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Purpose Radiographic tumor volume (RTV) of oral squamous cell carcinoma (SCC) is seldom measured in practice. Aims of the study are to estimate RTV of SCC and to investigate its relationship with clinical and pathological stage, tumor margin status, recurrence, and need for chemo/radiation. Methods The design is a retrospective cohort study. The predictor variable is SCC RTV. The primary outcome variables are clinical and pathological tumor size. The secondary outcomes are margin status and postoperative chemo/radiation. Tumor dimensions were measured on preoperative maxillofacial or neck computer tomography images with contrast. Information on patient and tumor characteristics was obtained. Pearson correlation, t test, ANOVA and log rank test were used for statistical analysis. The significance level was set at .05. Results Thirty-six subjects aged 36 to 86 were included in the study. Positive association was found between clinical T stage and RTV (P = .0003) and between pathologic T stage and RTV (P = .002). Mean value of RTV was significantly higher in the group with positive margins (P = .0004). RTV was significantly higher in cancers requiring adjuvant chemo/radiation (P = .033). Mean RTV for patients with recurrence was 1.86 cm3 as compared to 1.29 cm3 for patients with no recurrence. Higher tumor volumes were more likely to be associated with recurrence. Conclusions RTV is a variable that is readily available to head and neck surgeons. RTV is associated with clinical and pathological tumor sizes, margin status, need for adjuvant chemo/radiation and tumor recurrence.

Background: Previous studies have shown that smoking tobacco significantly increases both incidence and mortality rates for many diseases. Social media has become one of the most influential platforms for various smoking cessation interventions. However, results from smoking cessation interventions have differed from study to study. Limited studies have summarised cessation outcomes from social media–based interventions. Therefore, the objective of this review is to explore the effectiveness of using social media for smoking cessation. Methods: We searched PubMed, MEDLINE, PsycINFO, and CINAHL for articles between June 2008 and June 2018, and also assessed the references of selected articles. We included studies that used social media as intervention platforms, provided a baseline assessment before the intervention, and provided smoking cessation outcomes after the intervention. Results: We identified 13 original studies that enrolled between 16 and 1698 participants; 7-day Point Prevalence Abstinence (PPA) rate was the most frequently used measure of abstinence, with a range of 7%–75%, regardless of the measurement time, study design, and analysis methods. Social media–based smoking cessation interventions were effective, because (1) smokers reported higher 7-day PPA rates after intervention compared to baseline and (2) smokers reported higher 7-day PPA rates in intervention groups than in control groups. Moreover, at each time point, approximately half of all smokers in studies reporting abstinence were found to be biochemically abstinent. There were no significant differences in the effectiveness of smoking cessation outcomes between those that used existing popular social networking platforms (e.g. Pechmann et al’s studies) and those that used individually designed interactive platforms (e.g. MyLastDip, iQuit system, Quitxt system). Conclusions: This review highlights the effectiveness of social media–based smoking cessation intervention studies. Due to the widespread use of social media, as well as its low cost, we suggest embedding smoking cessation interventions within existing popular social media platforms.

Objectives To determine whether high fidelity simulation-based training (SBT) of interprofessional teams involving trauma transfers has an immediate impact on participants’ team-based attitudes and behaviors. Design A quasi-experimental, pre-/postintervention comparison design examined high fidelity SBT of inter-professional teams using a 2 scenario format with immediate after action structured debriefing. Pre-/postsession Readiness for Inter-Professional Learning Scale (RIPLS, 19 items, Likert-type) surveys as well as Interprofessional Teamwork (IPT, 15 items, Likert-type) questionnaires, and postscenario participant- and observer-rated Teamwork Assessment Scales (TAS, 3 subscales, 11 items, Likert-type) were completed during each training session. Mean RIPLS, IPT, and TAS scores were calculated and matched pre-/postscore differences compared using paired t-test or analysis of variance with Bonferroni adjustment. Setting A large, urban, academic, state health sciences institution in the Southeastern United States during the 2014 to 2015 academic year. Participants General surgery residents, emergency medicine residents, and senior undergraduate nursing students comprising ten interprofessional teams. Results From approximately 48 participants, matched pre-/postsession IPT surveys were available for 42 individuals; 45 had an observer TAS evaluation for both scenarios; and 40 completed TAS peer evaluations for both scenarios. 47 participants had matched RIPLS surveys. Statistically significant improvements in matched pre-/postscore differences occurred for all 15 IPT items. Observer TAS scores significantly improved on 2 of the 3 subscales comparing the second to the first scenario. Peer evaluations statistically improved comparing the second to the first scenario. Two of the 19 RIPLS items demonstrated statistically significant improvement. Conclusions Interprofessional trauma team transfer training using SBT changes attitudes toward key team-based competencies and leads to learning them in the simulated environment. Such improvement in team-based skill and attitudes is an important first step in adopting team-based behaviors in the actual clinical environment and improving transfer care.

Objective To evaluate the potential of various alternative milk beverages to support bacterial biofilm formation and acid production and cause unbalanced demineralization. Design in vitro assays were used to examine the ability of the beverages to support Streptococcus mutans’ biofilm formation and acid production from sugar fermentation and the capacity of the beverages to buffer pH changes. Biofilm formation was done using 96-well plate model. Acid production was measured using L-Lactate assay kit, and the buffering capacity was assessed by pH titration. For ex vivo caries model, enamel and dentine slabs and S. mutans biofilms were exposed to selected alternative milk beverages three times a day, 30 min each, and by the end of the experiments, slab’s demineralization was assessed by loss of surface microhardness. Results Of the alternative milk beverages tested in this study, Original Almond consistently supported the most S. mutans biofilms, followed by Chocolate Cashew Milk, while the least biofilms were measured with Unsweetened Flax Milk. The most acids and the lowest culture pH were measured with Toasted Coconut Almond Milk, while the least buffering capacity was measured with Unsweetened Coconut Milk. The results of ex vivo caries model showed that like Bovine Whole Milk, repeated exposure to Original Almond led to significant enamel and dentine slab demineralization, when compared to those exposed to saline as a control (P Conclusions These results further provide support that popular alternative milk beverages, especially those with supplemental sugars, are potentially cariogenic.

Background Vulvovaginal candidiasis (VVC) is a common infection affecting women worldwide. Reports of patterns/risk factors/trends for episodic/recurrent VVC (RVVC) are largely outdated. The purpose of this study was to obtain current patient perspectives of several aspects of VVC/RVVC. Methods Business cards containing on-line survey information were distributed to healthy volunteers and patients seeking standard, elective, or referral gynecologic care in university-affiliated Obstetrics/Gynecology clinics. The internet-based questionnaire was completed by 284 non-pregnant women (78% Caucasian, 14% African American, 8% Asian). Results The majority of the participants (78%) indicated a history of VVC with 34% defined as having RVVC. The most common signs/symptoms experienced were itching, burning and redness with similar ranking of symptoms among VVC and RVVC patients. Among risk factors, antibiotic use ranked highest followed by intercourse, humid weather and use of feminine hygiene products. A high number of respondents noted ‘no known cause’ (idiopathic episodes) that was surprisingly similar among women with a history of either VVC or RVVC. VVC/RVVC episodes reported were primarily physician-diagnosed (73%) with the remainder mostly reporting self-diagnosis and treating with over-the-counter (OTC) medications. Most physician-diagnosed attacks utilized a combination of pelvic examination and laboratory tests followed by prescribed antifungals. Physician-treated cases achieved a higher level of symptom relief (84%) compared to those who self-medicated (57%). The majority of women with RVVC (71%) required continual or long-term antifungal medication as maintenance therapy to control symptoms. Conclusions Current patient perspectives closely reflect historically documented estimates of VVC/RVVC prevalence and trends regarding symptomatology, disease management and post-treatment outcomes. Electronic supplementary material The online version of this article (10.1186/s12905-019-0748-8) contains supplementary material, which is available to authorized users.

