A Randomized Controlled Trial of an Emergency Department Intervention for Patients with Chronic Noncancer Pain.

BACKGROUND: Emergency Departments (EDs) are beginning to notify their physicians of patients reporting chronic noncancer pain (CNCP) who frequent EDs, and are suggesting that the physicians not prescribe opioids to these patients. OBJECTIVES: We hypothesized that this intervention would reduce both the number of opioids prescribed to these patients by their ED physicians and the number of these patients' return visits to the ED. METHODS: We conducted a randomized controlled trial of this intervention in 13 electronically linked EDs. Patients eligible for the study were characterized by CNCP, lacked evidence of sickle cell anemia and suicide ideation, and made frequent (>10) visits to the EDs over a 12-month period. We randomly assigned 411 of these patients to either an intervention group or a control group. Our intervention comprised both an alert placed in eligible patients' medical files and letters sent to the patients and their community-based providers. The alert suggested that physicians decline requests for opioid analgesic prescriptions and instead refer these patients to community-based providers to manage their ongoing pain. RESULTS: During the 12 months after randomization, patients in the intervention and control groups averaged 11.9 and 16.6 return visits, and received prescriptions for opioids on 16% and 26% of those visits, respectively. Altogether, patients in the intervention group made 1033 fewer return visits to the EDs in the follow-up year than those in the control group. CONCLUSION: This intervention constitutes a promising practice that EDs should consider to reduce the number of visits made by frequent visitors with CNCP.

Unintentional poisoning in North Carolina: an emerging public health problem.

Unintentional poisoning is a fast-growing public health problem that once evoked an image of a street denizen injecting heroin or snorting cocaine. Today's victim is white, male, and middle-aged--and the drugs are prescribed. In North Carolina, unintentional poisoning is the second-leading cause of death due to unintentional injury, and injuries due to any cause are the leading cause of potential years of life lost. Comprehensive prevention measures are needed now to stem this burgeoning problem.

Two critical thinking models-probing questions and conceptualization-adding 4 skillsets to the teacher's armamentarium.

Critical thinking is ubiquitous in patient care. One track for critical thinking develops skillsets emulating the thought process of the master clinician using probing questions and has been offered in treatment planning, literature search, and critique, risk assessment in caries and geriatrics, technology decision-making, EBD, and IPP. This paper offers 2 additional critical thinking skillsets following this emulation model in social work and ethics. Conceptualization, another form of critical thinking, is also ubiquitous in health care, yet almost no literature exists to guide learning and assess performance on conceptualization. This paper introduces for discussion 2 examples of conceptualization-"How and how much does this situation differ from the ideal?" and "How does the student/practitioner conceptualize the outcome prior to the imminent procedure?" -used continually by the practitioner in patient care situations. The result is 4 additional critical thinking skillsets at different stages of development in the armamentarium for the teacher.

Periodontal treatment needs in the Medicaid patient population: a retrospective study in a US dental school.

OBJECTIVES: The aim of this study was to use electronic health records (EHRs) from a US dental school clinic to retrospectively investigate associations between periodontal treatment needs and insurance type in a newly insured adult Medicaid population. We hypothesized that newly insured Medicaid patients, covered by the Iowa Dental Wellness Plan (DWP), would display greater need for treatment than patients with other sources of financing. METHODS: A retrospective chart review of EHRs of patients at the University of Iowa College of Dentistry and Dental Clinics (UI COD) from 2014 to 2016 was completed. The outcome of interest whether or not a new patient was indicated for scaling and root planing (SRP) based on clinical examination. Logistic regression models analyzed associations between treatment need and source of financing, adjusting for known periodontal disease risk indicators. RESULTS: A total of 1,259 patient charts were evaluated. SRP was indicated for 56 percent of all patients. Patients with DWP coverage had significantly greater unadjusted odds of being indicated for SRP than privately insured individuals (OR = 1.47, P = 0.009). However, this association did not remain significant after adjusting for known risk indicators. CONCLUSIONS: Although individuals enrolled in DWP were not significantly more likely to need treatment than individuals with other sources of financing when adjusting for risk indicators, their demonstrated clinical need was higher than privately insured adults. Public benefit programs could anticipate greater burden of periodontal need in low-income populations due to increased prevalence of risk factors in this population.

