American Board of Orthodontics: Progress of the scenario-based clinical examination.

In 2017, the directors of the American Board of Orthodontics (ABO) decided to move forward with a new clinical examination format-a scenario-based examination. The first examination of this type was administered in February 2019, and 2 more exams have been given since then. Each examination consisted of at least 6 scenarios with 4-7 questions for each scenario. Questions came from 4 domains or categories-data gathering and diagnosis, treatment objectives and planning, treatment implementation and management, and critical analysis and outcomes assessment. As of today, 49% of members of the American Association of Orthodontists are ABO certified. For more information about the scenario-based examination and ABO certification or certification renewal processes, go to AmericanBoardOrtho.com.

Hypertension and Heart Failure: Prevention, Targets, and Treatment.

Hypertension is possibly the most powerful, modifiable risk factor for the development of heart failure. Chronic hypertension drives cardiac remodeling within the left ventricle resulting in hypertensive heart disease, which ultimately manifests as heart failure. Early detection and appropriate management are necessary to prevent heart failure as well as other cardiovascular diseases. Achieving blood pressure goals in conjunction with using evidence-based treatments can improve clinical outcomes for patients with comorbid hypertension and heart failure.

American Board of Orthodontics: Update on the new scenario-based clinical examination.

The American Board of Orthodontics has updated its clinical examination process to remove barriers to the case-based examination, strengthen the specialty, and further distinguish board-certified orthodontists from other dental practitioners providing orthodontic care. The ABO adopted a scenario-based clinical examination and discontinued case requirements. The first new exam was administered in February 2019. It consisted of 6 scenarios with 4-7 questions for each scenario. The scenarios represent a variety of problems and patients, and the questions relate to data gathering and diagnosis, treatment objectives and planning, treatment implementation and management, and critical analysis and outcomes assessment. Feedback from the February 2019 exam was positive, and 4 more have been scheduled. For more information about the ABO certification process, go to AmericanBoardOrtho.com.

A retrospective study of opioid prescribing patterns at hospital discharge in surgical patients with obstructive sleep apnea.

PURPOSE: Obstructive sleep apnea (OSA) is a risk factor for complications with postoperative opioid use, and in those patients with known or suspected OSA, minimization of postoperative opioids is recommended. We hypothesize that despite these recommendations, surgical patients with known or suspected OSA are prescribed postoperative opioids at hospital discharge at similar doses to those without OSA. METHODS: This was a retrospective analysis of the electronic health records of surgical patients from 1 November 2016 to 30 April 2017 at a single academic institution. Patients with a known diagnosis of OSA or a STOP-Bang score ≥ 5 were compared with those without OSA for the amount of postoperative discharge opioid medication using multivariable linear regression. RESULTS: Of the 17,671 patients analyzed, 1,692 (9.6%) had known or suspected OSA with 1,450 (86%) of these patients discharged on opioid medications. Of the 15,979 patients without OSA, 12,273 (77%) were discharged on opioid medications. The total median [interquartile range (IQR)] oral morphine equivalents (OME) for all patients was 150 [0-338] mg and for patients with known or suspected OSA was 160 [0-450] mg, an unadjusted comparison showing an 18% difference in OME (95% confidence interval [CI], 3% to 35%; P = 0.02). The analysis, after adjusting for confounders, showed no significant difference in the amount of opioids prescribed to OSA or non-OSA patients (8% difference in total OME; 95% CI, -6% to 25%; P = 0.26). CONCLUSION: This study shows that surgical patients at risk for OSA or confirmed OSA are prescribed opioids at similar rates and doses upon discharge despite guidelines that recommend minimizing opioid use in OSA patients. These findings indicate a need to implement different strategies to reduce the prescription of opioids to patients with OSA.

American Board of Orthodontics: Time for change.

The American Board of Orthodontics (ABO) works to certify orthodontists in a fair, reliable, and valid manner. The process must examine an orthodontist's knowledge, abilities, and critical thinking skills to ensure that each certified orthodontist has the expertise to provide the highest level of patient care. Many medical specialty boards and 4 American Dental Association specialty boards use scenario-based testing for board certification. Changing to a scenario-based clinical examination will allow the ABO to test more orthodontists. The new process will not result in an easier examination; standards will not be lowered. It will offer an improved testing method that will be fair, valid, and reliable for the specialty of orthodontics while increasing accessibility and complementing residency curricula. The ABO's written examination will remain as it is.

Common errors observed at the American Board of Orthodontics clinical examination.