Background The study aimed to examine racial/ethnic differences in chemotherapy utilization by breast cancer subtype. Methods Data on female non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic stage I-III breast cancer patients diagnosed in 2011 were obtained from a project to enhance population-based National Program of Cancer Registry data for Comparative Effectiveness Research. Hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) were used to classify subtypes: HR+/HER2-; HR+/HER2+; HR-/HER2-; and HR-/HER2 + . We used multivariable logistic regression models to examine the association of race/ethnicity with three outcomes: chemotherapy (yes, no), neo-adjuvant chemotherapy (yes, no), and delayed chemotherapy (yes, no). Covariates included patient demographics, tumor characteristics, Charlson Comorbidity Index, other cancer treatment, and participating states/areas. Results The study included 25,535 patients (72.1% NHW, 13.7% NHB, and 14.2% Hispanics). NHB with HR+/HER2- (adjusted odds ratio [aOR] 1.22, 95% CI 1.04–1.42) and Hispanics with HR-/HER2- (aOR 1.62, 95% CI 1.15–2.28) were more likely to receive chemotherapy than their NHW counterparts. Both NHB and Hispanics were more likely to receive delayed chemotherapy than NHW, and the pattern was consistent across each subtype. No racial/ethnic differences were found in the receipt of neo-adjuvant chemotherapy. Conclusions Compared to NHW with the same subtype, NHB with HR+/HER2- and Hispanics with HR-/HER2- have higher odds of using chemotherapy; however, they are more likely to receive delayed chemotherapy, regardless of subtype. Whether the increased chemotherapy use among NHB with HR+/HER2- indicates overtreatment needs further investigation. Interventions to improve the timely chemotherapy among NHB and Hispanics are warranted.

This study sought to determine the bond strength of the Symetri Clear™ bracket after rebonding (reused) for a second and third time.Symetri Clear™ mandibular incisor brackets were bonded to bovine incisors and divided into six experimental groups. Two groups underwent tensile bond strength testing, and the remaining four groups were debonded using the manufacturer's recommended plier. Two groups were rebonded twice following surface preparation with Ortho SoloTM and two groups were rebonded twice without surface preparation. The rebonded brackets also underwent tensile bond strength testing after each rebonding event as well as receiving an Adhesive Remnant Index score.One-way ANOVA found a statistically significant difference in bond strength among the six groups (P0.0001). Tukey's Studentized Range (HSD, honestly significant difference) Test found significant differences in tensile bond strength of groups which did not undergo surface preparation prior to rebonding. One-way ANOVA found a P-value of 0.2563 and thus no significant difference in ARI among the different groups.There was no significant difference in the tensile bond strength of Symetri ClearTM brackets initially bonded with either Transbond™ XT or BluGloo™ and no significant difference between the initial tensile bond strength and the first or second rebond tensile bond strength. Rebonding Symetri Clear™ brackets without surface treatment did show significantly reduced tensile bond strength.

To date, no study has evaluated blood pressure following administration of each carpule given for dental procedures using a computerized dental anesthesia system. Blood pressures taken prior to performing invasive periodontal procedures were compared with those readings measured following delivery of each of up to three consecutive carpules of Marcaine or Xylocaine in varying order. Pressure differences were also adjusted for age, sex, race, and whether a prescribed anxiolytic was taken beforehand. Neither systolic nor diastolic blood pressures changed significantly as compared to initial blood pressure readings. However, compared with Whites, Hispanics, and Middle Easterners, Blacks had significantly higher systolic pressure at the third carpule delivery, the cause being unknown. Blood pressure in patients being anesthetized for root planing and various periodontal surgical procedures will not increase significantly when administering up to three carpules, whether Marcaine or Xylocaine, in varying order, using controlled flow dental anesthesia, and this method may be preferable to syringes in managing dental procedural stress.

Objectives Micro-invasive resin-infiltration has shown to inhibit lesion progression of proximal non-cavitated carious lesions, suggesting an alternative to early operative treatment. This split-mouth, randomized placebo-controlled clinical trial evaluated the effects of proximal lesion infiltration supplementary to standard-of-care management in high caries risk (HCR)-patients. Methods Forty-two HCR-subjects with two similar interproximal posterior lesions received professional HCR-regimen including repeated F-varnish applications. Two affected E2/D1-surfaces were randomized and concurrently treated by resin-infiltration or mock-infiltration (control). Individually standardized digital radiographs provided visual determination of lesion-size distribution at baseline and 2-year follow-up. Data were analyzed by logistic regression and McNemar’s test. Results Thirty-two lesion pairs (76%) were evaluated after 2 years. Categorical lesion depths were not different between groups (P > .5). Comparative pairwise assessment (image sets BL-2 yr) showed significantly more progression in control (7) versus infiltration (1) lesions (P = .035). Cumulative prevented fraction after two years was 97% for infiltrated lesions versus 74% for control lesions. Conclusions Two-year follow-up showed resin infiltration to be a highly efficacious (RRR: 86–89%) therapy. Long-term follow-up is needed to strengthen the evidence for efficacy of resin-infiltration as an adjunct to standard-of-care HCR-regimen including F-varnish. Clinical significance Showing 24% more stabilized lesions, the resin-infiltrated group performed significantly better than their controls, confirming successful early lesion management. Adjunct resin-infiltration provided an effective micro-invasive approach to inhibit short-term lesion progression.

Mediation analysis allows the examination of effects of a third variable in the pathway between an exposure and an outcome. The general multiple mediation analysis method, proposed by Yu et al, improves traditional methods (eg, estimation of natural and controlled direct effects) to enable consideration of multiple mediators/confounders simultaneously and the use of linear and nonlinear predictive models for estimating mediation/confounding effects. In this paper, we extend the method for time-to-event outcomes and apply the method to explore the racial disparity in breast cancer survivals. Breast cancer is the most common cancer and the second leading cause of cancer death among women of all races. Despite improvement of survival rates of breast cancer in the US, a significant difference between white and black women remains. Previous studies have found that more advanced and aggressive tumors and less than optimal treatment may explain the lower survival rates for black women as compared to white women. Due to limitations of current analytic methods and the lack of comprehensive data sets, researchers have not been able to differentiate the relative effect each factor contributes to the overall racial disparity. We use the CDC-funded Patterns of Care study to examine the determinants of racial disparities in breast cancer survival using a novel multiple mediation analysis. Using the proposed method, we applied the Cox hazard model and multiple additive regression trees as predictive models and found that all racial disparity in survival among Louisiana breast cancer patients were explained by factors included in the study.

Our recent studies have shown that BrpA in Streptococcus mutans plays a critical role in cell envelope biogenesis, stress responses, and biofilm formation. In this study, a 10-species consortium was used to assess how BrpA deficiency influences the establishment, persistence, and competitiveness of S. mutans during growth in a community under conditions typical of the oral cavity. Results showed that, like the wild-type, the brpA mutant was able to colonize and establish on the surfaces tested. Relative to the wild-type, however, the brpA mutant had a reduced ability to persist and grow in the 10-species consortium (P .001). A rat caries model was also used to examine the effect of BrpA, as well as Psr, a BrpA paralog, on S. mutans cariogenicity. The results showed no major differences in infectivity between the wild-type and the brpA and psr mutants. Unlike the wild-type, however, infection with the brpA mutant, but not the psr mutant, showed no significant differences in both total numbers of carious lesions and caries severity, compared with the control group that received bacterial growth medium (P .05). Metagenomic and quantitative polymerase chain reaction analysis showed that S. mutans infection caused major alterations in the composition of the rats' plaque microbiota and that significantly less S. mutans was identified in the rats infected with the brpA mutant compared with those infected with the wild-type and the psr mutant. These results further suggest that BrpA plays a critical role in S. mutans pathophysiology and that BrpA has potential as a therapeutic target in the modulation of S. mutans virulence.

