Creating Proper Occlusion With OccluSense® to Achieve Sound Function.

Proper occlusion is a foundational element of dentistry that affects various aspects of dental health, including a patient's oral function, structure, and esthetics. Among the tools dentists use to gauge a patient's occlusion are articulating paper and shimstock. A new system that combines both traditional and digital registration of the pressure distribution on occlusal surfaces can aid clinicians in further analyzing a patient's occlusion and more precisely diagnosing anomalies. In this article, three clinical cases are presented in which the OccluSense® system was used to address occlusion issues in restorative dentistry, orthodontics, and prosthodontics.

E-CPR in Cardiac Arrest due to Accidental Hypothermia Using Intensivist Cannulators: A Case Series of Nine Consecutive Patients.

Background: Severe accidental hypothermia (AH) accounts for over 1300 deaths/year in the United States. Early extracorporeal life support (ECLS) is recommended for hypothermic cardiac arrest. We describe the use of a rapid-deployment extracorporeal cardiopulmonary resuscitation (E-CPR) team using intensivist physicians (IPs) as cannulators and report the outcomes of consecutive patients cannulated for ECLS to manage cardiac arrest due to AH. Methods: We reviewed all patients managed with veno-arterial (V-A) ECLS for hypothermic cardiac arrest between January 1, 2017 and November 1, 2021. For each patient- age, sex, cause of hypothermia, initial core temperature, initial rhythm, time from arrest to cannulation, cannula configuration, pH, lactate, potassium, cannulation complications, duration of ECLS, hospital length of stay, mortality, and cerebral performance category (CPC) at discharge were reviewed. Results: Nine consecutive patients were identified that underwent V-A ECLS for cardiac arrest due to AH. Seven (78%) were witnessed arrests. Initial rhythm was ventricular fibrillation (VF) in eight patients and pulseless electrical activity (PEA) in one. The mean initial core temperature was 23.8 degrees Celsius. The mean time from arrest to cannulation was 58 min (range 17 to 251 min). There were no complications related to cannulation. The mean duration of ECLS was 39.1 h. All nine patients were discharged alive with a Cerebral Performance score of one or two. Conclusion: In this case series of consecutive patients reporting intensivist-deployed E-CPR for cardiac arrest due to AH, all patients survived to discharge with a favorable neurologic outcome. A rapidly available E-CPR team utilizing intensivist cannulators may improve outcomes in patients with cardiac arrest due to AH.

An Intensivist-Led Extracorporeal Membrane Oxygenation Program: Design, Implementation, and Outcomes of the First Five Years.

We describe the development, implementation, and outcomes of an intensivist-led adult extracorporeal life support (ECLS) program using intensivists both to perform venovenous (V-V), venoarterial (V-A), and extracorporeal cardiopulmonary resuscitation (ECPR) cannulations, and to manage patients on ECLS throughout their ICU course. All adults supported with ECLS at the University of New Mexico Hospital (UNMH) from February 1, 2017 to December 31, 2021 were retrospectively analyzed. A total of 203 ECLS cannulations were performed in 198 patients, including 116 V-A cannulations (including 65 during ECPR) and 87 V-V cannulations (including 38 in patients with COVID-19). UNMH intensivists performed 195 cannulations, with 9 cannulation complications. Cardiothoracic surgeons performed 8 cannulations. Overall survival to hospital discharge or transfer was 46.5%. Survival was 32.3% in the ECPR group and 56% in the non-ECPR V-A group. In the V-V cohort, survival was 66.7% in the COVID-19-negative patients and 34.2% in the COVID-19-positive patients. This large series of intensivist-performed ECLS cannulations-including V-A, V-V, and ECPR modalities-demonstrates the successful implementation of a comprehensive intensivist-led ECLS program. With outcomes comparable to those in the literature, our program serves as a model for the initiation and development of ECLS programs in settings with limited access to local subspecialty cardiothoracic surgical services.

Contemporary hemodynamic management of acute spinal cord injuries with intravenous and enteral vasoactive agents: A narrative review.

