Comparison of systemic health conditions between African American and Caucasian complete denture patients.

PURPOSE: To compare prevalence of systemic health conditions (SHC) between African American and Caucasian edentulous patients presenting for complete dentures (CD) at an urban dental school. METHODS: The study included patients presenting for CD 1/1-12/31/2010, ages 20 to 64 years, and either African American or Caucasian. Covariates included: age group, gender, employment status, Medicaid status, smoking history, and alcohol consumption. SHC included at least one of the following: arthritis, asthma, cancer, diabetes, emphysema, heart attack, heart murmur, heart surgery, hypertension, or stroke. RESULTS: The group (n = 88) was 44.3% African American, 65.9% ≥50, 45.5% male, 22.7% employed, and 67.0% with at least one SHC. African Americans were older (p = 0.001) and more likely to have one or more SHC (p = 0.011). Patients with at least one SHC were older (p = 0.018) and more likely female (p = 0.012). The total sample logistic regression model assessing SHC yielded only gender as statistically significant (males < OR 0.32, 95% CI 0.11 to 0.92). Caucasian males were less likely to have SHC (OR 0.17, 95% CI 0.04 to 0.77), and Caucasians ≥50 were more likely (OR 5.36, 95% CI 1.19 to 24.08). African Americans yielded no significant associations. CONCLUSIONS: Among selected completely edentulous denture patients at an urban dental school, two out of three patients had at least one SHC. This exploratory study suggests there may be health status differences between African American and Caucasian patients in this setting, calling for further study.

Use and Toxicity of Checkpoint Inhibitors for Solid Tumor Treatment in a Veteran Population.

BACKGROUND: New immunotherapy agents have provided additional options for the treatment of a variety of malignancies, including the programmed death 1 (PD-1) protein inhibitors nivolumab and pembrolizumab. Initial dosing was based on patient weight, but subsequent studies supported fixed dosing, thereby prompting a change in US Food and Drug Administration-approved dosing. Depending on patient weight, one dosing strategy may be more cost-effective than another; thereby, a combination of dosing strategies may be beneficial for institutions. While these agents have been shown to be efficacious, they have been associated with immune-related adverse events (IrAEs). The purpose of this study was to determine the dosing strategy used and identify actual and potential cost savings, as well as to determine the incidence of hypothyroidism with PD-1 inhibitors in patients of the US Department of Veterans Affairs (VA). METHODS: This was a retrospective chart review of VA patients who received a PD-1 inhibitor for the treatment of a solid tumor between January 2015 and July 2017. Data were collected from the VA Corporate Data Warehouse through the VA Informatics and Computing Infrastructure. The dosing strategy for a PD-1 inhibitor was categorized into weight-based vs fixed-dosing where possible and used to identify actual and potential cost-savings opportunities. Thyroid laboratory values and levothyroxine prescriptions were evaluated to determine the overall incidence of the prespecified IrAEs. Descriptive statistics were used for primary and secondary outcomes. RESULTS: Nivolumab was the primary PD-1 inhibitor used for solid tumor treatment. Both nivolumab and pembrolizumab were primarily dosed based on patient weight. Nivolumab orders resulted in $8,514,300 estimated actual cost savings with $5,591,250 estimated missed cost savings identified. Of the patients who received nivolumab, 3249 patients were evaluated for thyroid dysfunction; 514 (15.8%) developed primary hypothyroidism based on laboratory values and levothyroxine prescription data. CONCLUSIONS: Utilization of a combination of both weight-based and fixed-dosing strategies for nivolumab has the potential for cost savings, thereby benefiting the health care institution. The incidence of IrAEs identified among patients who received PD-1 inhibitor within the VA health care system was similar to the incidences reported in published literature. This further supports recommendations for close IrAE monitoring and treatment.

Assessing the Economic Value of Pharmacy Resident Participation in an Investigational Drug Service.