Mediation analysis allows the examination of effects of a third variable (mediator/confounder) in the causal pathway between an exposure and an outcome. The general multiple mediation analysis method (MMA), proposed by Yu et al., improves traditional methods (e.g., estimation of natural and controlled direct effects) to enable consideration of multiple mediators/confounders simultaneously and the use of linear and nonlinear predictive models for estimating mediation/confounding effects. Previous studies find that compared with non-Hispanic cancer survivors, Hispanic survivors are more likely to endure anxiety and depression after cancer diagnoses. In this paper, we applied MMA on MY-Health study to identify mediators/confounders and quantify the indirect effect of each identified mediator/confounder in explaining ethnic disparities in anxiety and depression among cancer survivors who enrolled in the study. We considered a number of socio-demographic variables, tumor characteristics, and treatment factors as potential mediators/confounders and found that most of the ethnic differences in anxiety or depression between Hispanic and non-Hispanic white cancer survivors were explained by younger diagnosis age, lower education level, lower proportions of employment, less likely of being born in the USA, less insurance, and less social support among Hispanic patients.

Introduction Limited field cone-beam computed tomography (CBCT) imaging has become a modality frequently used by endodontists to evaluate the teeth and surrounding tissues of their patients. Accurate image interpretation is vital to obtain needed treatment information as well as to discern coincidental findings that could be present. The goal of this study was to determine the accuracy of CBCT volume interpretation when performed by endodontists and endodontic residents. Methods Eighteen deidentified limited field CBCT scans were obtained and evaluated by an oral and maxillofacial radiologist and an endodontist experienced in reading CBCT images. Their collective findings were combined as the “gold standard” of interpretation for this investigation. Using standard CBCT software, 4 practicing endodontists and 5 second-year endodontic residents evaluated each scan and recorded any notable findings and whether or not each scan warranted referral to a radiology specialist. Their interpretations were then compared with the gold standard to determine accuracy and any significant differences among the groups. Results The overall accuracy was 58.3% for endodontists and 64.3% for residents. Paired t tests showed no statistically significant differences in accuracy between the 2 groups for findings in teeth or in bone, but residents were significantly better for maxillary sinus findings. Endodontists agreed with the gold standard 38.9% of the time and residents 49.8% of the time on necessity of referral. The Cohen kappa coefficient showed moderate agreement between the groups. Conclusions Endodontists and residents had similar accuracy in CBCT scan evaluation. More training and experience are warranted for both groups in order to maximize image assessment accuracy.

Objectives To investigate the race-specific second primary bladder cancer (SPBC) risk following prostatic irradiation. Methods Louisiana residents who were diagnosed with localized prostate cancer (PCa) in 1996–2013 and received surgery or radiation were included. Patients were followed until SPBC diagnosis, death, or Dec. 2018. The exposure variable was type of treatment (radiation only vs. surgery only). The outcome was time from PCa diagnosis to SPBC diagnosis, stratified by race. Fine and Gray’s competing risk model was applied with death as a competing event and adjustment of sociodemographic and tumor characteristics. We used 5 years and 10 years as lag time in the analyses. Results A total of 26,277 PCa patients with a median follow-up of 10.7 years were analyzed, including 18,598 white and 7679 black patients. About 42.9 % of whites and 45.7 % of blacks received radiation. SPBC counted for 1.84 % in the radiation group and 0.90 % in the surgery group among white patients and for 0.91 % and 0.58 %, respectively, among black patients. The adjusted subdistribution hazard ratio of SPBC was 1.80 (95 % CI: 1.30–2.48) for radiation recipients compared to surgery recipients among white patients; 1.93 (95 % CI: 1.36–2.74) if restricted to external beam radiation therapy (EBRT). The SPBC risk was not significantly different between irradiated and surgically treated among blacks. Conclusions The SPBC risk is almost two-fold among white irradiated PCa patients compared to their counterparts treated surgically. Our findings highlight the need for enhanced surveillance for white PCa survivors receiving radiotherapy, especially those received EBRT.

To evaluate the cariogenic properties of almond milk beverages, 6 almond milks, along with soy and whole bovine milk, were analyzed for their abilities to support Streptococcus mutans biofilm formation and acid production, and their capacity to buffer changes in pH. Biofilm formation by S. mutans was analyzed using an in vitro 96-well plate model and measured by crystal violet staining. Acid production by S. mutans was evaluated by a colorimetric L-lactate assay and pH measurement of bacterial cultures. Buffering capacity was assessed by a pH titration assay. Soy milk supported the most biofilm growth, while the least was observed with unsweetened almond milk (both p < 0.001). Among almond milks, sucrose-sweetened milk led to the highest level of biofilm formation (p < 0.001), while the least was observed with unsweetened milk (p < 0.05). Sucrose-sweetened almond milk yielded the lowest pH (4.56 ± 0.66), followed by soy milk and bovine milk; the highest pH was with unsweetened almond milk (6.48 ± 0.5). When analyzed by pH titration, the unsweetened almond milk displayed the weakest buffering capacity while bovine milk showed the highest (p < 0.001). These results suggest that the almond milk beverages, except those that are sweetened with sucrose, possess limited cariogenic properties, while soy milk exhibits the most cariogenic potential. As milk alternatives become increasingly popular, dentists must counsel their patients that almond milks, especially sucrose-sweetened varieties, have cariogenic potential. For patients who are lactose-intolerant or suffer from milk allergy, almond milks may be a better alternative than soy-based products.

Bayesian sequential and adaptive randomization designs are gaining popularity in clinical trials thanks to their potentials to reduce the number of required participants and save resources. We propose a Bayesian sequential design with adaptive randomization rates so as to more efficiently attribute newly recruited patients to different treatment arms. In this paper, we consider 2-arm clinical trials. Patients are allocated to the 2 arms with a randomization rate to achieve minimum variance for the test statistic. Algorithms are presented to calculate the optimal randomization rate, critical values, and power for the proposed design. Sensitivity analysis is implemented to check the influence on design by changing the prior distributions. Simulation studies are applied to compare the proposed method and traditional methods in terms of power and actual sample sizes. Simulations show that, when total sample size is fixed, the proposed design can obtain greater power and/or cost smaller actual sample size than the traditional Bayesian sequential design. Finally, we apply the proposed method to a real data set and compare the results with the Bayesian sequential design without adaptive randomization in terms of sample sizes. The proposed method can further reduce required sample size.

Several researchers have proposed solutions to control type I error rate in sequential designs. The use of Bayesian sequential design becomes more common; however, these designs are subject to inflation of the type I error rate. We propose a Bayesian sequential design for binary outcome using an alpha-spending function to control the overall type I error rate. Algorithms are presented for calculating critical values and power for the proposed designs. We also propose a new stopping rule for futility. Sensitivity analysis is implemented for assessing the effects of varying the parameters of the prior distribution and maximum total sample size on critical values. Alpha-spending functions are compared using power and actual sample size through simulations. Further simulations show that, when total sample size is fixed, the proposed design has greater power than the traditional Bayesian sequential design, which sets equal stopping bounds at all interim analyses. We also find that the proposed design with the new stopping for futility rule results in greater power and can stop earlier with a smaller actual sample size, compared with the traditional stopping rule for futility when all other conditions are held constant. Finally, we apply the proposed method to a real data set and compare the results with traditional designs.