Preventive dental care among Medicaid-enrolled senior adults: from community to nursing facility residence.

OBJECTIVE: The primary objective of this study was to determine whether the utilization rate of preventive oral health care services while senior adults were community-dwelling differed from the rate after those same senior adults were admitted to nursing facilities. A secondary objective was to evaluate other significant predictors of receipt of preventive oral health procedures after nursing facility entry. METHODS: Iowa Medicaid claims from 2007-2014 were accessed for adults who were 68+ years upon entry to a nursing facility and continuously enrolled in Medicaid for at least three years before and at least two years after admission (n = 874). Univariate, bivariate and multivariable analyses were conducted. RESULTS: During the five years that subjects were followed, 52.8% never received a dental exam and 75.9% never received a dental hygiene procedure. More Medicaid-enrolled senior adults received ≥1 preventive dental procedure in the two years while residing in a nursing facility compared to the three years before entry. In multivariable analyses, the strongest predictor of preventive oral health care utilization after entry was the receipt of preventive oral health services before entry (p < 0.01). CONCLUSIONS: The strongest predictor of receipt of dental procedures in the two years after nursing facility entry was the receipt of dental procedures in the three years before entry while community-dwelling. This underscores the importance of the senior adult establishing a source of dental care while community-dwelling.

Effect of a prophylactic brace on wrist and ulnocarpal joint biomechanics in a cadaveric model.

BACKGROUND: Wrist pain from repetitive dorsiflexion and compression during pommel horse exercises is common among male gymnasts. PURPOSE: To determine the biomechanical effects of a prophylactic wrist brace on the wrist and ulnocarpal joints during mechanical loading in a cadaveric model. HYPOTHESIS: The lateral wedge of the palmar pad of the brace will compensate for positive ulnar variance, distributing contact forces more evenly across the radioulnar carpal joint. STUDY DESIGN: Controlled laboratory study. METHODS: Six male and six female fixed cadaveric forearm-wrist specimens were subjected to a 32.13-kg compressive load applied through the long axis of the pronated forearm with a dorsiflexed wrist in contact with a support surface. Wrist joint dorsiflexion angle and ulnocarpal joint intraarticular peak pressure were assessed under three brace conditions: Ezy ProBrace with and without palmar pad and a nonbraced control. RESULTS: Wrist joint dorsiflexion angle was significantly reduced by the Ezy ProBrace with and without the palmar pad. However, ulnocarpal joint intraarticular peak pressure was reduced only by the brace with pad. CONCLUSION: Prevention of pathologic wrist changes requires intervention in pressure attenuation, which was achieved with the Ezy ProBrace with palmar pad. CLINICAL RELEVANCE: This brace may decrease the cumulative effects of repetitive stress of pommel horse exercise training.

2013 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 31st Annual Report.

