Invasive Endotyping in Patients With Angina and No Obstructive Coronary Artery Disease: A Randomized Controlled Trial.

BACKGROUND: We investigated the usefulness of invasive coronary function testing to diagnose the cause of angina in patients with no obstructive coronary arteries. METHODS: Outpatients referred for coronary computed tomography angiography in 3 hospitals in the United Kingdom were prospectively screened. After coronary computed tomography angiography, patients with unobstructed coronary arteries, and who consented, underwent invasive endotyping. The diagnostic assessments included coronary angiography, fractional flow reserve (patient excluded if ≤0.80), and, for those without obstructive coronary artery disease, coronary flow reserve (abnormal <2.0), index of microvascular resistance (abnormal ≥25), and intracoronary infusion of acetylcholine (0.182, 1.82, and 18.2 µg/mL; 2 mL/min for 2 minutes) to assess for microvascular and coronary spasm. Participants were randomly assigned to disclosure of the results of the coronary function tests to the invasive cardiologist (intervention group) or nondisclosure (control group, blinded). In the control group, a diagnosis of vasomotor angina was based on medical history, noninvasive tests, and coronary angiography. The primary outcome was the between-group difference in the reclassification rate of the initial diagnosis on the basis of coronary computed tomography angiography versus the final diagnosis after invasive endotyping. The Seattle Angina Questionnaire summary score and Treatment Satisfaction Questionnaire for Medication were secondary outcomes. RESULTS: Of 322 eligible patients, 250 (77.6%) underwent invasive endotyping; 19 (7.6%) had obstructive coronary disease, 127 (55.0%) had microvascular angina, 27 (11.7%) had vasospastic angina, 17 (7.4%) had both, and 60 (26.0%) had no abnormality. A total of 231 patients (mean age, 55.7 years; 64.5% women) were randomly assigned and followed up (median duration, 19.9 [12.6-26.9] months). The clinician diagnosed vasomotor angina in 51 (44.3%) patients in the intervention group and in 55 (47.4%) patients in the control group. After randomization, patients in the intervention group were 4-fold (odds ratio, 4.05 [95% CI, 2.32-7.24]; P<0.001) more likely to be diagnosed with a coronary vasomotor disorder; the frequency of this diagnosis increased to 76.5%. The frequency of normal coronary function (ie, no vasomotor disorder) was not different between the groups before randomization (51.3% versus 50.9%) but was reduced in the intervention group after randomization (23.5% versus 50.9%, P<0.001). At 6 and 12 months, the Seattle Angina Questionnaire summary score in the intervention versus control groups was 59.2±24.2 (2.3±16.2 change from baseline) versus 60.4±23.9 (4.6±16.4 change) and 63.7±23.5 (4.7±14.7 change) versus 66.0±19.3 (7.9±17.1 change), respectively, and not different between groups (global P=0.36). Compared with the control group, global treatment satisfaction was higher in the intervention group at 12 months (69.9±22.8 versus 61.7±26.9, P=0.013). CONCLUSIONS: For patients with angina and no obstructive coronary arteries, a diagnosis informed by invasive functional assessment had no effect on long-term angina burden, whereas treatment satisfaction improved. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03477890.

Focused UTUC pathways with a risk-stratified approach to diagnostic ureteroscopy: is it the need of the hour? A retrospective cohort analysis.

INTRODUCTION: Upper urinary tract urothelial cancer is a rare, aggressive variant of urinary tract cancer. There is often delay to diagnosis and management for this entity in view of diagnostic and staging challenges needing additional investigations and risk stratifications for improved outcomes. In this article, we share our experience in developing a dedicated diagnostic and treatment pathway for UTUC and assess its impact on time lines to radical nephroureterectomy (RNU). We also evaluate the impact of diagnostic ureteroscopy (DUR) on UTUC care pathways timelines. MATERIALS AND METHODS: A prospective database was maintained for all patients who underwent a RNU from January 2015 to August 2022 in a high-volume single tertiary care centre in the UK. In 2019, a Focused UTUC pathway (FUP) was implemented at the centre to streamline diagnostic and RNU pathways. A retrospective analysis of the database was conducted to compare time lines and diagnostic trends between the pre-FUP and FUP cohorts. Primary outcome measures were time to RNU from MDT. Secondary outcome measures were: impact of DUR on time to RNU from MDT and negative UTUC rates between DUR and non-DUR cohorts. Differences in continuous variables across categories were assessed using the independent sample t test. Categorical variables between cohorts were analysed using the chi-square (χ2). Statistical significance in this study was set as p < 0.05. RESULTS: A total of 500 patients with complete data were included in the analysis. The pre-FUP and FUP cohorts consisted of 313 patients and 187 patients, respectively. The overall cohort had a mean age (SD) of 70 years (9.3). 66% of the overall cohort were males. The median time to RNU from MDT in the FUP was significantly lower compared to the pre-FUP cohort; 62 days (IQR 59) vs. 48 days (IQR 41.5), p < 0.0001. The median time to RNU from MDT in patients who underwent a diagnostic URS in the FUP cohort was significantly lower compared to the pre-FUP cohort; 78.5 days (IQR 54.8) vs. 68 days (IQR 48), p-NS. The non-UTUC rates in the DUR and non-DUR cohorts were 6/248 (2.4%) and 14/251 (5.6%), respectively (NS). CONCLUSION: In this series, we illustrate the effectiveness of integrating a multidisciplinary approach with specialised personnel, ring-fenced clinics, efficient diagnostic assessment and optimised theatre capacity. By adopting a risk-stratified approach to diagnostic ureteroscopy, we have achieved a significant reduction in time to RNU.