Background We evaluated the effectiveness of implementing a proficiency-driven, simulation-based knot tying and suturing curriculum for medical students during their 3rd-year surgery clerkship. Methods Medical students on the 3rd-year surgical clerkship completed a proficiency-driven, simulation-based knot tying and suturing curriculum consisting of 6 tasks. The effectiveness was evaluated by comparing the initial presession scores to the final postsession scores on an 8-item self-efficacy scale and evaluating pass rates on end of clerkship skills testing. A paired t test was used to analyze data. Results Sixty-five students had matched preintervention and postintervention questionnaires for analysis. Pass rates approached 100% by the 3rd attempt on all tasks. Significant gains on all 8 items of the self-efficacy questionnaire from pretraining to post-training were noted. Timing of the general surgery rotation did not impact results. Conclusions Implementation of a simulation-based training, proficiency-driven knot tying and suturing curriculum for 3rd-year medical students during the surgery clerkship is feasible and effective in improving student self-efficacy and objective proficiency toward performance of the tasks taught.

Background The aim of this study was to assess one-year implant survival after lateral window sinus augmentation using PRGF combined with various bone grafting materials. Material and Methods This was a retrospective chart review and radiographic analysis of patients that had undergone lateral window sinus augmentation with PRGF and had dental implants placed at least 6 months post augmentation. All implants included were followed up for at least one year after placement. Demographic, sinus and implant related characteristics (residual ridge height, sinus membrane perforation, type of graft material, implant length and width and ISQ at placement) were analyzed. Results A total of 31 patients with 39 sinus augmentations and 48 implants were included. The mean follow up was 22.8 ± 9.9 months. Implant survival was 95.8%, with 2 implants overall failing. Among all the variables assessed, the only one found to be associated with an increased risk for implant failure was the use of xenograft as bone grafting material in the sinus. Conclusions Within the limitations of this study, dental implants placed in maxillary sinuses grafted with PRGF in combination with bone grafting materials, exhibit high implant survival rates after at least one year follow up. Key words:PRGF, sinus graft, growth factors, implant survival, platelet concentrates.

Introduction Quitting smoking has been proven to benefit smokers with diabetes. However, among older patients with diabetes, the evidence regarding an association between smoking status and the risk of type 2 diabetes mellitus-related emergency department (ED) visits has not been well investigated. Methods A retrospective cohort study was performed by using the Louisiana State University Health Care Services Division electronic health records from 2009 to 2011. Patients aged 65 years or older with type 2 diabetes and smoking status recorded at least twice in 2010 were selected. Selected patients with diabetes were classified into nonsmokers, former smokers, continuing smokers, and relapsed smokers. Cox proportional hazards regression models were used to estimate the adjusted hazard ratio (aHR) of 1-year type 2 diabetes-related ED visits for each group compared with nonsmokers. Results There were 174 (8.2%) continuing smokers and 77 (3.6%) relapsed smokers in 2,114 patients with diabetes who were studied. Rates of type 2 diabetes-related ED visits were highest in relapsed smokers (28.6%). Compared with nonsmokers, relapsed smokers had a significantly higher risk of type 2 diabetes-related ED visits (aHR = 1.62; 95% confidence interval [CI], 1.04-2.50). After stratifying by sex, a significantly increased risk of type 2 diabetes-related ED visits was shown only in male relapsed smokers (aHR = 2.05; 95% CI, 1.13-3.71) and female continuing smokers (aHR = 1.65; 95% CI, 1.10-2.47) compared with nonsmokers. Conclusion Older men with diabetes who were relapsed smokers had a higher risk of type 2 diabetes-related ED visits. Future research and clinical practice should focus on these patients and create more effective interventions for smoking cessation and diabetes management.

PURPOSE: To examine (1) the trend and associated factors of Oncotype DX (ODX) use among hormone receptor-positive (HR+) breast cancer (BC) patients in 2004–2015; (2) the trend of reported chemotherapy by Recurrence Score (RS); and (3) the survival differences associated with ODX use. METHODS: ODX data from Genomic Health Inc. were linked with 17 SEER registries data. HR + BC cases with lymph node negative (N0) or 1–3 positive LNs (N1) from 2004–2015 were analyzed. The Cochrane-Armitage trend test, logistic regression, Kaplan–Meier survival curve, and stratified Cox model were performed. Survival analysis was restricted to HR+/HER2− patients from 2010 to 2014, matched on propensity score. RESULTS: ODX use increased substantially from 2004 to 2015 (N0: 2.0% to 42.7%; N1: 0.3% to 27.9%). Non-Hispanic black and Medicaid insured patients had lower odds of receiving ODX. N0 patients with moderately differentiated or 2.1–5.0 cm tumor and N1 patients with well-differentiated or < 2.0 cm tumor had higher odds of using ODX. The reported chemotherapy use decreased significantly with low and intermediate RS, and increased for high RS among N0 patients. ODX use was associated with better breast cancer-specific survival [hazard ratio (95% CI) N0 1.96 (1.60–2.41), N1 1.90 (1.42–2.54)] and overall survival [N0 2.06 (1.83–2.31), N1 1.72 (1.42–2.09)], especially in the first 36 months. CONCLUSION: ODX use has increased significantly since 2004, nonetheless disparities remain, especially for racial/ethnic minorities and Medicaid insured patients. Administering chemotherapy based on ODX results has been improved among N0 patients. Patients receiving ODX had better survival than those not.

Summary Aim This study sought to determine whether a clinically acceptable shear bond strength (SBS) of metal orthodontic brackets is achievable to CAD/CAM (Computer-Aided Design/Manufacturing) lithium silicate infused with zirconia and whether a chemical pre-treatment bonding protocol produced a higher shear bond strength. Materials and methods Twenty lithium silicate infused with zirconia (CELTRA® DUO) samples, twenty zirconia samples, and twenty lithium disilicate samples were fabricated to replicate the facial surface of a mandibular left first molar. The samples were split into two test groups, one of which received a chemical pre-treatment protocol (hydrofluoric acid etch). Shear bond strength testing was conducted and the mean, maximum, minimal, and standard deviation SBS values for each were calculated and recorded in MPa. An Adhesive Resin Index (ARI) score was also assigned to each sample to assess the mode of bond failure. Results SBS of the lithium silicate infused with zirconia groups were significantly less than the chemically pre-treated lithium disilicate group, however both materials, when chemical pre-treatment protocol was used, were not statistically different than the enamel control. Conclusions Orthodontic bonding to lithium silicate infused with zirconia yielded a weaker shear bond strength than bonding to traditional lithium disilicate, however, when the surface was pre-treated with hydrofluoric acid etch it provides a bond strength that is within an acceptable clinical range.

Background The aim of this study was to identify any associations between predictor variables, mainly clinician training and dental implant outcome, among the residents in different departments and to compare statistical analysis with the use of MATLAB R2017a™ to SAS version 9.4. Methods Dental records were reviewed from January 1, 2011, to December 31, 2015. Two thousand forty-eight dental implants were placed on 471 patients seen by residents from the departments of Periodontics, Prosthodontics, and Oral and Maxillofacial Surgery (OMFS) at Louisiana State University Health Sciences Center School of Dentistry. The following parameters were investigated by means of multilevel logistic regression analysis: demographics, implant parameters, department, and residents’ year of training. Results A total of 1449 implants were included in the study. Overall, within a 1–5-year time period, 1343 (92.6%) implants had survived and 106 (7.4%) implants failed. Discipline (p = 0.0004), residents’ year of training (p

BACKGROUND Facial cellulitis of odontogenic origin (FCOO) can lead to systemic complications in children. Research on factors leading to improvement of outcomes is limited. AIM The aim of this study was to investigate patient characteristics, treatment modalities (antibiotics and route of administration), length of stay in the hospital, time till definitive treatment, and factors related to early treatment of FCOO. DESIGN A retrospective review was performed to identify children presenting to the emergency department of a paediatric hospital with FCOO over a 5-year period. Data were extracted from records of included patients. RESULTS Sixty-four records were included for analysis with mean age of 8.19 ± 4.5 years. Significantly more patients received clindamycin (79.7%) than penicillin-based antibiotic (18.8%) with P

