Evaluation of appropriate transmission-based precautions for non-SARS-CoV-2 respiratory viruses.

Appropriateness of transmission-based precautions after positive result for a non-SARS-CoV-2 virus was evaluated. Most patients (77.2%) lacked appropriate precautions within 3 hours of virus detection; 36.9% remained without appropriate precautions during their stay. With recent cessation of universal masking, adherence to infection control best practices is needed to optimize safety.

Evaluation of Basal Plus Versus Sliding Scale Insulin Therapy on Glucose Variability in Critically Ill Patients Without Preexisting Diabetes.

BACKGROUND: There is limited evidence evaluating the impact of insulin treatment strategies on glucose variability in critically ill patients without preexisting diabetes. OBJECTIVE: Compare basal plus insulin (BPI) and sliding scale insulin (SSI) impact on glycemic control outcomes in critically ill patients without preexisting diabetes experiencing hyperglycemia. METHODS: This multicenter, retrospective review analyzed critically ill patients with hyperglycemia who received either BPI or SSI. Patients with a hemoglobin A1C >6.5% during the admission of interest or in the previous 3 months, or a diagnosis of diabetes at the time of discharge were excluded. The primary outcome was glucose variability during the intensive care unit (ICU) admission. Secondary outcomes included hypoglycemia frequency, frequency of goal glucose levels, mortality, and length of stay. RESULTS: The analysis included 228 patients (39 in BPI, 189 in SSI). Average glucose variability was higher in the BPI group compared with the SSI group (85.8 mg/dL ± 33.1 vs 70.2 mg/dL ± 30.7; P = 0.009), which remained when controlling for baseline confounding (-12.1 [5.6], 95% CI -23.2 to -0.99; P = 0.033). Hypoglycemia incidence was similar between groups. BPI patients had a lower incidence of glucose values within goal range than SSI patients (P = 0.046). There was no difference in length of stay or hospital mortality. CONCLUSIONS AND RELEVANCE: The use of SSI compared with a BPI regimen may result in reduced glycemic variability in critically ill patients without preexisting diabetes. Future prospective studies, with a larger sample size, are warranted to confirm our exploratory findings and characterize clinically significant benefits.

Development and Initial Evaluation of an Advanced Pharmacy Practice Experience Readiness Assessment Plan.

Objective. To describe the composition of an advanced pharmacy practice experience (APPE) readiness assessment plan (APPE-RAP) along with initial findings following retrospective application to a cohort of students.Methods. The APPE-RAP uses existing summative assessment data within the ExamSoft platform on six skills and 12 ability-based outcomes from the pre-APPE curriculum. Thresholds were created to sort students into three readiness categories for skills and knowledge, determine overall readiness, and identify need for curricular review. Students that completed their third professional year in spring 2021 served as the pilot cohort. The APPE-RAP was applied after the cohort progressed to APPEs to analyze appropriateness of categorization and revise the plan before full implementation.Results. The APPE-RAP was applied to 131 students that progressed to APPEs in spring 2021. Overall, 87.9% were APPE ready for all skills and aggregate knowledge. Two skills met criteria for curricular review. Seven students (5.3%) were categorized as red on at least one skill after one remediation attempt. Nine students (7%) were categorized as red on an aggregate knowledge-based ability-based outcomes (ABO) evaluation. Four students (3.1%) did not pass one of their first two experiential rotations. Using a red categorization on aggregate knowledge as a risk indicator identified APPE failure with 94% specificity and a 98% negative predictive value.Conclusion. Existing assessment data may be leveraged to identify assessment targets to help quantify APPE readiness. Further research is warranted to identify additional assessment thresholds that enhance quantification of APPE readiness as well as the impact of focused remediation on attainment of APPE readiness.

Impact of Opioid Administration in the Intensive Care Unit and Subsequent Use in Opioid-Naïve Patients.