PURPOSE: Completion of postgraduate residency training gives pharmacists an opportunity to gain advanced practice experience, yet the availability of these positions is often limited. Through participation in an investigational drug service (IDS), residency programs may be able to expand learning experiences while demonstrating a financial benefit to the institution. The purpose of this assessment is to examine the economic value generated by pharmacy resident involvement within an IDS. METHODS: This was a single-center retrospective record review. All resident dispensations within the IDS from January 1, 2016, to December 31, 2017, were evaluated for cost avoidance, revenue, and waived revenue. Cost avoidance was defined as the cost of medications the institution would have incurred had the sponsor not provided therapies free of charge. Medical center contract acquisition costs were used to determine cost avoidance. Total economic value accounted for the personnel costs of resident dispensations. Descriptive statistics were utilized for all assessments. RESULTS: A total of 444 resident dispensations occurred during the study period on 15 IDS protocols. The total cost avoidance for resident dispensations was US$144 898. Total revenue for these dispensations was US$1424, and waived revenue fees totaled US$17 625. After accounting for the personnel cost of dispensations by the residents, the total economic value of resident participation in the IDS was US$159 150. CONCLUSION: Resident participation in the IDS contributed economic value to the institution. The IDS provides a unique learning experience for the pharmacy residents, cost savings for the institution, and supports the advancement of patient care.

Pediatric Provider Experiences with Implementation of Routine Mental Health Screening.

OBJECTIVE: Despite the utility of universal screening, most pediatric providers rarely use mental health (MH) screening tools. As such, provider descriptions of their experiences with universal screening are limited. The goal of this study was to describe barriers to, and facilitators of, universal MH screening implementation, the perceived impact of such screening, impressions of a screening-focused quality improvement (QI) Learning Collaborative, and lessons learned. METHOD: We invited primary care clinicians participating in a large-scale QI Learning Collaborative on MH screening (n = 107) to complete postproject interviews. Interviews were transcribed and analyzed using constant comparative qualitative analysis, an inductive, iterative process. RESULTS: Eleven interviews were completed and analyzed. Practice sites included academic health centers, a private practice, and a federally qualified health center. Providers described the positive impact of screening (increased identification of MH concerns) and barriers and facilitators of screening at the practice level (clinic and leadership buy-in and electronic medical record integration), the provider level (provider beliefs about the importance of screening), and the patient level (parent literacy). Challenges of linking families with care after screening included lack of adequate referrals, long wait lists, limited bilingual providers, insurance gaps, and inadequate feedback loops. Access to on-site MH clinicians and participation in the Learning Collaborative were described as beneficial. CONCLUSION: Findings elucidate how universal MH screening can be sustainably integrated into real-world primary care settings and may facilitate the uptake of American Academy of Pediatrics recommendations for best practices in screening for MH concerns.

Brand specific responses to smokeless tobacco in a rat lip canal model.

BACKGROUND: Different compositions of smokeless tobacco (ST) are widely thought to cause oral carcinoma at different rates but there is little direct evidence for this hypothesis. METHODS: We used a rat lip canal model to examine the mucosal changes induced by chronic daily exposure to four different brands of ST: Skoal, Copenhagen, Ettan Swedish Snus, and Stonewall, differing in measured levels of: tobacco specific nitrosamines (TSNAs), unprotonated nicotine, moisture, and pH. RESULTS: Exposure to the lip canal for 12 months produced changes in the mucosa marked by increases in S phase and M phase cells for the Skoal and Copenhagen exposed rats. This correlated with the high level of TSNAs and nicotine in these products. All the tobacco products, to different degrees, induced sites of moderate to severe dysplasia some with extensive rete peg outgrowth from the oral mucosa not seen in the controls. Many of these sites showed a loss of p16 expression. CONCLUSIONS: While all ST products caused dysplasia, the products with lower levels of TSNAs and unprotonated nicotine caused less, consistent with the model that tobacco with low levels of nitrosamines might potentially induce fewer carcinomas in human users.

Cerebrospinal Fluid Glucose and Lactate Levels After Subarachnoid Hemorrhage: A Multicenter Retrospective Study.