Objective: The objective of this study was to formulate experimental orthodontic bracket adhesives and test their mechanical properties, fluoride release and antibacterial activity. Methods: Four experimental antibacterial orthodontic bracket adhesives were prepared with different compositions of synthesized antibacterial monomers replacing total 5% of dental monomers in the control Transbond XT (3M): 5%C11, 3.5%C11+1.5%C2, 5%C16, and 3.5%C16+1.5%C2. Transbond XT alone was used as control. These groups were used to bond premolar brackets to extracted premolars. Shear bond strength (SBS) was tested using an Instron machine. For antibacterial test, disk specimens (10mm diameter, 1mm thick, n=4) were fabricated and incubated with cultures of cariogenic Streptococcus mutans for 48h, and following gentle sonication, S. mutans biofilms in colony-forming-units (CFU) on the disks were enumerated by plating on agar medium. The data were analyzed using ANOVA and Tukey test (α=0.05). Results: All experimental groups had similar shear bond strength (no significant difference) to the control. All experimental groups showed significant inhibitory effect against S. mutans biofilm formation, when compared to the control, but there was no significant difference between experimental groups. Conclusion: Antibacterial orthodontic adhesive can be fabricated to have similar mechanical properties but better caries-inhibitory effect than current adhesive. RESUMO Objetivo: o objetivo do presente estudo foi formular, experimentalmente, adesivos para colagem de braquetes ortodônticos e testar as suas propriedades mecânicas, sua liberação de flúor e sua atividade antibacteriana. Métodos: quatro adesivos ortodônticos antibacterianos foram preparados experimentalmente usando monômeros sintéticos antibacterianos com diferentes composições, substituindo-se 5% do monômero do grupo controle (Transbond XT, 3M) por: 5%C11; 3,5%C11 + 1,5%C2; 5%C16; ou 3,5%C16 + 1,5%C2. O Transbond XT original foi utilizado como controle. Esses diferentes adesivos foram usados para colar braquetes de pré-molares em pré-molares extraídos. A resistência da colagem ao cisalhamento (RCC) foi testada utilizando-se uma máquina Instron. Para os testes antibacterianos, amostras em formato de disco (10 mm de diâmetro, 1 mm de espessura, n = 4) foram fabricadas e incubadas por 48 horas com culturas cariogênicas de Streptococcus mutans. Após leve sonicação, os discos contendo os biofilmes de S. mutans em unidades formadoras de colônia (UFC) foram colocados em placas com meio de cultura ágar e numerados. Os dados foram analisados utilizando-se ANOVA e teste de Tukey (α?#8197;= 0,05). Resultados: todos os grupos experimentais apresentaram RCC semelhante (sem diferença significativa) ao grupo controle. Todos os grupos experimentais apresentaram significativo efeito inibitório contra a formação do biofilme de S. mutans, em comparação ao grupo controle, porém sem diferença significativa entre os grupos experimentais. Conclusão: adesivos ortodônticos antibacterianos podem ser produzidos para alcançar propriedades mecânicas semelhantes às dos adesivos atuais, porém com melhores efeitos inibitórios de cáries.

Summary Objective The aim of this study was to determine if there are differences between the shear bond strengths of 3 types of ceramic brackets when bonded to different ceramic substrates using an aluminium oxide air abrasion etchant protocol. Materials and methods Substrate groups consisting of thirty-six lithium disilicate (e.max® CAD) samples and thirty-six lithium silicate infused with zirconia (CELTRA® DUO) samples were fabricated to replicate the facial surface of a left maxillary central incisor. The surface of all samples was prepared with an aluminium oxide air abrasion etchant protocol. Each substrate group was split into three test groups (n = 12). Each test group was bonded using a different brand of ceramic orthodontic bracket. Shear bond strength (SBS) testing was conducted and the mean SBS values for each group were calculated and recorded in MPa. An Adhesive Resin Index (ARI) score was also assigned to each sample to assess the location of bond failure. Results Mean SBS of the e.max® CAD groups were significantly less than the CELTRA® DUO groups. Symetri brackets showed significantly higher shear bond strengths to both substrates than both of the other brackets tested. ARI scores of the e.max® CAD groups were significantly less than the CELTRA® DUO groups. Conclusion The Symetri bracket was the only bracket that was effective for both substrates (mean SBS > 6 mPa). The Etch Master protocol does not appear effective for e.max® CAD.

Triple Negative Breast Cancer (TNBC) is an aggressive, heterogeneous subtype of breast cancer, which is more frequently diagnosed in African American (AA) women than in European American (EA) women. The purpose of this study is to investigate the role of social determinants in racial disparities in TNBC. Data on Louisiana TNBC patients diagnosed in 2010–2012 were collected and geocoded to census tract of residence at diagnosis by the Louisiana Tumor Registry. Using multilevel statistical models, we analyzed the role of neighborhood concentrated disadvantage index (CDI), a robust measure of physical and social environment, in racial disparities in TNBC incidence, stage at diagnosis, and stage-specific survival for the study population. Controlling for age, we found that AA women had a 2.21 times the incidence of TNBC incidence compared to EA women. Interestingly, the incidence of TNBC was independent of neighborhood CDI and adjusting for neighborhood environment did not impact the observed racial disparity. AA women were more likely to be diagnosed at later stages and CDI was associated with more advanced stages of TNBC at diagnosis. CDI was also significantly associated with poorer stage-specific survival. Overall, our results suggest that neighborhood disadvantage contributes to racial disparities in stage at diagnosis and survival among TNBC patients, but not to disparities in incidence of the disease. Further research is needed to determine the mechanisms through which social determinants affect the promotion and progression of this disease and guide efforts to improve overall survival.

Background and objectives: Smoking is associated with a lower health-related quality of life (HRQOL). However, there is little information about the association between HRQOL in relation to race, income, and smoking status. The present study aimed to assess the association between HRQOL and smoking status for those of different races and income levels. Materials and Methods: This study applied a cross-sectional design using data from the 2017 patient survey of the Louisiana Tobacco Control Initiative. We obtained 1108 responses from patients at eight Louisiana public hospitals. The EuroQol (EQ-5D) US index score assessed HRQOL. Smoking status was classified into four groups: never smoked, former smoker, current smoker with a quit attempt, and current smoker without a quit attempt. Multivariate linear regression analyses were used to estimate the HRQOL for black or African Americans and whites. Results: The patients were predominantly black or African American (58.9%) with lower-income (71.2%). Bivariate analyses showed that there were differences in income levels between black or African Americans and whites (p = 0.006). Moreover, black or African Americans (median = 0.80) had a higher mean of HRQOL than whites (median = 0.76). Among lower-income black or African Americans, current smokers with a quit attempt had a lower HRQOL than current smokers (coefficient = &minus, 0.12, p &lt, 0.01). Conclusions: Racial and income disparities were evident with regards to HRQOL, with lower-income black or African Americans who were current smokers with a quit attempt having a lower HRQOL. Intervention programs for smoking cessation should target lower-income black or African American smokers who have a prior quit attempt and provide effective cessation services to help them quit smoking and improve their HRQOL.