Assessment of inter-centre agreement across multidisciplinary team meetings for patients with retroperitoneal sarcoma.

BACKGROUND: Decision-making in the management of patients with retroperitoneal sarcoma is complex and requires input from a number of different specialists. The aim of this study was to evaluate the levels of agreement in terms of resectability, treatment allocation, and organs proposed to be resected across different retroperitoneal sarcoma multidisciplinary team meetings. METHODS: The CT scans and clinical information of 21 anonymized retroperitoneal sarcoma patients were sent to all of the retroperitoneal sarcoma multidisciplinary team meetings in Great Britain, which were asked to give an opinion about resectability, treatment allocation, and organs proposed to be resected. The main outcome was inter-centre reliability, which was quantified using overall agreement, as well as the chance-corrected Krippendorff's alpha statistic. Based on the latter, the level of agreement was classified as: 'slight' (0.00-0.20), 'fair' (0.21-0.40), 'moderate' (0.41-0.60), 'substantial' (0.61-0.80), or 'near-perfect' (>0.80). RESULTS: Twenty-one patients were reviewed at 12 retroperitoneal sarcoma multidisciplinary team meetings, giving a total of 252 assessments for analysis. Consistency between centres was only 'slight' to 'fair', with rates of overall agreement and Krippendorff's alpha statistics of 85.4 per cent (211 of 247) and 0.37 (95 per cent c.i. 0.11 to 0.57) for resectability; 80.4 per cent (201 of 250) and 0.39 (95 per cent c.i. 0.33 to 0.45) for treatment allocation; and 53.0 per cent (131 of 247) and 0.20 (95 per cent c.i. 0.17 to 0.23) for the organs proposed to be resected. Depending on the centre that they had attended, 12 of 21 patients could either have been deemed resectable or unresectable, and 10 of 21 could have received either potentially curative or palliative treatment. CONCLUSIONS: Inter-centre agreement between retroperitoneal sarcoma multidisciplinary team meetings was low. Multidisciplinary team meetings may not provide the same standard of care for patients with retroperitoneal sarcoma across Great Britain.

Knowledge, attitude, and perception of public about participation in COVID-19 clinical trials: a study from Egypt and Saudi Arabia.

BACKGROUND: Pharmaceutical firms are striving to find potential treatments to prevent and treat COVID-19. One of the gold standards to evaluate treatment is a clinical trial; however, the difficulty in patient recruitment could act as a determinant. It is evident from the registry data that very few studies have been conducted involving the population of the Middle East and North Africa (MENA) region. AIM: To document knowledge, perception, and attitude of the public from Two large countries in the MENA region (Egypt and Saudi Arabia) towards participation in clinical trials focused on evaluating potential COVID-19 treatments. METHOD: A cross-sectional study was conducted that used a snowball sampling strategy for recruitment. General population 18 years old or older, who lived in Saudi Arabia or Egypt were invited. The survey was adopted from literature and was approved by an ethics committee. RESULTS: Out of 800 participants in the survey, 407 participants were from Egypt, and 393 were from Saudi Arabia. Most participants (48%) had moderate knowledge, i.e., > 60% < 80%. The results revealed poor attitude (88.5%) and poor perceptions (45.8%) regarding participation in COVID-19 clinical trials. Education and residence were identified as determinants of participants' knowledge, attitude, and perceptions. Participants' knowledge and understanding of COVID-19 trials did not impact their willingness to participate. This coupled with a poor attitude and perception among the masses drastically affects any potential for participation in future clinical trials. Conclusion: A relatively small proportion of participants were interested in enrolling in COVID-19 studies. Increased collective engagement through social media and healthcare professionals can help improve attitudes and perceptions toward trial participation.