PURPOSE: The pathophysiology and hemodynamic management of acute spinal cord injuries, including the use of intravenous and enteral vasoactive agents, are reviewed. SUMMARY: Spinal cord injuries are devastating neurological insults that in the acute setting lead to significant hemodynamic disturbances, including hypotension and bradycardia, that are influenced by the level of injury. High thoracic (usually defined as at or above T6) and cervical injuries often manifest with hypotension and bradycardia due to destruction of sympathetic nervous system activity and unopposed vagal stimulation to the myocardium, whereas lower thoracic injuries tend to result in hypotension alone due to venous pooling. Initial management includes maintaining euvolemia with crystalloids and maintaining or augmenting mean arterial pressure with the use of intravenous vasoactive agents to improve neurological outcomes. Choice of vasopressor should be based on patient-specific factors, particularly level of injury and presenting hemodynamics. This review includes the most recent literature on intravenous vasopressors as well as the limited evidence supporting the use of enteral vasoactive agents. Enteral vasoactive agents may be considered, when clinically appropriate, as a strategy to wean patients off of intravenous agents and facilitate transfer outside of the intensive care unit. CONCLUSION: The hemodynamic management of acute spinal cord injuries often requires the use of vasoactive agents to meet mean arterial pressure goals and improve neurological outcomes. Patient-specific factors must be considered when choosing intravenous and enteral vasoactive agents.

Transesophageal Echocardiography Performed by Intensivist and Emergency Physicians-A 5-Year, Single-Center Experience.

Purpose: Data on the use of transesophageal echocardiography (TEE) by intensivist physicians (IP) and emergency physicians (EP) are limited. This study aims to characterize the use of TEE by IPs and EPs in critically ill patients at a single center in the United States. Materials and Methods: Retrospective chart review of all critical care TEEs performed from January 1, 2016 to January 31, 2021. The personnel performing the exams, location of the exams, characteristics of exams, complications, and outcome of the patients were reviewed. Results: A total of 396 examinations was reviewed. TEE was performed by IPs (92%) and EPs (9%). The location of TEE included: intensive care unit (87%), emergency department (11%), and prehospital (2%) settings. The most common indications for TEE were: hemodynamic instability/shock (44%), cardiac arrest (23%), and extracorporeal membrane oxygenation (ECMO) facilitation, adjustment, or weaning (21%). The most common diagnosis based on TEE were: normal TEE (25%), left ventricular dysfunction (19%), and vasodilatory shock (15%). A management change resulted from 89% of exams performed. Complications occurred in 2% of critical care TEEs. Conclusion: TEE can be successfully performed by IPs and EPs on critically ill patients in multiple clinical settings. TEE frequently informed management changes with few complications.

How Dynamic Navigation Can Improve Accuracy and Minimize Errors.

The use of 3-dimensional imaging and guided surgery applications for implant dentistry has increased profoundly in the past several years. New technology has evolved to increase surgical speed and enhance patient comfort and care. Dynamic guided navigational surgery has improved dental implant surgery, enabling placement accuracy that compares favorably to traditional static guides. This article describes the benefits and improvements that guided navigational surgery provides, including efficient workflow, real-time feedback, enhanced access and visualization, and the ability to execute on-demand directional changes. Additionally, two clinical cases are presented that illustrate the use of dynamic navigation.

Safety of Transesophageal Echocardiography Performed by Intensivists and Emergency Physicians in Critically Ill Patients With Coagulopathy and Thrombocytopenia: A Single-Center Experience.