Introduction: Tobacco use, which is directly responsible for 10% of total deaths per year globally, remains consistently high, with approximately 20% of the population reporting regular consumption globally. Moreover, health disparities regarding tobacco consumption and smoking cessation are growing between rural and urban populations worldwide. Social media interventions for tobacco cessation may effectively reach both groups. The objective of this study was to evaluate the efficacy of a WeChat-delivered smoking cessation intervention among rural and urban Chinese smokers, and to assess moderating variables that may contribute to differential intervention efficacy. Methods: WeChat was used to recruit smokers into this intervention study between 1 July and 5 August 2019. Participants were randomized to one of three intervention schedules: participants in the Standard Group and the Enhanced Group received 20 smoking-related messages over 2 weeks, whereas participants in the Enhanced Group received an extra 6 oral health-related messages for one week. Participants in the control group received 20 smoking-related messages after the post-intervention assessment. Participants completed questionnaires at baseline and at 4 weeks follow-up. Our primary outcome was smoking cessation stage of change and secondary outcome was 24-h point prevalence abstinence (PPA). Urban and rural areas were based on self-reported living areas. Chi-squared test, Fisher’s exact test, ANOVA test, linear regression, and logistic regression were used for analysis. Results: Overall, 403 participants completed the intervention (233 rural, 107 suburban, 63 urban). Compared to urban participants, rural participants were more likely to have progressed to a later stage of change (β = 0.40, 95% CI: 0.13, 0.67) and to report higher 24-h PPA rates at follow-up (aOR = 3.23, 95% CI: 1.36, 7.68). After stratification by living area, the intervention effects in stage of change and 24-h PPA rate at follow-up were only found in the urban subgroup. Discussion: Smokers who lived in rural areas reported better smoking cessation outcomes compared with urban smokers, however, the efficacy of a WeChat-based smoking cessation intervention was only found for participants living in an urban area. WeChat based smoking cessation interventions should be used to promote smoking cessation in urban, suburban, and rural areas.

Study Objective The adolescent pregnancy rate in Louisiana (LA) and Mississippi (MS) is one of the highest in the United States. One approach to decrease that rate is to increase contraceptive use. We sought to characterize LA and MS family physicians' (FPs) contraception counseling for adolescents with a focus on the intrauterine contraceptive device (IUD). Design, Setting, Participants, Interventions, and Main Outcome Measures Online survey of resident and practicing physician members of the LA and MS Academy of FPs. Results Three hundred ninety-eight of 1616 invited FPs responded; 244 were included in our analysis. When counseling adolescents about contraception, respondents “frequently discussed” oral contraceptives and condoms 87.5% (210/240) and 83.8% (202/241) of the time, respectively. Newer and more highly effective contraceptives such as the ring, patch, IUD, and implant were “frequently discussed” only 34.6% (82/237)-39.3% (92/234) of the time. In the previous 6 months, 56% (136/243) of respondents ever discussed an IUD with an adolescent. Respondents were more likely to have discussed IUDs if they learned IUD insertion during residency, had on-site access to IUD inserters, believed they were competent and/or comfortable with IUD counseling. In 5 clinical scenarios asking whether the respondent would recommend an IUD to a 17- or a 27-year-old patient (in all scenarios patients were eligible for an IUD), respondents were restrictive overall and significantly fewer would recommend an IUD for the adolescent. Conclusion Our results suggest that there are missed opportunities for full-scope contraception counseling by LA and MS FPs. When these FPs counsel adolescents about contraception they less frequently discuss newer methods and more highly effective methods. Additionally many LA and MS FPs use overly restrictive eligibility criteria when considering IUDs.

High-fidelity simulation-based training is used increasingly for prelicensure student teams. Such sessions rely on faculty who are able to provide quality prebriefing and debriefing to foster learning among participants. We investigated how well faculty conducted prebriefing and debriefing as part of high-fidelity simulation-based training for interprofessional education.Two trained observers independently rated 38 video-recorded sessions of combinations of 4 faculty conducting prebriefings and debriefings of prelicensure student teams after high-fidelity simulation-based training. Assessment was undertaken using the Objective Structured Assessment of Debriefing, an 8-item tool using a 5-point Likert scale (1 as minimum and 5 as maximum). Mean scores for each item were calculated. Inter-rater agreement was determined using Cohen's kappa. A one-way between-subjects analysis of variance with post-hoc Tukey's studentized range procedure was conducted to compare the effect of team facilitator grouping on the quality of team performance of each Objective Structured Assessment of Debriefing element during a prebriefing or a debriefing. Trend analyses of teams with 4 or more observations were performed using Kendall's Tau coefficient test and linear regression analyses to identify whether teams showed improvement through time. Statistical significance was set at P.05.A total of 7 combinations of faculty conducted between 1 to 14 prebriefings or debriefings. In general, faculty combinations performed better during debriefings compared with prebriefings, with only 1 team having 1 mean item score3.50. Statistically significant differences between faculty combinations in mean item scores was more pronounced during the prebriefings (2 of 3 Objective Structured Assessment of Debriefing items rated) than during debriefings (1 of 8 Objective Structured Assessment of Debriefing items rated). Effect sizes were strong for all differences. Linear regression analysis revealed a statistically significant change through time for the 3 rated prebriefing items and for 7 of the 8 rated debriefing items.Interprofessional faculty combinations in this study tended to have good quality prebriefings and debriefings. The quality of the prebriefings and debriefings can, however, be influenced by the composition of the facilitator teams, most prominently for prebriefings, and team performance does appear to change through time, especially during the debriefing. Future work will focus on whether the quality of prebriefings and debriefings influences learning by trainees.

There is increasing interest in Bayesian group sequential design because of its potential to improve efficiency in clinical trials, to shorten drug development time, and to enhance statistical inference precision without undermining the clinical trial’s integrity or validity. We propose a Bayesian sequential design for clinical trials with time-to-event outcomes and use alpha spending functions to control the overall Type I error rate. Bayes factor is adapted for decision-making at interim analyses. Algorithms are presented to make decision rules and to calculate power of the proposed tests. Sensitivity analysis is implemented to evaluate the impact of different choices of prior parameters on choosing critical values. The power of tests, the expected event size of the proposed design, and the quality of estimators are studied through simulations, and compared with the frequentist group sequential design. Simulations show that at fixed total number of events, the proposed design can achieve greater power and require smaller expected event size when appropriate priors are chosen, compared with the frequentist group sequential design. The feasibility of the proposed design is further illustrated on a real dataset. Supplementary materials for this article are available online.

Background: The dentist has a responsibility to provide nutritional counseling and fluoride consumption recommendations. The purpose of this study was to measure and compare the concentrations of fluoride in a large number of alternative milk beverages and bovine milk. Study design: Thirty-three milk alternatives, including 9 diverse types and 11 different brands, were analyzed using a fluoride ion-selective electrode (ISE) and an ISE meter. Fluoride concentrations were then compared among different types and between different brands. Results: Fluoride concentration ranged from 0.01 ppm (Malk® Pure Cashew Milk) to 0.80 ppm (Almond Breeze® Original Unsweetened Almond Milk) with a mean concentration of 0.32 ppm. When compared, bovine whole milk (0.03±0.00 ppm) was found to be significantly lower in fluoride than all samples analyzed except Malk Pure Cashew Milk, Soy Milk Vanilla, Rice Milk, and Pecan Milk. Major differences also existed between the same milk alternative types of different brands. Conclusion: The amount of fluoride varies among different types of milk alternatives and different brands. To ensure that the dental team can provide proper recommendations regarding fluoride use, manufacturers should consider placing fluoride concentrations on nutrition labels.