Guideline adherence for the surgical treatment of T1 renal tumours correlates with hospital volume: an analysis from the British Association of Urological Surgeons Nephrectomy Audit.

OBJECTIVE: To assess European Association of Urology guideline adherence on the surgical management of patients with T1 renal tumours and the effects of centralisation of care. PATIENTS AND METHODS: Retrospective data from all kidney tumours that underwent radical nephrectomy (RN) or partial nephrectomy (PN) in the period 2012-2016 from the British Association of Urological Surgeons Nephrectomy Audit were retrieved and analysed. We assessed total surgical hospital volume (HV; RN and PN performed) per centre, PN rates, complication rates, and completeness of data. Descriptive analyses were performed, and confidence intervals were used to illustrate the association between hospital volume and proportion of PN. Chi- squared and Cochran-Armitage trend tests were used to evaluate differences and trends. RESULTS: In total, 13 045 surgically treated T1 tumours were included in the analyses. Over time, there was an increase in PN use (39.7% in 2012 to 44.9% in 2016). Registration of the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) complexity score was included in March 2016 and documented in 39% of cases. Missing information on postoperative complications appeared constant over the years (8.5-9%).  A clear association was found between annual HV and the proportion of T1 tumours treated with PN rather than RN (from 18.1% in centres performing <25 cases/year [lowest volume] to 61.8% in centres performing ≥100 cases/year [high volume]), which persisted after adjustment for PADUA complexity. Overall and major (Clavien-Dindo grade ≥III) complication rate decreased with increasing HV (from 12.2% and 2.9% in low-volume centres to 10.7% and 2.2% in high-volume centres, respectively), for all patients including those treated with PN. CONCLUSION: Closer guideline adherence was exhibited by higher surgical volume centres. Treatment of T1 tumours using PN increased with increasing HV, and was accompanied by an inverse association of HV with complication rate. These results support the centralisation of kidney cancer specialist cancer surgical services to improve patient outcomes.

Enhancing Student Learning in Dental Anatomy by Using Virtual Three-Dimensional Models.

In order to provide restorations and dental prostheses that are esthetically pleasing, functional and in harmony with a patient's occlusion, practitioners must have a thorough knowledge of dental anatomy. Recent studies have shown that virtual three-dimensional (3D) models greatly enhance educational outcomes in dental anatomy courses. This article describes a novel educational technique and uses videos and web-based portals to demonstrate how to create a virtual 3D tooth model from a scan of a natural tooth for use in dental anatomy courses.

Circumferential Strain Predicts Major Adverse Cardiovascular Events Following an Acute ST-Segment-Elevation Myocardial Infarction.

Purpose To investigate the prognostic value of circumferential left ventricular (LV) strain measured by using cardiac MRI for prediction of major adverse cardiac events (MACE) following an acute ST-segment-elevation myocardial infarction (STEMI). Materials and Methods Participants with acute STEMI were prospectively enrolled from May 11, 2011, to November 22, 2012. Cardiac MRI was performed at 1.5 T during the index hospitalization. Displacement encoding with stimulated echoes (DENSE) and feature tracking of cine cardiac MRI was used to assess circumferential LV strain. MACE that occurred after discharge were independently assessed by cardiologists blinded to the baseline observations. Results A total of 259 participants (mean age, 58 years ± 11 [standard deviation]; 198 men [mean age, 58 years ± 11] and 61 women [mean age, 58 years ± 12]) underwent cardiac MRI 2.2 days ± 1.9 after STEMI. Average infarct size was 18% ± 13 of LV mass and circumferential strain was -13% ± 3 (DENSE method) and -24% ± 7 (feature- tracking method). Fifty-one percent (131 of 259 participants) had presence of microvascular obstruction. During a median follow-up period of 4 years, 8% (21 of 259) experienced MACE. Area under the curve (AUC) for DENSE was different from that of feature tracking (AUC, 0.76 vs 0.62; P = .03). AUC for DENSE was similar to that of initial infarct size (P = .06) and extent of microvascular obstruction (P = .08). DENSE-derived strain provided incremental prognostic benefit over infarct size for prediction of MACE (hazard ratio, 1.3; P < .01). Conclusion Circumferential strain has independent prognostic importance in study participants with acute ST-segment-elevation myocardial infarction. Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Kramer in this issue.