INTRODUCTION: The use of transesophageal echocardiography (TEE) by intensivist physicians (IPs) and emergency physicians (EPs) in critically ill patients is increasing in the intensive care unit, emergency department, and prehospital environments. Coagulopathy and thrombocytopenia are common in critically ill patients. The risk of performing TEE in these patients is unknown. The goal of this study was to assess whether TEE is safe when performed by IPs or EPs in critically ill patients with high bleeding risk (HBR). METHODS: All TEEs performed by an IP or EP between January 1, 2016, and July 31, 2019, were reviewed as part of a quality assurance database. A TEE performed on a patient was deemed HBR if the patient met at least one of the following criteria: undergoing therapeutic anticoagulation, had an INR > 2, activated partial thromboplastin time >40 seconds, fibrinogen <150 mg/dL, and/or platelet count <50 000/µL. The medical record was reviewed on each patient to determine whether upper esophageal bleeding, oropharyngeal bleeding, esophageal perforation, or dislodgement of an artificial airway occurred during or after the TEE. RESULTS: A total of 228 examinations were reviewed: 80 in the high-risk group and 148 in the low-risk group (LBR). There were complications potentially attributable to TEE in 8 (4%) of the 228 exams. Total complications were not different between groups: 4 (5%) in the HBR group versus 4 (3%) in the LBR group (odds ratio [OR] = 1.89 [0.34-10.44], P =.368). Upper esophageal bleeding occurred in 5 total examinations (2%), which was not different between groups: 3 (4%) in the HBR group and 2 (1%) in the LBR group (OR = 2.84 [0.31-34.55], P = .238). There were no deaths attributable to TEE in either group. CONCLUSION: Transesophageal echocardiography can be safely performed by IPs and EPs in critically ill patients at high risk of bleeding with minimal complications.

Venoarterial extracorporeal membrane oxygenation is an effective management strategy for massive pulmonary embolism patients.

OBJECTIVE: Treatment of massive pulmonary embolism (MPE) is controversial, with mortality rates ranging from 25% to 65%. Patients commonly present with profound shock or cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used as a form of acute cardiopulmonary support in critically ill patients. We reviewed our institution's pulmonary embolism response team experience using VA-ECMO for patients presenting with advanced shock and/or cardiac arrest from MPE. METHODS: From March 2017 to July 2019 we retrospectively reviewed 17 consecutive patients at our institution with MPE who were placed on VA-ECMO for initial hemodynamic stabilization. RESULTS: The mean patient age and body mass index was 55.8 years and 31.8, respectively. Ten of 17 patients (59%) required cardiopulmonary resuscitation before or during VA-ECMO cannulation. All patients had evidence of profound shock with a mean initial lactate of 8.95 mmol/L, a mean pH of 7.10, and a mean serum creatinine of 1.78 mg/dL. Seventeen of 17 cannulations (100%) were performed percutaneously, with 41% (n = 7) of patients placed on VA-ECMO while awake and using local analgesia. Five of 17 patients (29%) required reperfusion cannulas, with 0% incidence of limb loss. Overall survival was 13 of 17 patients (76%), with causes of death resulting from anoxic brain injury (n = 2), septic shock (n = 1), and cardiopulmonary resuscitation-induced hemorrhage from liver laceration (n = 1). In survivors, 12 of 13 patients (92%) were discharged without evidence of neurologic insult. The median duration of the VA-ECMO run for survivors was 86 hours (range, 45-218 hours). In survivors, the median length of time from ECMO cannulation to lactate clearance (<2.0 mmol/L) was 10 hours and the median length of time from ECMO cannulation to freedom from vasopressors was 6 hours. Three of 13 patients (23%) required concomitant percutaneous thrombectomy and catheter-directed thrombolysis to address persistent right heart dysfunction, with the remaining survivors (77%) receiving VA-ECMO and anticoagulation alone as definitive therapy for their MPE. The median intensive care and hospital length of stay for survivors was 9 and 13 days, respectively. CONCLUSIONS: VA-ECMO was effective at salvaging highly unstable patients with MPE. Survivors had rapid reversal of multiple organ failure with ECMO as their primary therapy. The majority of survivors required ECMO and anticoagulation alone for definitive therapy of their MPE.

The Root Membrane Technique: A Retrospective Clinical Study With Up to 10 Years of Follow-Up.