BACKGROUND: In patients with subarachnoid hemorrhage (SAH), abnormalities in glucose and lactate metabolism have been described using cerebral microdialysis. Glucose and lactate concentrations in cerebrospinal fluid (CSF) are more easily accessible, but scarce data are available in this setting. The aim of this study is to assess the relationship of CSF glucose and lactate with blood concentrations and with unfavorable neurological outcome after SAH. METHODS: A retrospective cohort study was conducted in 5 European University intensive care units. Patients aged 18 years and above who were admitted after a nontraumatic SAH over a 4-year period (2011 to 2014) were included if they had an external ventricular drain placed, daily analysis of CSF including glucose (±lactate) concentrations for 1 to 4 consecutive days, and concomitant analysis of glucose and lactate concentrations in the arterial blood. RESULTS: A total of 144 patients were included in the final analysis (median age: 58 [49 to 66] y; male sex: 77/144). Median time from admission to external ventricular drain placement was 1 (0 to 3) day; median Glasgow Coma Scale on admission was 10 (7 to 13), and CT-scan Fisher scale was 4. A total of 81 (56%) patients had unfavorable neurological outcome at 3 months (Glasgow Outcome Scale ≤3). There was a weak correlation between blood and CSF glucose (r=0.07, P=0.007), and between blood and CSF lactate levels (r=0.58, P<0.001) on day 1, which were not influenced by insulin therapy. The presence of shock and low CSF glucose/lactate ratio were the only independent predictors of unfavorable outcome. CONCLUSIONS: CSF glucose and lactate levels poorly correlated with blood concentrations. Low CSF glucose/lactate ratio was associated with poor neurological outcome.

Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study.

OBJECTIVE: Patients are at risk of harm from medication errors. Barcode medication administration (BCMA) systems are recommended to mitigate preventable adverse drug events (ADEs). Our hypothesis was that a BCMA system would reduce preventable ADEs by 45% in a neonatal intensive care unit. STUDY DESIGN: We conducted a prospective, observational, cohort study of a BCMA system intervention in a neonatal intensive care unit. Participants were admitted neonates during 50 weeks. Medication errors and potential or preventable ADEs were detected by a daily structured audit of each subject's medical record, with assignment of an event as a preventable ADE made by blinded assessors. The generalized estimating equation method was used in modeling the targeted, preventable ADE rate with covariates. RESULTS: A total of 92,398 medication doses were administered to 958 subjects. The generalized estimating equation method yielded a relative risk of preventable ADE when the system was implemented of 0.53 (95% confidence limits 0.29 to 0.91, P = .04), adjusted for log(10)doses of medication/subject/day, a significant predictive covariate (P < .001), as well as for birth weight, sex, Caucasian race, birth cohort number, and nursing hours/subject/day. CONCLUSION: The BCMA system reduced the risk of targeted, preventable ADEs by 47%, controlling for the number of medication doses/subject/day, an important risk exposure.

Pediatric squamous cell carcinoma arising in an alpha-fetoprotein-producing mature cystic teratoma of the mandible.

Teratomas, most often diagnosed in younger patients, represent the most frequently identified subtype of pediatric germ cell tumors. It is very uncommon for teratomas to present in the head and neck region and demonstrate malignant transformation. We present a case of squamous cell carcinoma arising in an alpha-fetoprotein-producing cystic teratoma of the mandible in a 2-year-old female that is, to the best of our knowledge, the first such published report. The patient was treated with surgical excision along with chemotherapy and has remained disease-free 2 years after the conclusion of therapy.

Radiographic diagnosis of synovial chondromatosis of the temporomandibular joint: a case report.