Enhancing Student Learning of Removable Prosthodontics Using the Latest Advancements in Virtual 3D Modeling.

When educating dental students or prosthodontic residents, a picture can be worth a thousand words. If that is so, then what could enhanced 3D modeling be worth relative to enhancing student learning? The answer is undoubtedly more than what a picture can provide. That is why the use of 3D models has become increasingly common with respect to patient care. The 3D modeling allows the patient to visualize more clearly the proposed treatments and outcomes; however, while 3D modeling has started to make an appearance in dental education, many of the current 3D modeling techniques do not offer the flexibility needed for dental education and enhanced student learning. At the University of Iowa, the use of 3D modeling software has enabled the creation of 3D models that can be altered or customized to be used in a more flexible way to teach students in the arts and complexities of removable partial denture (RPD) design and associated components. This educational technique article will: (1) demonstrate how these 3D models can be used to enhance student perception and learning regarding RPDs; and (2) will demonstrate using videos and web-based portals to show how the 3D RPD models were created and then used for educational purposes.

Enhancing Student Learning in Removable Partial Denture Design by Using Virtual Three-Dimensional Models Versus Traditional Two-Dimensional Drawings: A Comparative Study.

PURPOSE: To compare the use of virtual 3D casts as an alternative to paper-based exercises in preclinical removable partial denture (RPD) design in terms of student outcomes (as evidenced by exercise evaluation scores), as well as student attitudes related to the 2 formats. The first hypothesis of this study is that virtual 3D digital models in the exercise will result in better student outcomes as evidenced by the final exercise score compared to the 2D drawings. The second hypothesis is that virtual 3D digital models in the exercise will result in greater student acceptance compared to the 2D drawings. MATERIALS AND METHODS: Students were divided into 2 equal, randomly assigned groups Both groups were made to solve 2 exercises: a class II exercise and a class IV exercise. Group 1 received the first exercise (exercise #1) as a Kennedy class IV design exercise in virtual 3D and the second exercise (exercise #2) as a Kennedy class II design exercise in traditional format. Group 2 would receive the opposite exercise #1 as a Kennedy class IV in traditional format and exercise #2 as a Kennedy class II in virtual 3D format. Virtual 3D casts were made to be identical to the traditional exercises. Students were then asked to complete a short survey to assess their preferences. The Wilcoxon Rank Sum test was used to compare the distribution of scores of exercises using the virtual 3D format with the scores when students used the traditional 2D format. Preference comparisons for the 2 formats were accomplished using exact binomial tests. RESULTS: There was no difference in learning outcomes based on the distribution of student scores for either exercise independent of presentation format (p > 0.52). There was also no difference in individual student score between 2 identical exercises, independent of whether the exercise was using 3D virtual models or 2D drawings. A greater proportion of students agreed with the statements that favored the use of the virtual 3D models than disagreed with respect to all 7 questions asked, based upon the sign test (comparing agreement vs. disagreement with the statement, p < 0.0003 in all instances). CONCLUSION: Despite there being no difference in learning outcomes (final scores), the students showed an overwhelming preference in having the virtual 3D casts part as part of the curriculum.

Prosthodontic Management of a Patient with Moebius Syndrome: A Clinical Report.

Moebius/MÓ§bius Syndrome (MS) is an extremely rare congenital disorder characterized by uni- or bilateral palsy of the abducens (VI) and the facial (VII) nerves, causing facial paralysis. Dysfunction of cranial nerves III through XII is common, most often the glossopharyngeal (IX) and hypoglossus (XII). Afflicted individuals seeking prosthodontic care, particularly removable prosthetics, present multiple challenges related to inherent facial and tongue muscle weakness and microstomia. Other extraoral anomalies may include congenital multiple arthrogryposis and malformations of the upper and lower limbs. This clinical report describes the rehabilitation of a patient with Moebius Syndrome using a maxillary 2-implant retained overdenture and mandibular partial removable denture prosthesis.

Comparative Prognostic Utility of Indexes of Microvascular Function Alone or in Combination in Patients With an Acute ST-Segment-Elevation Myocardial Infarction.