The American Board of Orthodontics has developed tools to help examinees select patients to be used for the Board examination. The Case Management Form can be used to evaluate aspects of a patient's treatment that cannot be measured by other tools. The Case Management Form is a structured treatment-neutral assessment of orthodontic objectives and outcomes associated with a patient's treatment. Despite the availability of this form, examiners continue to see problems, including lack of attention to finishing details, inappropriate treatment objectives, excessive proclination of mandibular incisors due to treatment mechanics, excessive expansion of mandibular intercanine width, closing skeletal open bite with extrusion of anterior teeth leading to excessive gingival display, and failure to recognize the importance of controlling the eruption or extrusion of molars during treatment. In addition, some examinees exhibit a lack of understanding of proper cephalometric tracing and superimposition techniques, which lead to improper interpretation of cephalometric data and treatment outcomes.

Certification renewal process of the American Board of Orthodontics.

The American Board of Orthodontics was established in 1929 and is the oldest specialty board in dentistry. Its goal is to protect the public by ensuring competency through the certification of eligible orthodontists. Originally, applicants for certification submitted a thesis, 5 case reports, and a set of casts with appliances. Once granted, the certification never expired. Requirements have changed over the years. In 1950, 15 cases were required, and then 10 in 1987. The Board has continued to refine and improve the certification process. In 1998, certification became time limited, and a renewal process was initiated. The Board continues to improve the recertification process.

Hypertension and Heart Failure: Prevention, Targets, and Treatment.

Hypertension is possibly the most powerful, modifiable risk factor for the development of heart failure. Chronic hypertension drives cardiac remodeling within the left ventricle resulting in hypertensive heart disease, which ultimately manifests as heart failure. Early detection and appropriate management are necessary to prevent heart failure as well as other cardiovascular diseases. Achieving blood pressure goals in conjunction with using evidence-based treatments can improve clinical outcomes for patients with comorbid hypertension and heart failure.

Corrigendum to "Risk Factor Control Across the Spectrum of Cardiovascular Risk: Findings from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)" [American Journal of Preventive Cardiology, Volume 5, March 2021, 100147].

[This corrects the article DOI: 10.1016/j.ajpc.2021.100147.].

Acoustic and Aerodynamic Comparisons of Voice Qualities Produced After Voice Training.

Characteristics of true vocal fold vibration such as the proportion of closed phase of vibration to open phase, longitudinal tension, and the amount of medial compression are used to define four conditions during Estill Voice Training. However, it is unknown whether trainees achieve these phonatory differences after training. Acoustic and aerodynamic measures were used to determine differences in Slack, Thick, Thin, and Stiff conditions. Twenty-four female speech-language pathology graduate students received training perceiving and producing these four conditions and volunteered to participate 3-5 months later. After a 20-minute refresher training, participants were recorded using the Phonatory Aerodynamic System with electroglottography and Computerized Speech Lab. Four Estill Voice Training experts independently categorized the voice quality productions. Aerodynamic and acoustic measures of productions classified by at least three of four experts as having the intended quality determined if measures differentiated among voice qualities and supported the hypothesized physiological concepts used in training at Bonferroni corrected P ≤ 0.0063. Results showed that Slack had low fundamental frequency (fo), low sound pressure level (SPL), and high vibratory instability; Thick had high subglottal pressure (Psg), high SPL, and high vibratory stability; Stiff had high airflow while Thin had lower Psg than Thick. Seven measures differentiated the four qualities with 88.1% accuracy while only Psg, airflow, and jitter were required to differentiate Thick, Stiff, and Thin with 88.7% accuracy. As acoustic and aerodynamic measures differentiated among voice qualities and supported the theoretical physiological characteristics used in training, they could be used to track accuracy during training.

Risk factor control across the spectrum of cardiovascular risk: Findings from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

BACKGROUND: Presence of cardiovascular disease (CVD) risk factors (RFs) should prompt patients and their providers to work aggressively towards controlling those that are modifiable. The extent to which a greater CVD RF burden is related to CVD RF control in a contemporary and diverse Hispanic/Latino population is not well-understood. METHODS: Using multicenter community-based data from the Hispanic Community Health Study/Study of Latinos, we assessed the self-reported prevalence of hypertension, hypercholesterolemia, diabetes, and prevalent CVD (ischemic heart disease or stroke). We used contemporaneous guidelines to define RF control. Multivariable logistic regression for complex survey sampling was used to examine whether having more CVD RFs was associated with CVD RF control (adjusting for age, sex, Hispanic background group, education, and health insurance). RESULTS: Our sample included 8521 participants with at least one CVD RF or prevalent CVD. The mean age in HCHS/SOL target population was 49 (SE 0.3) years and 56% were women. Frequency of one, two, or three self-reported CVD RFs was 57%, 26%, 8%, respectively, and overall 9% of participants had prevalent CVD. After adjusting for sociodemographic factors, compared to those reporting one CVD RF, individuals with three CVD RFs were the least likely to have blood pressure, cholesterol, and glucose optimally controlled (odds ratio [OR]: 0.56; 95% confidence interval [CI]: 0.40-0.80). However, those with prevalent CVD were more likely to have all three risk factors controlled, (OR: 1.43; 95% CI: 1.01-2.01). CONCLUSION: Hispanic/Latino adults with three major CVD RFs represent a group with poor overall CVD RF control. Secondary CVD prevention fares better. The potential contributors to inadequate CVD RF control in this highly vulnerable group warrants further investigation.