BACKGROUND: Opioids are a mainstay of therapy for patients in the intensive care unit (ICU) as part of the analgesia-first approach to sedation. Despite knowledge of acute consequences of opioid based analgosedation, less is known about the potential long-term consequences, including the effect of opioid administration in the ICU on subsequent opioid use in opioid-naïve patients. OBJECTIVE: To evaluate the relationship between ICU opioid administration to opioid-naïve patients and subsequent opioid use following discharge. METHODS: A query of the electronic medical record was performed to identify opioid-naïve adult patients admitted directly to an ICU. Patients who received continuous intravenous infusion of fentanyl, hydromorphone, or morphine were screened for inclusion into the analysis. RESULTS: Of the 342 patients included for analysis, 164 (47.1%) received an opioid at hospital discharge. In total, 17 of the 342 patients (5.0%) became long-term users, noted to be more common in patients who received an opioid prescription at discharge (8.7% vs 1.6%; P = 0.006). Neither total ICU morphine milligram equivalent (MME) nor average daily ICU MME administration were found to correlate with daily MME prescription quantity at discharge (R2 = 0.008 and R2 = 0.03, respectively). Following control for potentially confounding variables, total ICU MME administration remained an insignificant predictor of subsequent receipt of an opioid prescription at discharge and long-term opioid use. CONCLUSION AND RELEVANCE: This study failed to find a significant relationship between ICU opioid use in opioid-naïve patients and subsequent opioid use. These findings highlight the need to focus on transitions points between the ICU and discharge as potential opportunities to reduce inappropriate opioid continuation.

Review of psychiatric comorbidities and their associations with opioid use in elective lumbar spine surgery.

The opioid epidemic is an ongoing concern in the United States and efforts to ameliorate this crisis are underway on multiple fronts. Opiate use is an important consideration for patients undergoing lumbar spine surgery with concurrent psychiatric diagnoses and more information is needed regarding the factors involved in these patients. That information may help guide opioid prescribing practices for individual patients with certain psychiatric conditions that are undergoing these procedures. This study was done to identify psychiatric conditions that are associated with preoperative and postoperative opioid use in this cohort of veteran patients undergoing elective lumbar spine surgery.A 3 month preoperative and 3 month postoperative chart review was conducted on 25 patients per year who underwent elective lumbar spine surgery over a 16-year period at the Veterans Affairs Nebraska-Western Iowa Healthcare Center (n = 376 after exclusion criteria applied). The association between psychiatric comorbidities and use of opioids during the 90-day period after surgery was assessed using a linear model that adjusted for surgical type, opioid use prior to surgery, and other relevant comorbidities.Patients are more likely to use opioids preoperatively if they have major depression (P = .02), hepatitis C (P = .01), or musculoskeletal disorders (P = .04). PTSD (P = .02) and lumbar fusion surgery (P < .0001) are associated with increased postoperative use, after adjusting for preoperative use and other comorbidities.Certain psychiatric comorbidities are significantly correlated with opioid use for this cohort of lumbar spine surgery patients in the preoperative and postoperative periods. Awareness of an individual's psychiatric comorbidity burden may help guide opioid prescription use.

Clinical and Short-Term Radiographic Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion With Expandable Lordotic Devices.