BACKGROUND: Primary percutaneous coronary intervention is frequently successful at restoring coronary artery blood flow in patients with acute ST-segment-elevation myocardial infarction; however, failed myocardial reperfusion commonly passes undetected in up to half of these patients. The index of microvascular resistance (IMR) is a novel invasive measure of coronary microvascular function. We aimed to investigate the pathological and prognostic significance of an IMR>40, alone or in combination with a coronary flow reserve (CFR≤2.0), in the culprit artery after emergency percutaneous coronary intervention for acute ST-segment-elevation myocardial infarction. METHODS: Patients with acute ST-segment-elevation myocardial infarction were prospectively enrolled during emergency percutaneous coronary intervention and categorized according to IMR (≤40 or >40) and CFR (≤2.0 or >2.0). Cardiac magnetic resonance imaging was acquired 2 days and 6 months after myocardial infarction. All-cause death or first heart failure hospitalization was a prespecified outcome (median follow-up, 845 days). RESULTS: IMR and CFR were measured in the culprit artery at the end of percutaneous coronary intervention in 283 patients with ST-segment-elevation myocardial infarction (mean±SD age, 60±12 years; 73% male). The median IMR and CFR were 25 (interquartile range, 15-48) and 1.6 (interquartile range, 1.1-2.1), respectively. An IMR>40 was a multivariable associate of myocardial hemorrhage (odds ratio, 2.10; 95% confidence interval, 1.03-4.27; P=0.042). An IMR>40 was closely associated with microvascular obstruction. Symptom-to-reperfusion time, TIMI (Thrombolysis in Myocardial Infarction) blush grade, and no (≤30%) ST-segment resolution were not associated with these pathologies. An IMR>40 was a multivariable associate of the changes in left ventricular ejection fraction (coefficient, -2.12; 95% confidence interval, -4.02 to -0.23; P=0.028) and left ventricular end-diastolic volume (coefficient, 7.85; 95% confidence interval, 0.41-15.29; P=0.039) at 6 months independently of infarct size. An IMR>40 (odds ratio, 4.36; 95% confidence interval, 2.10-9.06; P<0.001) was a multivariable associate of all-cause death or heart failure. Compared with an IMR>40, the combination of IMR>40 and CFR≤2.0 did not have incremental prognostic value. CONCLUSIONS: An IMR>40 is a multivariable associate of left ventricular and clinical outcomes after ST-segment-elevation myocardial infarction independently of the infarction size. Compared with standard clinical measures of the efficacy of myocardial reperfusion, including the ischemic time, ST-segment elevation, angiographic blush grade, and CFR, IMR has superior clinical value for risk stratification and may be considered a reference test for failed myocardial reperfusion. CLINICAL TRIAL REGISTRATION: URL: https//www.clinicaltrials.gov. Unique identifier: NCT02072850.

Prognostic significance of infarct core pathology revealed by quantitative non-contrast in comparison with contrast cardiac magnetic resonance imaging in reperfused ST-elevation myocardial infarction survivors.

AIMS: To assess the prognostic significance of infarct core tissue characteristics using cardiac magnetic resonance (CMR) imaging in survivors of acute ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: We performed an observational prospective single centre cohort study in 300 reperfused STEMI patients (mean ± SD age 59 ± 12 years, 74% male) who underwent CMR 2 days and 6 months post-myocardial infarction (n = 267). Native T1 was measured in myocardial regions of interest (n = 288). Adverse remodelling was defined as an increase in left ventricular (LV) end-diastolic volume ≥20% at 6 months. All-cause death or first heart failure hospitalization was a pre-specified outcome that was assessed during follow-up (median duration 845 days). One hundred and sixty (56%) patients had a hypo-intense infarct core disclosed by native T1. In multivariable regression, infarct core native T1 was inversely associated with adverse remodelling [odds ratio (95% confidence interval (CI)] per 10 ms reduction in native T1: 0.91 (0.82, 0.00); P = 0.061). Thirty (10.4%) of 288 patients died or experienced a heart failure event and 13 of these events occurred post-discharge. Native T1 values (ms) within the hypo-intense infarct core (n = 160 STEMI patients) were inversely associated with the risk of all-cause death or first hospitalization for heart failure post-discharge (for a 10 ms increase in native T1: hazard ratio 0.730, 95% CI 0.617, 0.863; P < 0.001) including after adjustment for left ventricular ejection fraction, infarct core T2 and myocardial haemorrhage. The prognostic results for microvascular obstruction were similar. CONCLUSION: Infarct core native T1 represents a novel non-contrast CMR biomarker with potential for infarct characterization and prognostication in STEMI survivors. Confirmatory studies are warranted. CLINICALTRIALS. GOV IDENTIFIER: NCT02072850.

Enhanced degradation of ibuprofen in an integrated constructed wetland-microbial fuel cell: treatment efficiency, electrochemical characterization, and microbial community dynamics.

