Preoperative dental screening prior to cardiac valve surgery and 90-day postoperative mortality.

BACKGROUND: Preoperative dental screening before cardiac valve surgery is widely accepted but its required scope remains unclear. This study evaluates two preoperative dental screening (PDS) approaches, a focused approach (FocA) and a comprehensive approach (CompA), to compare postsurgical 90-day mortality. METHODS: Retrospective cohort analysis was performed on all patients who underwent valve surgery at Brigham and Women's Hospital with FocA and Massachusetts General Hospital with CompA of PDS approach from January 2009 to December 2016. Patients with intravenous drug abuse and systemic infections were excluded. Univariate, multivariable, and subgroup analysis was performed. RESULTS: A total of 1835 patients were included in the study. With FocA 96% of patients (1097/1143) received dental clearance in a single encounter with 3.3% receiving radiographs and undergoing dental extractions. With CompA 35.5% of patients (245/692) received dental clearance in a single encounter, 94.2% received radiographs, and 21.8% underwent dental extractions. There was no significant difference in 90-day mortality when comparing both PDS approach (10% vs 8.4%, P = .257). This remained unchanged in a multivariable model after adjusting for risk factors (odds ratio:1.32 [95%CI:0.91-1.93] [P = .14]). Reoperation due to infection was less in FocA (0.5%) vs CompA (2.6) (P < .001) and postoperative septicemia was increased in the FocA (1.7%) cohort when compared to the CompA (0.7%) (P < .001) patients. CONCLUSIONS: There was no difference in post valve surgery 90-day mortality between patients who underwent a FocA vs CompA of PDS.

Long-Term Utilization Patterns of Topical Therapy and Clinical Outcomes of Oral Chronic Graft-versus-Host Disease.

An open-label phase 2 study of topical dexamethasone versus tacrolimus solutions in new-onset oral chronic graft-versus-host disease (cGVHD) revealed the superior efficacy of dexamethasone. The objective of this study was to report long-term patterns of topical therapy utilization and clinical outcomes in this cohort after completing the 30-day trial. A retrospective record review was performed from the date of study completion to January 2017. Topical therapies, systemic immunosuppressive therapies, objective measurements (National Institutes of Health severity score, oral mucosal scores), patient- reported outcomes (dryness, sensitivity, pain), and adverse events were recorded for oral cGVHD-related outpatient visits. Follow-up (FU) periods were defined as FU1 (0-1 month), FU2 (1-3 months), FU3 (3-6 months), FU4 (6-12 months), FU5 (12-18 months), and FU6 (18-24 months). Forty patients (52.5% males, median age, 56 years) completed the clinical trial and were included in the analysis. Topical therapies used were dexamethasone, tacrolimus, clobetasol, or a combination of these agents. At FU1, all 40 patients were receiving topical therapy, which decreased to 54.5% (12 out of 22) at FU6. Clinician-reported oral mucosal scores (0-12) and patient-reported sensitivity scores (0-10) decreased over time from FU1 (median mucosal score, 3; sensitivity, 3) to FU6 (mucosal score, 1; sensitivity, 2). Intralesional steroid therapy was provided to 6 patients for management of refractory oral ulcerations, all within the first year of follow-up. Patients with de novo symptomatic oral cGVHD may require long-term care with topical immunomodulatory therapy for up to 2 years, if not longer. Topical steroid and tacrolimus therapies are safe and effective in managing symptomatic oral cGVHD. Second-line topical therapy for refractory oral cGVHD requires further investigation.