BACKGROUND: Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a well-accepted procedure for the treatment of degenerative lumbar disease. However, its ability to restore lumbar lordosis has been limited. Development of expandable lordotic interbody devices has challenged this limitation, furthering the scope of minimally invasive surgery. OBJECTIVE: To evaluate the radiographic and clinical effects of expandable lordotic interbody devices placed through an MIS-TLIF approach. METHODS: We conducted a retrospective review of 32 1-level and 18 2-level MIS-TLIFs performed using lordotic expandable interbody devices. Lumbar radiographic measurements, Oswestry Disability Index scores (ODI), and Visual Analogue Scale scores (VAS) were obtained at preoperative, 6 wk follow up, and last follow up time points. Last follow up occurred at a mean of 11.5 ± 7.6 mo (mean ± SD). RESULTS: At 6-wk follow-up, segmental lordosis, disc height, and foraminal height increased by an average of 3.4°, 6.4 mm, and 4.4 mm, respectively. Only the 2-level group showed a significant increase in lumbar lordosis of 5.8°. No significant changes occurred in sacral slope, pelvic tilt, or pelvic incidence. Average ODI and VAS decreased by -12.0 and -4.5, respectively. Postoperative lumbar lordosis inversely correlated with preoperative lordosis in patients with an initial Pelvic Incidence to Lumbar Lordosis mismatch (PI-LL) of >10°, (r = -0.5, P = .009). CONCLUSION: When applied across 2-levels, MIS-TLIF using expandable lordotic interbody devices produced a significant increase in lumbar lordosis. Preoperative lumbar lordosis was found to be a predictor of postoperative lumbar lordotic change in patients with sagittal imbalance.

Cohort analysis of desmopressin effect on hematoma expansion in patients with spontaneous intracerebral hemorrhage and documented pre-ictus antiplatelet use.

Antiplatelet therapy at the time of spontaneous intracerebral hemorrhage (sICH) may increase risk for hemorrhage expansion and mortality. Current guidelines recommend considering a single dose of desmopressin in sICH associated with cyclooxygenase-1 inhibitors or adenosine diphosphate receptor inhibitors. Adult subjects with sICH and concomitant antiplatelet therapy admitted to a large, tertiary care center were included. We sought to compare the risk of hematoma expansion in patients that received desmopressin for antiplatelet reversal in the setting of sICH to similar patients that did not receive desmopressin. The primary outcomes were the incidence of relative and absolute hematoma expansion. In total, 71 patients (29 received desmopressin, 42 did not receive desmopressin) were analyzed. All patients in the desmopressin group received a 0.3 mcg/kg intravenous dose prior to hematoma expansion assessment. Relative hematoma expansion occurred in 5/29 (17%) with desmopressin compared to 11/42 (26%) without desmopressin (OR 0.59 [95% CI 0.18-1.92]). Absolute hematoma expansion occurred in 9/29 (30%) with desmopressin compared to 12/42 (28%) without desmopressin (OR 1.13 [95% CI 0.40-3.16]). Multiple logistic regression controlling for significant covariates did not reveal a significant effect of desmopressin on relative or absolute hematoma expansion (OR 0.65 [95% CI 0.18-2.43] and OR 1.55 [0.48-4.99], respectively). We failed to find evidence that desmopressin administration for antiplatelet reversal in sICH reduces the incidence of hematoma expansion. Larger studies, focusing on the early phase of sICH, are needed to characterize the clinical efficacy and safety of desmopressin for antiplatelet reversal before widespread implementation.

Pilot project to assess and improve neurosurgery resident and staff perception of feedback to residents for self-improvement goal formation.

OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) has pushed for more frequent and comprehensive feedback for residents during their training, but there is scant evidence for how neurosurgery residents view the current feedback system as it applies to providing information for self-improvement and goal formation. The authors sought to assess neurosurgery resident and staff perceptions of the current resident feedback system in providing specific, meaningful, achievable, realistic, and timely (SMART) goals. The authors then created a pilot project to improve the most unfavorably viewed aspect of the feedback system. METHODS: The authors conducted an anonymous survey of neurosurgery residents and staff at an academic medical institution to assess SMART goals for resident feedback and used the results to create a pilot intervention to address the most unfavorably viewed aspect of the feedback system. The authors then conducted a postintervention survey to see if perceptions had improved for the target of the intervention. RESULTS: Neurosurgery residents and staff completed an anonymous online survey, for which the results indicated that resident feedback was not occurring in a timely manner. The authors created a simple anonymous feedback form. The form was distributed monthly to neurosurgery residents, neurosurgical staff, and nurses, and the results were reported monthly to each resident for 6 months. A postintervention survey was then administered, and the results indicated that the opinions of the neurosurgery residents and staff on the timeliness of resident feedback had changed from a negative to a nonnegative opinion (p = 0.01). CONCLUSIONS: The required ACGME feedback methods may not be providing adequate feedback for goal formation for self-improvement for neurosurgery residents. Simple interventions, such as anonymous feedback questionnaires, can improve neurosurgery resident and staff perception of feedback to residents for self-improvement and goal formation.