Predicting Patient Needs for Interdisciplinary Services in a Voice and Swallowing Center.

In a subspecialty interdisciplinary voice and swallowing clinic, patient referrals come from a wide variety of disciplines for various reasons, which can make scheduling their initial evaluations challenging. Depending on the nature of complaints and symptoms, patients may best be evaluated either by a single provider (a laryngologist) or by an interdisciplinary team that includes a speech-language pathologist. If not scheduled appropriately, the provider and the patient may lose valuable time, resources, and money. This was a retrospective chart review of 76 patients who received an interdisciplinary evaluation in our Voice and Swallowing Center's first 7 months of operation. Two factors were examined for their predictive values: the most common reasons for referral and the disciplines that commonly refer to the clinic. The goal was to probe for any variables known at the time of referral that could inform us whether an interdisciplinary evaluation would be beneficial or not. This information informs resource planning for space, equipment, scheduling, and staffing. The results showed that the most common reasons for a referral to the Voice and Swallowing Center were dysphonia (34.8%), dyspnea/paradoxical vocal fold motion ("PVFM," 20.2%), and dysphagia (18%). Statistical analysis of the results indicated that certain reasons for referral were more likely to require an interdisciplinary evaluation than others: dysphonia, irritable larynx syndrome/chronic cough, and PVFM. Referrals most commonly came from providers with a background discipline of primary care (26%) and otolaryngology (22%). The discipline of a referring provider alone was not a strong enough indicator to reliably predict the type of evaluation needed. Examining the available data on referral patterns, as this study has done, has the potential to inform providers how to better anticipate their patients' needs and also improve clinic operations.

Comorbid Dysphagia and Dyspnea in Muscle Tension Dysphonia: A Global Laryngeal Musculoskeletal Problem.

OBJECTIVE: To characterize the associated symptoms of dysphagia and dyspnea among patients presenting with muscle tension dysphonia (MTD). STUDY DESIGN: Retrospective chart review performed over a 14-month period from October 2014 to December 2015. SETTING: Voice and swallowing center of a tertiary academic medical center. SUBJECTS AND METHODS: Thirty-eight patients with MTD were included for analysis. Clinical data were collected and analyzed, including perceptual voice evaluation and patient-reported outcomes measures. RESULTS: Among patients with a diagnosis of MTD, the incidence of reported dysphagia during clinical history and examination was 44.7%. Among patients with MTD, 60.5% had an EAT-10 (10-item Eating Assessment Tool) score ≥3 (ie, abnormal). Patients who reported dysphagia and/or had abnormal EAT-10 score (≥3) had significantly greater voice impairment than that of patients without dysphagia (P = .02). Patients who reported dysphagia also had significantly higher Clinical COPD Questionnaire scores than those of patients who reported only dysphonia (P = .002). CONCLUSIONS: Patients presenting for dysphonia who are diagnosed with MTD have a high rate of comorbid dysphagia. Patients who reported dysphagia had significantly higher self-reported voice impairment and greater severity of breathing dysfunction as measured by the Clinical COPD Questionnaire. The coincidence of these symptoms in this patient cohort may suggest an underlying pathophysiology that has yet to be elucidated. Further prospective studies are needed to clarify the underlying cause of dysphagia and breathing dysfunction in the setting of MTD and to investigate diagnostic and therapeutic paradigms.

Consensus-Based Attributes for Identifying Patients With Spasmodic Dysphonia and Other Voice Disorders.