Over the past few decades, there has been a growing concern regarding the fate and transport of pharmaceuticals, particularly antibiotics, as emerging contaminants in the environment. It has been proposed that the presence of antibiotics at concentrations typically found in wastewater can impact the dynamics of bacterial populations and facilitate the spread of antibiotic resistance. The efficiency of currently-used wastewater treatment technologies in eliminating pharmaceuticals is often insufficient, resulting in the release of low concentrations of these compounds into the environment. In this study, we addressed these challenges by evaluating how different influent ibuprofen (IBU) concentrations influenced the efficiency of a laboratory-scale, integrated constructed wetland-microbial fuel cell (CW-MFC) system seeded with Eichhornia crassipes, in terms of organic matter removal, electricity generation, and change of bacterial community structure compared to unplanted, sediment MFC (S-MFC) and abiotic S-MFC (AS-MFC). We observed that the addition of IBU (5 mg L-1) resulted in a notable decrease in chemical oxygen demand (COD) and electricity generation, suggesting that high influent IBU concentrations caused partial inhibition for the electroactive microbial community due to its complexity and aromaticity. However, CW-MFC could recover from IBU inhibition after an acclimation period compared to unplanted S-MFC, even though the influent IBU level was increased up to 20 mg L-1, suggesting that plants in CW-MFCs have a beneficial role in relieving the inhibition of anode respiration due to the presence of high levels of IBU; thus, promoting the metabolic activity of the electroactive microbial community. Similarly, IBU removal efficiency for CW-MFC (i.e., 49-62%) was much higher compared to SMFC (i.e., 29-42%), and AS-MFC (i.e., 20-22%) during all experimental phases. In addition, our high throughput sequencing revealed that the high performance of CW-MFCs compared to S-MFC was associated with increasing the relative abundances of several microbial groups that are closely affiliated with anode respiration and organic matter fermentation. In summary, our results show that the CW-MFC system demonstrates suitability for high removal efficiency of IBU and effective electricity generation.

The use of artificial intelligence and game-based learning in removable partial denture design: A comparative study.

PURPOSE: The purpose of this study was to compare student performance in removable partial denture (RPD) design during a pre-clinical RPD course with and without using a recently developed computer software named AiDental. Additionally, student perceptions associated with the use of this software were assessed. METHODS: The AiDental software consists of a learning environment containing an RPD design system that automatically designs RPDs based on the user's input. The software also contains an RPD game component that compares the user's RPD Design to an automatically generated RPD ideal design. The study was conducted in two phases. In phase one, pre-clinical second-year dental students who participated in the study were randomly divided into two groups: The AiDental group with AiDental software access (n = 36), and the conventional group without software access (n = 37). Both groups received conventional RPD instruction and practice, however, the AiDental group had additional access to the AiDental software. After 2 weeks, both groups took a mock practical test, which was collected and graded by the principal investigator (PI). The PI was blinded from group assignment and no identifying information was used in the mock practical. In phase two, all students were granted access to the AiDental software for the remainder of the pre-clinical course duration. At the conclusion of the course, all students were given a survey to evaluate their perceptions of the AiDental software. Descriptive statistics were calculated and analyzed. Variables related to perceptions of both the AiDental designer and game were assessed using Spearman's rank correlation test, the chi-square test, Fisher's exact test, and the non-parametric Wilcoxon rank-sum test as appropriate. In addition, a thematic analysis of the responses to the optional comments section was conducted using the Braun and Clarke method. RESULTS: Phase one results showed that subjects in the AiDental group were more likely than subjects in the conventional group to receive a final grade of A or B. Phase two results showed generally favorable student perceptions towards the software, and additionally, the results showed that age was significantly negatively correlated with ease of use of the software, improving decision-making, and critical thinking relative to RPD design choices. However, no correlation between age and using the software as a reference were noted. CONCLUSIONS: The use of AiDental's automated feedback and gamification techniques in RPD education had a positive effect on student grades and it was well-liked by students. Thus, the results suggest that AiDental has the potential to be a useful adjunct to pre-clinical teaching.

A survey on utilization and barriers of digital removable prostheses in the US dental education.

PURPOSE: Gaining knowledge on the extent of digital technology implementation in dental education and the barriers to it will help inform future directions to promote the use of such technology and will enhance dental education. This study aimed to investigate the utilization of digitally fabricated removable prostheses and the potential obstacles to implementing such technology in US dental schools. METHODS: A survey was developed and distributed to the restorative dentistry department chairs and postdoctoral prosthodontic program directors. The survey delivery protocol included follow-up emails 1 week, 3 weeks, and 4 weeks after the initial email. The collected data were analyzed descriptively. RESULTS: The response rate was 85% and 45% for predoctoral and postdoctoral prosthodontic programs, respectively. The results showed that 88.06% of the predoctoral programs and 95.65% of the postdoctoral prosthodontic programs implement digital complete dentures in the curriculum; however, the digital removable partial dentures implementation rate was recorded at 70.77% in predoctoral programs and 61.9% in postdoctoral prosthodontic programs. CONCLUSIONS: Dental schools are challenged by cost, design software limitations, IT and laboratory support, and faculty training. Multifaceted support is instrumental in further implementing digital removable prosthodontics into dental education.