Association of Preoperative Diagnosis with Clinical Yield of Muscle Biopsy.

BACKGROUND: Muscle biopsy is a common diagnostic marker for myopathy assessment; however, it has a relatively low pathologic yield of less than 60%. Additionally, both diagnostic and non-diagnostic muscle biopsies can provide guidance for treatment, i.e, provide therapeutic usefulness. PURPOSE: We designed a study to determine if having a documented definitive preoperative differential diagnosis would affect the pathologic yield and therapeutic usefulness of muscle biopsies for myopathy.  Methods: This was a retrospective, single institution chart review of 106 consecutive muscle biopsies in adult patients, which looked at the presence or absence of a definitive preoperative differential diagnosis and relation to diagnostic yield and therapeutic usefulness of muscle biopsies.  Results: Of 106 muscle biopsies, 50 biopsies (47%) had a definitive preoperative differential diagnosis, 52 biopsies (49%) returned definitive pathology, and 93 biopsies (88%) provided therapeutic information. The presence of a documented differential diagnosis increased the odds of pathologic yield by 3.73 (p-value < 0.01) and therapeutic usefulness by 3.40 (p-value 0.08). If pathology was diagnostic then the therapeutic usefulness of the biopsy was 4.54 times more likely (p-value < 0.01).  Conclusion: Documentation of a definitive preoperative differential diagnosis, when pursuing muscle biopsy for myopathy, is associated with an increased pathologic diagnostic yield. Definitive pathology was associated with an increase in the therapeutic usefulness of the muscle biopsy.

Referring Service Effect on Muscle Biopsy Diagnosis and Management in Myopathy.

Introduction Requests for muscle biopsy for evaluation of myopathy originate from a variety of different specialties. It is unknown whether the specialty of the referring service affects the likelihood of diagnostic biopsy or the therapeutic usefulness of a biopsy. Methods We reviewed 106 consecutive muscle biopsies requested by healthcare providers in neurology, rheumatology, family medicine, oncology, and gastroenterology. We tested for an association between referring service and whether the biopsy yielded a definitive pathology result or provided therapeutically useful results. Results Half of the biopsies (49%) returned definitive pathology and 88% of the biopsies provided information that contributed to therapeutic decisions. The diagnostic yield for muscle biopsies referred by different services was not statistically significant (p-value 0.1344) nor was the therapeutic yield statistically significant for muscle biopsies referred by different services (p-value 0.5525). Discussion The specialty of the service that requests a muscle biopsy does not influence the likelihood of obtaining a definitive pathological diagnosis or therapeutically useful information. Other factors may be more important in determining the likelihood of obtaining a clinically useful biopsy result.

Treatment of Salmonella-Contaminated Eggs and Pork with a Broad-Spectrum, Single Bacteriophage: Assessment of Efficacy and Resistance Development.

