001); these associations remained significant across all HNC sites. CONCLUSIONS: Among patients with oral and laryngeal cancers, those who are married are less likely to present with metastatic disease. In addition, married patients are more likely to receive definitive treatment and less likely to die from HNC across all HNC sites. This suggests that spousal support may have a role in the surveillance of visual and symptomatic HNC types and leads to higher rates of treatment and better survival across all HNC sites.

Upper Airway Length is Predictive of Obstructive Sleep Apnea in Syndromic Craniosynostosis.

PURPOSE: Midfacial hypoplasia is a characteristic feature of the syndromic craniosynostoses and predisposes these patients to developing obstructive sleep apnea (OSA). The purpose of this study was to identify anatomic factors associated with airway obstruction in patients with syndromic craniosynostoses. MATERIALS AND METHODS: This was a retrospective cohort study. The authors enrolled a study sample composed of patients with syndromic craniosynostoses. The predictor variables were age, gender, body mass index (BMI), syndromic diagnosis, and parameters of upper airway length and size measured on lateral cephalograms. To control for age, upper airway length was corrected for differences in patient height. The outcome variable was OSA status (present or absent). Descriptive, bivariate, and regression statistics were computed. For all analyses, a P value less than or equal to .05 was considered statistically significant. RESULTS: The sample was composed of 50 patients with a mean age of 10.3 ± 0.6 years, 50% were boys, and 24 (48%) had OSA. Patients with and without OSA did not differ statistically in age, gender, BMI, or syndromic diagnosis. Those with OSA had increased upper airway length (P = .016), decreased posterior airway space (P = .001), and more severe midfacial retrusion (P = .022) compared to patients without OSA. After adjusting for covariates, the odds ratio for OSA was 32.9 in patients with an upper airway longer than 45.3 mm per meter of height (P = .018), and for every 1-mm decrease in posterior airway space, the risk of OSA increased by 30% (P = .022). CONCLUSIONS: Patients with syndromic craniosynostosis and OSA have a longer upper airway, smaller posterior airway space, and more severe midfacial retrusion than those without OSA.

Increasing value in plagiocephaly care: a time-driven activity-based costing pilot study.

BACKGROUND: Process management within a health care setting is poorly understood and often leads to an incomplete understanding of the true costs of patient care. Using time-driven activity-based costing methods, we evaluated the high-volume, low-complexity diagnosis of plagiocephaly to increase value within our clinic. METHODS: A total of 59 plagiocephaly patients were evaluated in phase 1 (n = 31) and phase 2 (n = 28) of this study. During phase 1, a process map was created, encompassing each of the 5 clinicians and administrative personnel delivering 23 unique activities. After analysis of the phase 1 process maps, average times as well as costs of these activities were evaluated for potential modifications in workflow. These modifications were implemented in phase 2 to determine overall impact on visit-time and costs of care. RESULTS: Improvements in patient education, workflow coordination, and examination room allocation were implemented during phase 2, resulting in a reduced patient visit-time of 13:25 (19.9% improvement) and an increased cost of $8.22 per patient (7.7% increase) due to changes in physician process times. However, this increased cost was directly offset by the availability of 2 additional appointments per day, potentially generating $7904 of additional annual revenue. Quantifying the impact of a 19.9% reduction in patient visit-time at an increased cost of 7.7% resulted in an increased value ratio of 1.113. CONCLUSIONS: This pilot study effectively demonstrates the novel use of time-driven activity-based costing in combination with the value equation as a metric for continuous process improvement programs within the health care setting.

The value of postoperative visits for third molar removal.

PURPOSE: The clinical follow-up visit after third molar extraction has been cited as time consuming and of little benefit to patients. Although telephone follow-up has the potential to add value to the surgical management of third molars, sparse information exists on the financial context of this alternative. The purpose of this study was to show the change in value of third molar extraction with telephone follow-up through 1) measurement of the postoperative complication rate and 2) costs of telephone versus clinical follow-up. MATERIALS AND METHODS: Bivariate comparisons were computed to assess for differences in follow-up type. Cost was calculated from a provider's perspective using micro-costing analysis that quantified cost differences between postoperative telephone and clinical follow-ups. Each visit type was divided into clinical activities and clinicians involved. Cost rates (dollars per minute) were derived for each clinician. Each clinical activity time was multiplied by clinician cost rate to derive an activity-based cost for each activity. Individual activity-based costs were summed to derive the total cost of telephone versus clinical follow-up visit. RESULTS: Patients who had a telephone follow-up had a similar postoperative complication rate (2.1%) as those who had a clinical follow-up (1.9%; P = .94). The total cost estimates were $14.26 for telephone follow-up and $63.33 for clinical follow-up. Overall, there was a cost savings of $49.07 per patient, or a 77.4% decrease in cost, when using telephone follow-up. CONCLUSION: Telephone follow-ups added value to the operative management of patients having third molar extractions by controlling for postoperative complication rate and decreasing cost of care.

The role of phenotyping in chronic prostatitis/chronic pelvic pain syndrome.

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a chronic pain syndrome identified by the presence of noninfectious pelvic or perineal pain lasting longer than 3 months. Current diagnoses and treatments for the syndrome solely depend on and target symptoms, respectively. Thus far, the mechanistic disturbances responsible for the pathogenesis of CP/CPPS have remained largely elusive and treatments, and therefore, continue to be ineffective. To move toward successful management and treatment of CP/CPPS, it is necessary to elicit the underlying biological mechanisms responsible for the syndrome. Therefore, a phenotyping system that is able to bridge the gap between current symptom-based diagnosis and future mechanistic approaches to diagnosis and treatment is needed. In this article, we examine current CP/CPPS phenotyping systems, analyze their utility, and make suggestions for changes in clinical approaches to the syndrome that would both promulgate a mechanistic understanding and advance treatment approaches.

Impact of African-American race on presentation, treatment, and survival of head and neck cancer.

OBJECTIVES: To determine the associations between African American race and stage at diagnosis, receipt of definitive therapy, and cancer-specific mortality among patients with head and neck cancer. MATERIALS AND METHODS: The Surveillance, Epidemiology and End Results (SEER) database was used to conduct a retrospective study on 34,437 patients diagnosed with head and neck cancer from 2007 to 2010. Multivariable logistic regression analyses were applied to determine the impact of race on cancer stage at presentation (metastatic vs. non-metastatic) and receipt of definitive treatment. Fine and Gray competing-risks regression modeled the association between race and head and neck cancer-specific mortality. RESULTS: African Americans were more likely to present with metastatic cancer compared to non-African Americans (Adjusted Odds Ratio [AOR] 1.76; CI 1.50-2.07; P<0.001). Among patients with non-metastatic disease, African Americans were less likely to receive definitive treatment (AOR 0.63; CI 0.55-0.72; P<0.001). After a median follow-up of 19months, African Americans with non-metastatic disease were found to have a higher risk of head and neck cancer specific mortality (AHR 1.19; 95% CI 1.09-1.29; P<0.001). CONCLUSION: African Americans with head and neck cancer are more likely to present with metastatic disease, less likely to be treated definitively, and are more likely to die from head and neck cancer. The unacceptably high rates of disparity found in this study should serve as immediate targets for urgent healthcare policy intervention.