Development of a high fidelity, multidisciplinary, crisis simulation model for robotic surgical teams.

Immediate access to the patient in crisis situations, such as cardiac arrest during robotic surgery, can be challenging. We aimed to present a full immersion simulation module to train robotic surgical teams to manage a crisis scenario, enhance teamwork, establish clear lines of communication, improve coordination and speed of response. Start time of cardiopulmonary resuscitation (CPR), first defibrillator shock and robotic de-docking time from the first 'cardiac arrest call' were recorded. Observational Teamwork Assessment for Surgery (OTAS) scores were used in control and test simulations to assess performance along with a participant survey. Repeat scenarios and assessment were conducted at a 6-month interval for the same team to validate knowledge retention and an additional scenario was run with a new anaesthetic team to validate modular design. OTAS scores improved across all specialty teams after training with emergency algorithm and at retention validity re-test (p = 0.0181; p = 0.0063). There was an overall reduction in time to CPR (101-48 s), first defibrillator shock (> 302 s to 86 s) and robot de dock time (86-25 s) Improvement remained constant at retention validity re-test. Replacing the anaesthetic team showed improvement in time to CPR, first shock and robotic de-dock times and did not affect OTAS scores (p = 0.1588). The module was rated highly for realism and crisis training by all teams. This high-fidelity simulation training module is realistic and feasible to deliver. Its modular design allows for efficient assessment and feedback, optimising staff training time and making it a valuable addition to robotic team training.

Resilient Stud Versus Bar Attachments for Inclined Implants Supporting Mandibular Overdentures. An In Vitro Study of Loading and Dislodging Strains.

PURPOSE: To evaluate strain around resilient stud and bar attachments for inclined implants supporting mandibular overdentures during loading and dislodging. MATERIALS AND METHODS: A mandibular edentulous model was printed using the laser sintering technique. Two vertical implants and two 30-degree distally inclined implants were placed in canine and premolar areas, respectively. Overdentures were attached to the implants with either a resilient stud (Locator, group 1) or a bar/clip (group 2) attachment. Three strain gauges were mounted at the buccal, lingual, and proximal surfaces of each implant. Microstrains were registered during vertical loading and dislodging force applications and compared between attachments (resilient stud and bar) and implant positions (vertical and inclined). RESULTS: For canine implants, bar overdentures recorded significantly higher microstrains than Locator overdentures during vertical loading. For premolar (inclined) implants, Locator overdentures recorded significantly higher microstrains than bar overdentures during vertical dislodging. For both groups (during loading) and the bar overdenture group (during dislodging), canine (vertical) implants showed significantly higher microstrains than premolar (inclined) implants. CONCLUSION: Within the limitations of this in vitro study, canine (vertical) implants may be at risk of increased stresses during loading if bar attachments are used for vertical and inclined implants supporting mandibular overdentures, and premolar (inclined) implants may be at risk of increased stresses during dislodging if Locator attachments are used. For both attachments, canine implants showed significantly higher microstrains than premolar implants during loading and dislodging.

Patient Satisfaction and Prosthetic Complications of Maxillary Implant Overdentures Opposing Mandibular Implant Overdentures with Bar, Telescopic, and Stud Attachments: A 1-Year Prospective Trial.