Numerous studies have assessed the efficacy of phage-based methods to inhibit Salmonella contamination in food products. As with most antibacterials, bacteria can develop resistance to phage in vitro. Here, we applied a single broad-spectrum Salmonella phage, vB_SalS_SJ_2 (SJ2; 108 PFU; MOI = 10), to Salmonella-contaminated meat and eggs to quantify the development of resistance in actual food matrices. Treatment with a single phage significantly reduced Salmonella Typhimurium contamination in both ground pork and liquid egg at various time points. Similarly, the same phage significantly reduced Salmonella Enteritidis in both food matrices. Efficacy was temperature dependent as larger reductions were seen at higher temperatures (21°C) versus lower temperatures (4°C) at 24 h. Following phage treatment, over 10,000 Salmonella isolates were examined for resistance to the treatment phage. The percentages of phage-resistant Salmonella (either serovar) recovered from phage-treated versus untreated pork did not differ. Conversely, significantly (p < 0.05) higher percentages of phage-resistant Salmonella Typhimurium (92.50% vs. 0.56% of control) and Salmonella Enteritidis (50.83% vs. 0.56% of control) isolates were observed in phage-treated versus untreated egg samples after incubation at room temperature for 48 h. Taken together, these data indicate that the food matrix may influence the emergence of phage resistance with resistance developing more rapidly in foods with less complex microbial communities. Future studies will focus on the impact the development of resistance in production and processing settings may have on the efficacy of phage treatments for longer term biocontrol of pathogens.

The impact of orally administered phages on host immune response and surrounding microbial communities.

Numerous studies have shown the efficacy of phage therapy in reducing foodborne pathogen carriage in food animals. Fewer studies have focused on host reactions, especially in terms of phage-mediated acute immune responses and effects on the gut microbiome. Here we administered E. coli O157:H7 phages in low (single dose of 105 PFU) or high (single dose of 107 PFU) quantities to mice. While there were time points at which cytokine levels in different treatment groups differed from one another, all cytokine levels remained within normal ranges for mice regardless of treatment. Similarly, the patterns of these differences were not dose related, indicating that phage treatment did not result in a strong acute immune response as measured here. In separate experiments, 3-week-old pigs received a diet containing an in-feed antibiotic or daily phage treatment. After two weeks, microbial DNA of ileal, cecal, and fecal contents was characterized using 16S rRNA sequencing. There were no statistical differences in performance among the different groups. Compared to control pigs (no antibiotic, no phage), antibiotic treatment significantly altered ileal microbiome composition (P < 0.05), with Bacilli being most affected (antibiotic treated: 22%; control: 76%; FDR = 0.0572). No significant differences were observed in cecal and fecal microbiome composition between antibiotic-treated and control pigs, and there were no differences in gut microbiome composition between phage treated and control pigs in any intestinal compartment. Significant abundance differences were observed at the OTU level, with OTUs belonging to genera such as Lactobacillus and Streptococcus being over- or under-represented in either antibiotic or phage treated groups compared to control pigs. Determining whether these changes are deleterious to host, however, requires further study.

Treatment of Severe Alcohol Withdrawal.

OBJECTIVE: Approximately 50% of patients with alcohol dependence experience alcohol withdrawal. Severe alcohol withdrawal is characterized by seizures and/or delirium tremens, often refractory to standard doses of benzodiazepines, and requires aggressive treatment. This review aims to summarize the literature pertaining to the pharmacotherapy of severe alcohol withdrawal. DATA SOURCES: PubMed (January 1960 to October 2015) was searched using the search termsalcohol withdrawal, delirium tremens, intensive care, andrefractory Supplemental references were generated through review of identified literature citations. STUDY SELECTION AND DATA EXTRACTION: Available English language articles assessing pharmacotherapy options for adult patients with severe alcohol withdrawal were included. DATA SYNTHESIS: A PubMed search yielded 739 articles for evaluation, of which 27 were included. The number of randomized controlled trials was limited, so many of these are retrospective analyses and case reports. Benzodiazepines remain the treatment of choice, with diazepam having the most favorable pharmacokinetic profile. Protocolized escalation of benzodiazepines as an alternative to a symptom-triggered approach may decrease the need for mechanical ventilation and intensive care unit (ICU) length of stay. Propofol is appropriate for patients refractory to benzodiazepines; however, the roles of phenobarbital, dexmedetomidine, and ketamine remain unclear. CONCLUSIONS: Severe alcohol withdrawal is not clearly defined, and limited data regarding management are available. Protocolized administration of benzodiazepines, in combination with phenobarbital, may reduce the need for mechanical ventilation and lead to shorter ICU stays. Propofol is a viable alternative for patients refractory to benzodiazepines; however, the role of other agents remains unclear. Randomized, prospective studies are needed to clearly define effective treatment strategies.