Importance: A roadblock for research on adductor spasmodic dysphonia (ADSD), abductor SD (ABSD), voice tremor (VT), and muscular tension dysphonia (MTD) is the lack of criteria for selecting patients with these disorders. Objective: To determine the agreement among experts not using standard guidelines to classify patients with ABSD, ADSD, VT, and MTD, and develop expert consensus attributes for classifying patients for research. Design, Setting and Participants: From 2011 to 2016, a multicenter observational study examined agreement among blinded experts when classifying patients with ADSD, ABSD, VT or MTD (first study). Subsequently, a 4-stage Delphi method study used reiterative stages of review by an expert panel and 46 community experts to develop consensus on attributes to be used for classifying patients with the 4 disorders (second study). The study used a convenience sample of 178 patients clinically diagnosed with ADSD, ABSD, VT MTD, vocal fold paresis/paralysis, psychogenic voice disorders, or hypophonia secondary to Parkinson disease. Participants were aged 18 years or older, without laryngeal structural disease or surgery for ADSD and underwent speech and nasolaryngoscopy video recordings following a standard protocol. Exposures: Speech and nasolaryngoscopy video recordings following a standard protocol. Main Outcomes and Measures: Specialists at 4 sites classified 178 patients into 11 categories. Four international experts independently classified 75 patients using the same categories without guidelines after viewing speech and nasolaryngoscopy video recordings. Each member from the 4 sites also classified 50 patients from other sites after viewing video clips of voice/laryngeal tasks. Interrater κ less than 0.40 indicated poor classification agreement among rater pairs and across recruiting sites. Consequently, a Delphi panel of 13 experts identified and ranked speech and laryngeal movement attributes for classifying ADSD, ABSD, VT, and MTD, which were reviewed by 46 community specialists. Based on the median attribute rankings, a final attribute list was created for each disorder. Results: When classifying patients without guidelines, raters differed in their classification distributions (likelihood ratio, χ2 = 107.66), had poor interrater agreement, and poor agreement with site categories. For 11 categories, the highest agreement was 34%, with no κ values greater than 0.26. In external rater pairs, the highest κ was 0.23 and the highest agreement was 38.5%. Using 6 categories, the highest percent agreement was 73.3% and the highest κ was 0.40. The Delphi method yielded 18 attributes for classifying disorders from speech and nasolaryngoscopic examinations. Conclusions and Relevance: Specialists without guidelines had poor agreement when classifying patients for research, leading to a Delphi-based development of the Spasmodic Dysphonia Attributes Inventory for classifying patients with ADSD, ABSD, VT, and MTD for research.

Evaluation of crown-root angulation of lateral incisors adjacent to palatally impacted canines.

BACKGROUND: The objective of this study is to explore differences in crown-to-root angulation between lateral incisors adjacent to palatally impacted canines (PICs) and lateral incisors adjacent to normally erupted canines (NECs). METHODS: Orthodontic records of 100 subjects (51 with PICs and 49 with NECs) were reviewed. Crown-to-root angulations of all lateral incisors were measured manually on the final panoramic radiographs. Also, three experienced orthodontists were asked to visually inspect the morphology of the lateral incisors on the panoramic radiographs. A mixed model was used to test the difference in crown-to-root angulation of the lateral incisor between the experimental and the control groups. The association between the examiners' observations and the presence of a canine impaction was assessed by means of a chi-square test. All analyses were performed at the 0.05 level of statistical significance. RESULTS: A significant (p = 0.009) difference of 2.3° in crown-to-root angulation was found between groups. Also, 66.7% of the lateral incisors that were identified as "abnormal" by the panel of orthodontists were adjacent to a PIC. A percentage of 65.2 of lateral incisors that were identified as "normal" were located adjacent to NECs. CONCLUSIONS: The root of lateral incisors adjacent to PICs is angulated more mesially compared to lateral incisors adjacent to NECs. In addition, clinicians are somewhat able to predict if a canine is palatally impacted by visually observing the crown-to-root angulation of the adjacent lateral incisor. Evaluating the crown-to-root angulation of a lateral incisor on a panoramic image might facilitate an early diagnosis of palatally impacted canines.

A Role for YouTube in Telerehabilitation.

YouTube (http://youtube.com) is a free video sharing website that allows users to post and view videos. Although there are definite limitations in the applicability of this website to telerehabilitation, the YouTube technology offers potential uses that should not be overlooked. For example, some types of therapy, such as errorless learning therapy for certain language and cognitive deficits can be provided remotely via YouTube. In addition, the website's social networking capabilities, via the asynchronous posting of comments and videos in response to posted videos, enables individuals to gain valuable emotional support by communicating with others with similar health and rehabilitation challenges. This article addresses the benefits and limitations of YouTube in the context of telerehabilitation and reports patient feedback on errorless learning therapy for aphasia delivered via videos posted on YouTube.