PURPOSE: To evaluate patient satisfaction and prosthetic complications of maxillary conventional dentures and implant overdentures opposing mandibular implant overdentures with different attachments. MATERIALS AND METHODS: A total of 60 patients with maxillary conventional dentures (maxillary CD) and mandibular two-implant overdentures received four implants in the maxilla. The implants were connected to the maxillary overdentures with a stud attachment (maxillary OD). The participants were classified into three groups according to the type of mandibular overdenture attachment: bar overdentures (BOD, n = 20), resilient telescopic overdentures (TOD, n = 20), and resilient stud/Locator overdentures (LOD, n = 20). Patient satisfaction (using a visual analog scale [VAS] and oral health-related quality of life (OHRQoL)] and prosthetic/soft tissue complications were evaluated for maxillary CD and maxillary OD after 1 year of insertion. RESULTS: LOD showed higher VAS and oral health impact profile (OHIP-14) scores with maxillary CD and maxillary OD than BOD and TOD except for ease of chewing (VAS) and satisfactory diet (OHIP-7). For maxillary CD, TOD showed a significantly higher frequency of prosthetic and soft tissue complications than BOD and LOD. For all groups, maxillary OD showed significantly higher patient satisfaction regarding VAS and OHIP-14 scores, and lower prosthetic and soft tissue complications than the maxillary CD. CONCLUSION: Locator-retained maxillary overdentures opposing mandibular implant overdentures improved patient satisfaction and reduced prosthetic complications compared to conventional maxillary dentures. Such overdentures are best opposed by Locator-retained mandibular overdentures, as they increase patient satisfaction and reduce prosthetic and soft tissue complications compared to the bar and telescopic attachments.

Axial and Nonaxial Retention Forces of Different Designs of Milled Bar Attachments for Maxillary Implant Overdentures: An In Vitro Study.

PURPOSE: To compare the axial and nonaxial retention forces of different milled bar attachment designs for maxillary implant overdentures. MATERIALS AND METHODS: Four implants were placed in the canine and second premolar areas of an edentulous maxillary ridge model and connected to a cobalt-chromium milled bar either with or without Locator attachments. According to the type of bar and overlying housing, the following groups (n = 10 each) were investigated: group 1 (MWM) = milled bar without attachments and metal housing; group 2 (MWP) = milled bar without attachments and PEEK housing; group 3 (MAM) = milled bar with Locator attachments and metal housing; and group 4 (MAP) = milled bar with Locator attachments and PEEK housing. Axial and nonaxial (anterior, posterior, and lateral) retention forces were measured both at baseline and after wear simulation, then compared between groups and dislodging directions. RESULTS: MAM showed the highest axial (53.20 ± 2.28 N) and nonaxial (anterior [33.80 ± 1.48 N], posterior [37.60 ± 2.07 N], and lateral [34.40 ± 1.67 N]) retention forces at baseline, followed by MAP, then MWM, and MWP (P < .001). MAP showed the highest axial (42.80 ± 2.28 N) and nonaxial (anterior [24.00 ± 1.58 N], posterior [29.40 ± 2.07 N], and lateral [27.80 ± 1.64 N]) retention forces after wear simulation, followed by MAM, then MWP, and finally MWM (P < .001). MAM showed the highest axial (25.25 ± 2.45 N) and nonaxial (anterior [28.29 ± 4.03 N], posterior [24.40 ± 3.25 N], and lateral [25.55 ± 1.65 N]) retention loss, followed by MWM, then MAP, and finally MWP (P < .001). For all groups, the highest retention forces were noted with axial dislodging, followed by posterior dislodging, then lateral dislodging, and finally vertical dislodging (P < .001). CONCLUSION: Milled bars with PEEK housings and Locator attachments for maxillary implant overdentures were associated with the highest axial and nonaxial retention forces after wear simulation, while milled bars with metal housing and no attachments showed the lowest forces. Milled bars with metal housing and attachments showed the highest retention loss, while milled bars with PEEK housing with no attachments showed retention gain.

Conceptualizing the next patient interaction: A clinical skillset using an emulation model in critical thinking.

CONCEPTUALIZING: The next patient interaction is logical, essential, and largely done intuitively. MAIN PURPOSE: To design and test a succinct learning guide for student guidance and student-faculty interaction in conceptualizing the next patient interaction. METHODS: In 2021 and 2022, faculty scored questions from 1-5: Recognize deviation from the ideal? Articulate how and how much the situation deviated? Gage consequences of the situation? Assess own capabilities? To what extent does the student have a clear grasp of the procedural outcome? Faculty were also given open-ended questions. RESULTS: Forty-eight reports were completed, 25 D3 and 23 D4. Three hundred thirty-five faculty entries were made in the questions calling for a 1-5 response out of a possible 336 responses. Statistically significant differences were noted. Students were better able to recognize the situation as different from ideal than to articulate how and how much the situation deviated. Students were better able to grasp how and how much this situation differs from the ideal than to assess own capabilities. D4 students were better able to recognize deviation from the ideal and to articulate how and how much the situation deviated than were D3 students. For open-ended questions, more students were scored as "Prepared" than were scored as "Unsure" and "Missed" combined. CONCLUSIONS: The exercise is seen as a succinct and constructive (nonjudgmental) path to guide the student's conceptualization of the next patient encounter before the encounter begins. Next steps will be incremental for wider use in a clinical teaching environment.