PURPOSE: Immediate implant placement in conjunction with intentional root retention is a recently introduced technique, but the majority of existing documentation is limited to short-term reports with low level of evidence. Hence, the aim of this study was to document the long-term clinical and radiographic results of the root membrane technique. METHODS: This retrospective study reports on clinical results of the root membrane technique for periodontal ligament-mediated immediate implant placement with up to 10 years of follow-up from 3 private dental practices. Anterior implants placed with immediate loading from January 2006 to December 2016 were assessed. Kaplan-Meier estimators were computed for reporting of implant success and survival. RESULTS: A sample of 182 patients (82 men and 100 women, age range: 18-83 years) received 250 immediate implants (230 maxilla, 20 mandible) after the root membrane concept and followed-up for a mean of 49.94 months (±32.5). Overall, 5 implant failures were recorded for a 10-year cumulative patient-level implant survival rate of 96.5%. Considering mechanical and biological complications, the 10-year cumulative implant success rate was 87.9%. CONCLUSIONS: Within the limits of the retrospective design, the root membrane technique showed long-term success rates comparable to those of conventional immediate implants.

Alveolar Ridge Reconstruction with Titanium Meshes and Simultaneous Implant Placement: A Retrospective, Multicenter Clinical Study.

Objective. To evaluate horizontal bone gain and implant survival and complication rates in patients treated with titanium meshes placed simultaneously with dental implants and fixed over them. Methods. Twenty-five patients treated with 40 implants and simultaneous guided bone regeneration with titanium meshes (i-Gen®, MegaGen, Gyeongbuk, Republic of Korea) were selected for inclusion in the present retrospective multicenter study. Primary outcomes were horizontal bone gain and implant survival; secondary outcomes were biological and prosthetic complications. Results. After the removal of titanium meshes, the CBCT evaluation revealed a mean horizontal bone gain of 3.67 mm (±0.89). The most frequent complications were mild postoperative edema (12/25 patients: 48%) and discomfort after surgery (10/25 patients: 40%); these complications were resolved within one week. Titanium mesh exposure occurred in 6 patients (6/25 : 24%): one of these suffered partial loss of the graft and another experienced complete graft loss and implant failure. An implant survival rate of 97.5% (implant-based) and a peri-implant marginal bone loss of 0.43 mm (±0.15) were recorded after 1 year. Conclusions. The horizontal ridge reconstruction with titanium meshes placed simultaneously with dental implants achieved predictable satisfactory results. Prospective randomized controlled trials on a larger sample of patients are required to validate these positive outcomes.

Effects of ethnicity on deceased organ donation in a minority-majority state.

OBJECTIVE: To define how ethnicity affects donation rates in New Mexico when compared with the United States. We hypothesized that deceased donation rates in New Mexico would reflect the ethnic rates of the population. DESIGN: We performed a retrospective review of the Organ Procurement Database for New Mexico from 2009 to June 2012. METHODS: Rates for donors and transplant candidates were calculated relative to 2010 census population estimates by ethnicity for non-Hispanic Whites, Hispanics, and American Indians. Poisson regression analyses were used to test whether United States and New Mexico rates differed. Rates were scaled to 100,000 patient-years for reporting. SETTING: State of New Mexico population compared to United States population. SUBJECTS: Reported deaths to New Mexico Donor Services and United Network for Organ Sharing from 2009 to 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Non-Hispanic White age-adjusted donor rates per 100,000 patient-years were 2.58 in New Mexico versus 2.60 in the United States, Hispanic donor rates were 1.98 in New Mexico versus 2.03 nationwide, and American Indian donor rates in New Mexico were 0.26 versus 1.23 nationwide (rate ratio = 0.21; 95% CI, 0.05-0.86). American Indians have significantly lower donor rates in New Mexico compared to non-Hispanic Whites (rate ratio = 0.11) and Hispanics (rate ratio = 0.13) and nationally (non-Hispanic Whites: rate ratio = 0.32 and Hispanics: rate ratio = 0.43). Hispanics and non-Hispanic Whites had similar donor rates regardless of geographic strata (Hispanics vs non-Hispanic Whites, New Mexico: 0.83; United States: 0.75). In New Mexico, Hispanic patients were 1.43 times more likely to be listed as transplant candidates than non-Hispanic Whites and American Indians were 3.32 times more likely to be listed than non-Hispanic Whites. In the United States, Hispanic patients were 1.90 times more likely to be listed as transplant candidates than non-Hispanic Whites and American Indians were 1.55 times more likely to be listed than non-Hispanic Whites. CONCLUSIONS: Donor and transplant candidate rates did not show strong differences by geographic strata. These findings suggest that further work is needed to elucidate the causes for ethnic differences in rates of consent and donation, particularly in the American Indian population.