Synovial chondromatosis is a rare, benign condition that usually affects the larger diarthroidal joints of the axial skeleton. Approximately 120 cases of synovial chondromatosis involving the temporomandibular joint (TMJ) have been reported. People with this condition may present with swelling, pain, intracapsular sounds and limitation of mandibular movement. Because it is important to differentiate synovial chondromatosis from other joint pathologies, a thorough history and appreciation of clinical features of these conditions are necessary. Radiographs are an important component of the diagnostic armamentarium for discerning conditions that mimic synovial chondromatosis. A case of synovial chondromatosis diagnosed radiographically with the aid of volumetric computed tomography is described, followed by a discussion of potential causative factors and management strategies. A brief review of the differential diagnosis of synovial chondromatosis involving the TMJ is also provided.

Society of Behavioral Medicine position statement: Society of Behavioral Medicine supports oral cancer early detection by all healthcare providers.

In response to the increasing incidence of certain oral and oropharyngeal cancers, the Society of Behavioral Medicine (SBM) calls on healthcare providers and legislators to expand awareness of oral and oropharyngeal cancer risk factors, increase early detection, and support policies that increase utilization of dental services. SBM supports the American Dental Association's 2017 guideline for evaluating potentially malignant oral cavity disorders and makes the following recommendations to healthcare providers and legislators. We encourage healthcare providers and healthcare systems to treat oral exams as a routine part of patient examination; communicate to patients about oral/oropharyngeal cancers and risk factors; encourage HPV vaccination for appropriate patients based on recommendations from the Advisory Committee on Immunization Practices; support avoidance of tobacco use and reduction of alcohol consumption; and follow the current recommendations for evaluating potentially malignant oral cavity lesions. Because greater evidence is needed to inform practice guidelines in the primary care setting, we call for more research in collaborative health and dental services. We encourage legislators to support policies that expand Medicaid to cover adult dental services, increase Medicaid reimbursement for dental services, and require dental care under any modification of, or replacement of, the Affordable Care Act.

A familial pattern of multiple idiopathic cervical root resorption in a father and son: a 22-year follow-up.

BACKGROUND: The etiology of idiopathic cervical root resorption has not been elucidated clearly. However, the process has been linked to trauma, intracanal bleaching, and partial-thickness connective tissue grafts. METHODS: This study describes a familial pattern of multiple idiopathic cervical root resorption in a father and son. RESULTS: The father was a healthy 63-year-old white male who presented with the first resorption lesion in 1983. Twenty-seven additional lesions were identified on 16 teeth over 22 years. Five teeth were lost as a result of extensive resorption. The son was a healthy 43-year-old when a resorption lesion was identified in 1993. A lesion identified on another tooth 12 years later resulted in extraction. CONCLUSIONS: Close relatives of those affected by multiple idiopathic cervical root resorption should be examined carefully for cervical resorption. This study also showed that early treatment can prevent or delay the need for extraction.

Case report: an unusually large epulis on the maxillary gingiva of a 24-year-old woman.

A 24-year-old woman had a red mass (2.4 x 1.4 cm) on her left maxillary gingiva (between teeth No. 11 and 12) that interfered with normal occlusion and speech. Although pyogenic granuloma was the clinical diagnosis, histopathologic examination revealed that the lesion was actually focal fibrous hyperplasia with focal mucinosis degeneration. This article illustrates the role of the oral and maxillofacial pathologist in establishing an accurate diagnosis of oral lesions and discusses the differential diagnosis of gingival enlargements.

Problems and Solutions for Interprofessional Education in North American Dental Schools.

Interprofessional education (IPE) is a relatively new part of dental education. Its implementation is mandated by accreditation standards, but it is also essential to good patient care. Diverse dental schools from various regions of North America outline problems they have faced in IPE and the solutions that they have found to surmount these problems. Commonalities and unique features of these problems and solutions are discussed.

Tobacco dependence education: A survey of US and Canadian dental schools.