High-fidelity simulation (HFS) operating room (OR) inter-professional team training improves healthcare students' team-based attitudes and behaviours. Such improvements can diminish tribalism among the professions in the OR by overcoming entrenched perceptions of team members. We investigated whether simulation-based interprofessional student OR team training impacts students differently based on their professional background. From 2010 to 2013, HFS OR interprofessional student team training sessions were conducted involving senior medical students, senior undergraduate nursing students, and nurse anaesthesia students. The training involved a two-scenario format, each followed by a structured debriefing focusing on team-based competencies. Before and after each session, students completed a 15-item teamwork competencies self-efficacy survey as well as, from 2012-2013, the Readiness for Interprofessional Learning Scale (RIPLS). At the end of each session, they also completed a 6-item rating scale assessing overall team function during the session. Mean scores were calculated for each student professional group, post/pre mean differences were determined, and student t-test and ANOVA analyses were employed to compare within and between-group differences, respectively. Response rates were over 80% for each scale used. Medical students and undergraduate nursing students had significant improvements in team-based attitudes post- to pre-session. Medical students and nurse anaesthesia students had significant improvements in RIPLS scores. Statistically significant improvements from post- to pre-session were seen overall for both team-based attitudes (effect size = 0.83) and RIPLS (effect size = 0.37). The difference between the team-based scores between professions was significant; RIPLS differences were not. No significant difference existed between professions related to overall teamwork scores. HFS OR team training of healthcare students has beneficial but variable benefits for each professional group.

Purpose: Over the past three decades, Hepatocellular Carcinoma (HCC) is one of few cancers for which incidence has increased in the United States (US). It is likely social determinants at the population level are driving this increase. We designed a population-based study to explore whether social determinants at the neighborhood level are geographically associated with HCC incidence in Louisiana by examining the association of HCC incidence with neighborhood concentrated disadvantage. Methods: Primary HCC cases diagnosed from 2008 to 2012 identified from the Louisiana Tumor Registry were geocoded to census tract of residence at the time of diagnosis. Neighborhood concentrated disadvantage index (CDI) for each census tract was calculated according to the PhenX Toolkit data protocol based on population and socioeconomic measures from the US Census. The incidence of HCC was modeled using multilevel binomial regression with individuals nested within neighborhoods. Results: The study included 1,418 HCC cases. Incidence of HCC was greater among males than females and among black than white. In multilevel models controlling for age, race, and sex, neighborhood CDI was positively associated with the incidence of HCC. A one standard deviation increase in CDI was associated with a 22% increase in HCC risk [Risk Ratio (RR) = 1.22; 95% CI (1.15, 1.31)]. Adjusting for contextual effects of an individual's neighborhood reduced the disparity in HCC incidence. Conclusion: Neighborhood concentrated disadvantage, a robust measure of an adverse social environment, was found to be a geographically associated with HCC incidence. Differential exposure to neighborhoods characterized by concentrated disadvantage partially explained the racial disparity in HCC for Louisiana. Our results suggest that increasing rates of HCC, and existing racial disparities for the disease, are partially explained by measures of an adverse social environment.

PURPOSE/OBJECTIVES In addition to an established peer mentoring programme, the Louisiana State University Health Sciences Center, School of Dentistry introduced a faculty-student mentoring programme, the first-year dental student (D1)-Faculty Guide Program, in 2013. The intent of the D1-Guide Program was to provide faculty mentorship for D1 students. The purpose of this study was to evaluate the outcomes of the programme and identify areas for improvement. METHODS Faculty members, D2 and D3 students were surveyed regarding their experiences and perceptions of the D1-Guide Program with a seven question and 12 question survey, respectively, via Survey Monkey® and data were analysed. RESULTS The response rate for the students and faculty was 61% and 64%, respectively. The majority of faculty (92%) felt comfortable serving as a guide to the D1 students with 79% of those surveyed having served as a guide for 3 or 4 years. The majority of students (81%) felt that the D1-Guide Program provided mentoring that was not redundant to existing peer mentoring and valuable to their acclimation to dental school. CONCLUSIONS Despite adding additional duties for faculty and students, the D1-Guide Program was considered valuable during the student's first year of dental school with encouragement to continue the programme. The programme helped establish a student-faculty rapport beyond the boundaries of the classroom.

We propose in this article a Bayesian sequential design using alpha spending functions to control the overall type I error in phase III clinical trials. We provide algorithms to calculate critical values, power, and sample sizes for the proposed design. Sensitivity analysis is implemented to check the effects from different prior distributions, and conservative priors are recommended. We compare the power and actual sample sizes of the proposed Bayesian sequential design with different alpha spending functions through simulations. We also compare the power of the proposed method with frequentist sequential design using the same alpha spending function. Simulations show that, at the same sample size, the proposed method provides larger power than the corresponding frequentist sequential design. It also has larger power than traditional Bayesian sequential design which sets equal critical values for all interim analyses. When compared with other alpha spending functions, O’Brien-Fleming alpha spending function has the largest power and is the most conservative in terms that at the same sample size, the null hypothesis is the least likely to be rejected at early stage of clinical trials. And finally, we show that adding a step of stop for futility in the Bayesian sequential design can reduce the overall type I error and reduce the actual sample sizes.

PURPOSE: To investigate the impact of chemotherapy relative dose intensity (RDI) on cause-specific and overall survival for stage I–III breast cancer: estrogen receptor or progesterone receptor positive, human epidermal-growth factor receptor negative (ER+/PR+ and HER2−) vs. triple-negative (TNBC) and to identify the optimal RDI cut-off points in these two patient populations. METHODS: Data were collected by the Louisiana Tumor Registry for two CDC-funded projects. Women diagnosed with stage I–III ER+/PR+, HER2− breast cancer, or TNBC in 2011 with complete information on RDI were included. Five RDI cut-off points (95, 90, 85, 80, and 75%) were evaluated on cause-specific and overall survival, adjusting for multiple demographic variables, tumor characteristics, comorbidity, use of granulocyte-growth factor/cytokines, chemotherapy delay, chemotherapy regimens, and use of hormone therapy. Cox proportional hazards models and Kaplan–Meier survival curves were estimated and adjusted by stabilized inverse probability treatment weighting (IPTW) of propensity score. RESULTS: Of 494 ER+/PR+, HER2− patients and 180 TNBC patients, RDI < 85% accounted for 30.4 and 27.8%, respectively. Among ER+/PR+, HER2− patients, 85% was the only cut-off point at which the low RDI was significantly associated with worse overall survival (HR = 1.93; 95% CI 1.09–3.40). Among TNBC patients, 75% was the cut-off point at which the high RDI was associated with better cause-specific (HR = 2.64; 95% CI 1.09, 6.38) and overall survival (HR = 2.39; 95% CI 1.04–5.51). CONCLUSIONS: Higher RDI of chemotherapy is associated with better survival for ER+/PR+, HER2− patients and TNBC patients. To optimize survival benefits, RDI should be maintained ≥ 85% in ER+/PR+, HER2− patients, and ≥ 75% in TNBC patients.

Research shows aconsistent racial disparity in obesity between white and black adults in the United States. Accounting for the disparity is a challenge given the variety of the contributing factors, the nature of the association, and the multilevel relationships among the factors. We used the multivariable mediation analysis (MMA) method to explore the racial disparity in obesity considering not only the individual behavior but also geospatially derived environmental risk factors. Results from generalized linear models (GLM) were compared with those from multiple additive regression trees (MART) which allow for hierarchical data structure, and fitting of nonlinear and complex interactive relationships. As results, both individual and geographically defined factors contributed to the racial disparity in obesity. MART performed better than GLM models in that MART explained a larger proportion of the racial disparity in obesity. However, there remained disparities that cannot be explained by factors collected in this study.