Serum Trimethylamine-N-Oxide is Elevated in CKD and Correlates with Coronary Atherosclerosis Burden.

Trimethlyamine-N-oxide (TMAO) was recently identified as a promoter of atherosclerosis. Patients with CKD exhibit accelerated development of atherosclerosis; however, no studies have explored the relationship between TMAO and atherosclerosis formation in this group. This study measured serum concentrations and urinary excretion of TMAO in a CKD cohort (n=104), identified the effect of renal transplant on serum TMAO concentration in a subset of these patients (n=6), and explored the cross-sectional relationship between serum TMAO and coronary atherosclerosis burden in a separate CKD cohort (n=220) undergoing coronary angiography. Additional exploratory analyses examined the relationship between baseline serum TMAO and long-term survival after coronary angiography. Serum TMAO concentrations demonstrated a strong inverse association with eGFR (r(2)=0.31, P<0.001). TMAO concentrations were markedly higher in patients receiving dialysis (median [interquartile range], 94.4 µM [54.8-133.0 µM] for dialysis-dependent patients versus 3.3 µM [3.1-6.0 µM] for healthy controls; P<0.001); whereas renal transplantation resulted in substantial reductions in TMAO concentrations (median [min-max] 71.2 µM [29.2-189.7 µM] pretransplant versus 11.4 µM [8.9-20.2 µM] post-transplant; P=0.03). TMAO concentration was an independent predictor for coronary atherosclerosis burden (P=0.02) and predicted long-term mortality independent of traditional cardiac risk factors (hazard ratio, 1.26 per 10 µM increment in TMAO concentration; 95% confidence interval, 1.13 to 1.40; P<0.001). In conclusion, serum TMAO concentrations substantially increase with decrements in kidney function, and this effect is reversed by renal transplantation. Increased TMAO concentrations correlate with coronary atherosclerosis burden and may associate with long-term mortality in patients with CKD undergoing coronary angiography.

Optimizing Anticoagulation Management Through the Use of a Hospital Engagement Network Metric for Inpatient Anticoagulant-Associated Hemorrhage.

BACKGROUND: The University HealthSystem Consortium (UHC), a national hospital engagement network (HEN), establishes health-system metrics to assess and improve quality of care. In 2012, a metric for inpatient anticoagulant hemorrhage was developed. The utility of this metric to improve anticoagulation care has not been assessed. OBJECTIVE: To identify opportunities to improve anticoagulation safety through the use of a HEN metric for inpatient anticoagulant-associated hemorrhage. METHODS: This was a single-center, retrospective, observational study of metric identified patients with presumed inpatient anticoagulant hemorrhage. Records were reviewed to confirm anticoagulant hemorrhage and identify bleed site and severity. A structured process was used to assess bleed preventability and subsequently identify opportunities for improving care. Each bleed was reviewed by 2 investigators. RESULTS: Anticoagulant hemorrhage was confirmed in 85.9% (61/71) with heparin infusion the most common anticoagulant. Patients were primarily medical, with a mean age of 72.7 ± 15 years. The most common bleed sites were gastrointestinal (24.6%) and retroperitoneal (21.3%). Major bleeding occurred in 60.7% (37/61). Anticoagulant hemorrhage was preventable in 18% (11/61) of cases with heparin protocol noncompliance the most common cause of a preventable bleed. Several opportunities for improving heparin infusion therapy were recognized and protocol changes were implemented. CONCLUSIONS: The UHC metric accurately captures inpatient anticoagulant-associated hemorrhage the majority of time. The UHC metric on anticoagulant-associated hemorrhage can be a useful part of a health system's overall plan for the safe use of anticoagulants in the hospital setting.