Family presence during brain death evaluation: a randomized controlled trial*.

OBJECTIVE: To evaluate if a family presence educational intervention during brain death evaluation improves understanding of brain death without affecting psychological distress. DESIGN: Randomized controlled trial. SETTING: Four ICUs at an academic tertiary care center. SUBJECTS: Immediate family members of patients suspected to have suffered brain death. INTERVENTIONS: Subjects were group randomized to presence or absence at bedside throughout the brain death evaluation with a trained chaperone. All randomized subjects were administered a validated "understanding brain death" survey before and after the intervention. Subjects were assessed for psychological well-being between 30 and 90 days after the intervention. MEASUREMENTS AND MAIN RESULTS: Follow-up assessment of psychological well-being was performed using the Impact of Event Scale and General Health Questionnaire. Brain death understanding, Impact of Event Scale, and General Health Questionnaire scores were analyzed using Wilcoxon nonparametric tests. Analyses were adjusted for within family correlation. Fifty-eight family members of 17 patients undergoing brain death evaluation were enrolled: 38 family members were present for 11 brain death evaluations and 20 family members were absent for six brain death evaluations. Baseline understanding scores were similar between groups (median 3.0 [presence group] vs 2.5 [control], p = 0.482). Scores increased by a median of 2 (interquartile range, 1-2) if present versus 0 (interquartile range, 0-0) if absent (p < 0.001). Sixty-six percent of those in the intervention group achieved perfect postintervention "understanding" scores, compared with 20% of subjects who were not present (p = 0.02). Median Impact of Event Scale and General Health Questionnaire scores were similar between groups at follow-up (Impact of Event Scale: present = 20.5, absent = 23.5, p = 0.211; General Health Questionnaire: present = 13.5, absent = 13.0, p = 0.250). CONCLUSIONS: Family presence during brain death evaluation improves understanding of brain death with no apparent adverse impact on psychological well-being. Family presence during brain death evaluation is feasible and safe.

Efficacy of facemask ventilation techniques in novice providers.

STUDY OBJECTIVE: To determine which of two facemask grip techniques for two-person facemask ventilation was more effective in novice clinicians, the traditional E-C clamp (EC) grip or a thenar eminence (TE) technique. DESIGN: Prospective, randomized, crossover comparison study. SETTING: Operating room of a university hospital. SUBJECTS: 60 novice clinicians (medical and paramedic students). MEASUREMENTS: Subjects were assigned to perform, in a random order, each of the two mask-grip techniques on consenting ASA physical status 1, 2, and 3 patients undergoing elective general anesthesia while the ventilator delivered a fixed 500 mL tidal volume (VT). In a crossover manner, subjects performed each facemask ventilation technique (EC and TE) for one minute (12 breaths/min). The primary outcome was the mean expired VT compared between techniques. As a secondary outcome, we examined mean peak inspiratory pressure (PIP). MAIN RESULTS: The TE grip provided greater expired VT (379 mL vs 269 mL), with a mean difference of 110 mL (P < 0.0001; 95% CI: 65, 157). Using the EC grip first had an average VT improvement of 200 mL after crossover to the TE grip (95% CI: 134, 267). When the TE grip was used first, mean VTs were greater than for EC by 24 mL (95% CI: -25, 74). When considering only the first 12 breaths delivered (prior to crossover), the TE grip resulted in mean VTs of 339 mL vs 221 mL for the EC grip (P = 0.0128; 95% CI: 26, 209). There was no significant difference in PIP values using the two grips: the TE mean (SD) was 14.2 (7.0) cm H2O, and the EC mean (SD) was 13.5 (9.0) cm H2O (P = 0.49). CONCLUSIONS: The TE facemask ventilation grip results in improved ventilation over the EC grip in the hands of novice providers.