BACKGROUND: This is the 31st Annual Report of the American Association of Poison Control Centers' (AAPCC) National Poison Data System (NPDS). As of January 1, 2013, 57 of the nation's poison centers (PCs) uploaded case data automatically to NPDS. The upload interval was 8.08 [7.10, 11.63] (median [25%, 75%]) minutes, creating a near real-time national exposure and information database and surveillance system. METHODOLOGY: We analyzed the case data tabulating specific indices from NPDS. The methodology was similar to that of previous years. Where changes were introduced, the differences are identified. Poison center (PC) cases with medical outcomes of death were evaluated by a team of 38 medical and clinical toxicologist reviewers using an ordinal scale of 1-6 to assess the Relative Contribution to Fatality (RCF) of the exposure to the death. RESULTS: In 2013, 3,060,122 closed encounters were logged by NPDS: 2,188,013 human exposures, 59,496 animal exposures, 806,347 information calls, 6,116 human-confirmed nonexposures, and 150 animal-confirmed nonexposures. Total encounters showed a 9.3% decline from 2012, while health care facility human exposure calls were essentially flat, decreasing by 0.1%.All information calls decreased 21.4% and health care facility (HCF) information calls decreased 8.5%, medication identification requests (drug ID) decreased 26.8%, and human exposures reported to US PCs decreased 3.8%. Human exposures with less serious outcomes have decreased 3.7% per year since 2008 while those with more serious outcomes (moderate, major or death) have increased by 4.7% per year since 2000. The top five substance classes most frequently involved in all human exposures were analgesics (11.5%), cosmetics/personal care products (7.7%), household cleaning substances (7.6%), sedatives/hypnotics/antipsychotics (5.9%), and antidepressants (4.2%). Sedative/hypnotics/antipsychotics exposures as a class increased most rapidly (2,559 calls/year) over the last 13 years for cases showing more serious outcomes. The top five most common exposures in children of 5 years or less were cosmetics/personal care products (13.8%), household cleaning substances (10.4%), analgesics (9.8%), foreign bodies/toys/miscellaneous (6.9%), and topical preparations (6.1%). Drug identification requests comprised 50.7% of all information calls. NPDS documented 2,477 human exposures resulting in death with 2,113 human fatalities judged related (RCF of 1, undoubtedly responsible; 2, probably responsible; or 3, contributory). CONCLUSIONS: These data support the continued value of PC expertise and need for specialized medical toxicology information to manage the more severe exposures, despite a decrease in calls involving less severe exposures. Unintentional and intentional exposures continue to be a significant cause of morbidity and mortality in the United States. The near real-time, always current status of NPDS represents a national public health resource to collect and monitor US exposure cases and information calls. The continuing mission of NPDS is to provide a nationwide infrastructure for public health surveillance for all types of exposures, public health event identification, resilience response and situational awareness tracking. NPDS is a model system for the nation and global public health.

Concepts in critical thinking applied to caries risk assessment in dental education.

Much progress has been made in the science of caries risk assessment and ways to analyze caries risk, yet dental education has seen little movement toward the development of frameworks to guide learning and assess critical thinking in caries risk assessment. In the absence of previous proactive implementation of a learning framework that takes the knowledge of caries risk and critically applies it to the patient with the succinctness demanded in the clinical setting, the purpose of this study was to develop a model learning framework that combines the science of caries risk assessment with principles of critical thinking from the education literature. This article also describes the implementation of that model at one dental school and presents some preliminary assessment data.

Outcomes mapping: a method for dental schools to coordinate learning and assessment based on desired characteristics of a graduate.

This project, utilizing a seldom-used approach to dental education, was designed to define the desired characteristics of a graduating dental student; convert those characteristics to educational outcomes; and use those outcomes to map a dental school's learning and assessment programs, based on outcomes rather than courses and disciplines. A detailed rubric of the outcomes expected of a graduating dental student from this school was developed, building on Commission on Dental Accreditation (CODA) standards and the school's competencies. The presence of each characteristic in the rubric was mapped within and across courses and disciplines. To assess implementation of the rubric, members of two faculty committees and all fourth-year students were asked to use it to rate 1) the importance of each characteristic, 2) the extent to which the school teaches and assesses each, and 3) the extent to which each counts toward overall assessment of competence. All thirty-three faculty members (100 percent) on the committees participated, as did forty-six of the fifty-five students (84 percent). The groups gave high scores to the importance of each characteristic, especially for knowledge and technical competence (then separate categories but merged in the final rubric) and for self-assessment, as well as the extent to which they are being taught and assessed. Respondents most commonly named critical thinking as the area that should be emphasized more. Mapping the curriculum and creating its related database allow the faculty and administration to more systematically coordinate learning and assessment than was possible with a course-based approach.