Influence of preparation design and existing condition of tooth structure on load to failure of ceramic laminate veneers.

STATEMENT OF PROBLEM: Although investigators have evaluated the effect of ceramic veneer preparation design, limited information is available regarding preparation design in association with the condition of existing tooth structure. PURPOSE: The purpose of this in vitro study was to evaluate the effect of preparation design and the amount of existing tooth structure on the fracture resistance of pressable ceramic laminate veneers. MATERIAL AND METHODS: Thirty-two extracted human maxillary central incisors were allocated into 4 groups (n=8) to test for 2 variables: (1) the preparation design (a 2 mm incisal reduction shoulder finish line with or without palatal chamfer) and (2) the existing amount of tooth structure (non-worn tooth or worn tooth). Measurement of the remaining enamel thickness on the inciso-occlusal surface was made after the tooth was prepared. All prepared teeth were restored with pressable ceramic (IPS Empress) veneers, and the veneers were luted with resin cement (Rely-X Veneer). These luted specimens were loaded to failure in a universal testing machine, in the compression mode, with a crosshead speed of 0.05 mm/min. The data were analyzed using a 2-way ANOVA and Tukey's HSD multiple comparison test (α=.05) RESULTS: Preparation design and the amount of existing tooth structure had a significant effect on the load to failure value (P<.001); however, the interaction between preparation design and existing amount of tooth structure was not significant (P=.702). Mean (SD) load to failure values were as follows: a preparation design with a palatal chamfer margin with a non-worn tooth (166.67 N (28.89)) revealed a significantly higher failure load than the group with a shoulder finish line alone (131.84 N (18.88)) (P<.01). The preparation design with a palatal chamfer margin for worn teeth (119.56 N (23.88)) revealed a significantly higher failure load than a shoulder finish line design alone (90.56 N (9.32)) (P<.05). The preparation design with a shoulder finish line for worn teeth had a significantly lower failure load than those on non-worn teeth (P<.003). CONCLUSIONS: Preparation design and the amount of existing tooth structure had a significant effect on load to failure for ceramic veneers. This study revealed that using a palatal chamfer margin design significantly increased the load to failure compared to a shoulder finish line.

Esthetic templates for complex restorative cases: rationale and management.

UNLABELLED: Complex restorative cases require difficult clinical decisions regarding the final esthetic outcome in which the operator must visualize the definitive restorative position of the teeth. These critical decisions need to be made before treatment is rendered. Communicating these decisions to the patient and the treatment team are crucial prior to achieving clinical success. The esthetic template is the conduit for providing excellent communication. The selection of the appropriate esthetic template is based on four sequential decisions: (1) dentofacial analysis, (2) blueprint development, (3) matrix management, and (4) template application. When utilizing an esthetic template, the clinician must know where the teeth should be placed based on a dentofacial analysis. The dentofacial analysis must then be communicated to the laboratory, and then a blueprint is developed from the diagnostic casts. A matrix is then fabricated from the blueprint and then related back to the existing dentition. The esthetic template is an invaluable communicator that can be utilized in office, with the patient at home, or even within the multidisciplinary treatment team. Clearly, the effective use of esthetic templates demonstrates a reversible way to visualize difficult esthetic decisions before any irreversible procedures are completed. Esthetic templates are a physical means of communication that provide the patient, technician, and multidisciplinary team an instrument to predictably manage complex restorative cases. The purpose of this article is to present a rationale for esthetic template selection and management of several techniques for complex restorative cases. CLINICAL SIGNIFICANCE: Complex restorative cases require difficult clinical decisions regarding the final esthetic outcome in which the operator must visualize the definitive restorative position of the teeth. The use of an esthetic template commensurate with a rationale for selection enables the operator, patient, and entire interdisciplinary team to visualize the final esthetic outcome.