BACKGROUND: Tobacco use is the leading preventable cause of morbidity and premature mortality and is a significant factor in the development of oral disease. Tobacco dependence education (TDE) has not, however, been consistently integrated into predoctoral education. The authors conducted a study assessing the content and extent of TDE and intervention skills in US and Canadian dental schools. METHODS: In 2013, the authors contacted the academic deans of the 74 accredited US and Canadian dental schools to identify the educator who would be most appropriately described as the tobacco-use cessation "champion" at their institution. The authors e-mailed an introductory letter to each school's champion with a hyperlink to a 45-item survey; 2 follow-up emails were sent with links to the survey. RESULTS: The response rate was 66% (N = 49). TDE was taught at 92% of dental schools; 90% of respondents indicated that faculty members were confident to extremely confident in teaching tobacco-related pathology. Only 49% reported this level of confidence in teaching students how to help patients quit tobacco. TDE is taught in periodontics (82%), oral pathology (77%), clinic (66%), oral diagnosis (59%), public health dentistry (55%), pharmacology (55%), oral medicine (52%), and other disciplines (less than 50%). CONCLUSIONS: The survey responses revealed that TDE is not a curricular component in all US and Canadian dental schools. Faculty members were most confident in teaching tobacco-related pathology but may lack the interest and skills needed to integrate TDE as part of patient care. PRACTICE IMPLICATIONS: Patients who use tobacco in any form are at an increased risk of developing periodontitis, developing oral cancer, and having poorer surgical outcomes, emphasizing the need for the dental team to be well-prepared through predoctoral dental education.

Does dental disease hurt your heart?

Recent research has yielded conflicting data regarding the relationship between dental disease, particularly periodontitis, and cardiovascular disease. A causative relationship would have major ramifications for health care. There is a plausible theoretical basis for such a link, as increased levels of inflammatory mediators may increase the risk of atherosclerotic plaque formation. Nevertheless, a clinical confirmation of a causative relationship has been difficult, in part because cardiovascular disease and periodontal disease share common risk factors such as increasing age and tobacco use, and because cardiovascular medications may increase the risk of periodontitis. Patients should be encouraged to control documented risk factors for cardiovascular disease and to maintain oral health for its well-known health benefits.

Adverse oral sequelae to bisphosphonate administration.

Osteonecrosis of the jaws following the administration of bisphosphonate class drugs, both intravenous and oral, has recently been reported in the literature. A case series of five patients is presented. The clinical presentation, management, and proposed etiology of this adverse reaction are reviewed. Recommendations for identifying patients who may be at risk via medical history, present and past medications, specific drugs involved and recommended precautions involving various dental interventions are also discussed.

Selective Mycobacterium tuberculosis Shikimate Kinase Inhibitors as Potential Antibacterials.

Owing to the persistence of tuberculosis (TB) as well as the emergence of multidrug-resistant and extensively drug-resistant (XDR) forms of the disease, the development of new antitubercular drugs is crucial. Developing inhibitors of shikimate kinase (SK) in the shikimate pathway will provide a selective target for antitubercular agents. Many studies have used in silico technology to identify compounds that are anticipated to interact with and inhibit SK. To a much more limited extent, SK inhibition has been evaluated by in vitro methods with purified enzyme. Currently, there are no data on in vivo activity of Mycobacterium tuberculosis shikimate kinase (MtSK) inhibitors available in the literature. In this review, we present a summary of the progress of SK inhibitor discovery and evaluation with particular attention toward development of new antitubercular agents.

Improving communication and coordination of complex perinatal patients.

Pregnant women with complex medical problems require comprehensive communication among members of their healthcare team. Using the Magnet Hospital model, our Patient and Perinatal Interprofessional Team at Seton Medical Center Austin focused on improving communication and patient satisfaction by initiating Perinatal Patient Care Conferences. Pregnant women with medical or obstetric complications and their families became a part of care plan development prior to admission to promote consistent communication and excellent care. We report our 7-year history of proactive meetings with pregnant women and their families in a nonclinical environment to discuss diagnosis, treatment, and prognosis. A collaborative written plan of care is developed that accommodates the woman's needs and wishes and is then disseminated among the healthcare team. This process has decreased women's and caregivers' anxiety and supported a culture of safety across the continuum of care.