ObjectiveIn surgery, dysfunctional teamwork is perpetuated by a ‘silo’ mentality modelled by students. Interprofessional education using high-fidelity simulation-based training (SBT) may counteract such modelling. We sought to determine whether SBT of interprofessional student teams (1) changes long-term teamwork attitudes and (2) is an effective form of team training.DesignA quasiexperimental, pre/postintervention comparison design was employed at an academic health sciences institution. High-fidelity simulation-based training of 42 interprofessional teams of third year surgery clerkship medical students and senior undergraduate nursing students was undertaken using a two-scenario format with immediate after action debriefing. Pre/postintervention TeamSTEPPS Teamwork Attitudes questionnaires (5 subscales, 30 items, Likert type) were given to the medical student and undergraduate nursing student classes. Pre/postsession Readiness for Inter-Professional Learning (RIPL; 19 items, Likert type) surveys and postscenario participant-rated and observer-rated Teamwork Assessment Scales (3 subscales, 11 items, Likert type) were given during each training session. Mean TeamSTEPPS Teamwork Attitudes Questionnaire, RIPL and Teamwork Assessment Scales scores were calculated; matched pre/postscore differences and trained versus non-trained TeamSTEPPS Teamwork Attitudes Questionnaire scores were compared using paired t-test or analysis of variance.ResultsBoth student groups had 10 significantly improved RIPL items as well as TeamSTEPPS Teamwork Attitudes Questionnaire (TTAQ) mutual support subscales. Medical students had a significantly improved TTAQ team structure subscale. Over a simulation-based training session, each observer-rated Teamwork Assessment Scales subscale and two self-rated Teamwork Assessment Scales subscales significantly improved. Trained students had significantly higher TTAQ team structure subscales than non-trained students.ConclusionsInterprofessional education using high-fidelity simulation-based training of students is effective at teaching teamwork, changing interprofessional attitudes and improving long-term teamwork attitudes.

Persistent postconcussion syndrome (PPCS) after mild traumatic brain injury (mTBI) is a significant public health and military problem for which there is limited treatment evidence. The aim of this study was to determine whether forty 150 kPa hyperbaric oxygen therapies (HBOTs) can improve symptoms and cognitive function in subjects with the PPCS of mTBI, using a randomized controlled crossover design with 2-month follow-up. Sixty-three civilian and military subjects with mTBI/PPCS were randomized to either 40 HBOTs at 150 kPa/60 minutes, once daily, 5 days per week in 8 weeks or an equivalent no-treatment control period. The Control Group was then crossed over to HBOT. Subjects underwent symptom, neuropsychological, and psychological testing, before and after treatment or control with retesting 2 months after the 40th HBOT. Fifty subjects completed the protocol with primary outcome testing. HBOT subjects experienced significant improvements in Neurobehavioral Symptom Inventory, Memory Index, Automated Neuropsychological Assessment Metrics, Hamilton Depression Scale, Hamilton Anxiety Scale, Post-Traumatic Stress Disorder Checklist, Pittsburgh Sleep Quality Index, and Quality Of Life after Brain Injury compared to the Control Group. After crossing over to HBOT the Control Group experienced near-identical significant improvements. Further improvements were experienced by both groups during the 2-month follow-up period. These data indicate that 40 HBOTs at 150 kPa/60 minutes demonstrated statistically significant improvements in postconcussion and Post-Traumatic Stress Disorder symptoms, memory, cognitive functions, depression, anxiety, sleep, and quality of life in civilian and military subjects with mTBI/PPCS compared to controls. Improvements persisted at least 2 months after the 40th HBOT. The study was registered on ClinicalTrials.gov (NCT02089594) on March 18, 2014 and with the U.S. Food and Drug Administration under Investigational New Drug #113823. The Institutional Review Boards of the United States Army Medical Research and Materiel Command Office of Research Protections Human Research Protection Office and the Louisiana State University School of Medicine (approval No. 7381) approved the study on May 13, 2014 and December 20, 2013, respectively.

Background Adherence to self-management recommendations is critical for patients with chronic disease. Compared to nonsmokers, smokers with conditions such as diabetes, HIV, and heart disease are less likely to adhere to provider recommendations. Regarding lung disease, asthma and COPD can be caused and/or exacerbated by smoking, however little is known on the relationship between adherence and smoking status in these patients. The purpose of this study was to characterize the relationship between smoking status and adherence to multiple measures of self-care- including medication taking, medication filling, appointment keeping, yearly vaccinations, carrying medical supplies, and healthcare utilization- in patients with asthma and/or COPD. In addition to smoking status, we also included an examination of these measures by race/ethnicity, gender, and diagnosis. Methods This study employed a cross-sectional design on a convenience sample of n = 84 patients (40–64 years old) with a diagnosis of asthma and/or COPD. The study was conducted between November 2015 and February 2016 in the waiting rooms of the outpatient pulmonary clinics at the University Medical Center of New Orleans. Patients completed surveys while awaiting their clinic appointments. Smoking status, gender, race, and diagnosis were explored as predictors of adherence using descriptive statistics, chi square, and regression analyses. Results Compared to nonsmokers, smokers were less adherent to medication filling (p

Introduction This study aimed to determine the feasibility of using electronic health record (EHR) data from a federally qualified health center (FQHC) to assess the association between street connectivity, a measure of walkability for the local environment, and BMI obtained from EHRs. Methods The study included patients who visited Daughters of Charity clinics in 2012–2013. A total of 31,297 patients were eligible, of which 28,307 were geocoded. BMI and sociodemographic information were compiled into a de-identified database. The street connectivity measure was intersection density, calculated as the number of three-way or greater intersections per unit area. Multilevel analyses of BMI, measured on 17,946 patients who were aged ≥20 years, not pregnant, had complete sociodemographic information, and a BMI value that was not considered an outlier, were conducted using random intercept models. Results Overall, on average, patients were aged 44.1 years, had a BMI of 30.2, and were mainly non-Hispanic black (59.4%). An inverse association between BMI and intersection density was observed in multilevel models controlling for age, gender, race, and marital status. Tests for multiple interactions were conducted and a significant interaction between race and intersection density indicated the decrease in BMI was strongest for non-Hispanic whites (decreased by 2) compared with blacks or Hispanics (decreased by 0.6) ( p =0.0121). Conclusions EHRs were successfully used to assess the relationship between street connectivity and BMI in a multilevel framework. Increasing street connectivity levels measured as intersection density were inversely associated with directly measured BMI obtained from EHRs, demonstrating the feasibility of the approach.

Purpose Colorectal cancer (CRC) continues to demonstrate racial disparities in incidence and survival in the United States. This study investigates the role of neighborhood concentrated disadvantage in racial disparities in CRC incidence in Louisiana. Methods Louisiana Tumor Registry and U.S. Census data were used to assess the incidence of CRC diagnosed in individuals 35 years and older between 2008 and 2012. Neighborhood concentrated disadvantage index (CDI) was calculated based on the PhenX Toolkit protocol. The incidence of CRC was modeled using multilevel binomial regression with individuals nested within neighborhoods. Results Our study included 10,198 cases of CRC. Adjusting for age and sex, CRC risk was 28% higher for blacks than whites (risk ratio [RR] = 1.28; 95% confidence interval [CI] = 1.22–1.33). One SD increase in CDI was associated with 14% increase in risk for whites (RR = 1.14; 95% CI = 1.10–1.18) and 5% increase for blacks (RR = 1.05; 95% CI = 1.02–1.09). After controlling for differential effects of CDI by race, racial disparities were not observed in disadvantaged areas. Conclusion CRC incidence increased with neighborhood disadvantage and racial disparities diminished with mounting disadvantage. Our results suggest additional dimensions to racial disparities in CRC outside of neighborhood disadvantage that warrants further research.

Mediation refers to the effect transmitted by mediators that intervene in the relationship between an exposure and a response variable. Mediation analysis has been broadly studied in many fields. However, it remains a challenge for researchers to consider complicated associations among variables and to differentiate individual effects from multiple mediators. [1] proposed general definitions of mediation effects that were adaptable to all different types of response (categorical or continuous), exposure, or mediation variables. With these definitions, multiple mediators of different types can be considered simultaneously, and the indirect effects carried by individual mediators can be separated from the total effect. Moreover, the derived mediation analysis can be performed with general predictive models. That is, the relationships among variables can be modeled using not only generalized linear models but also nonparametric models such as the Multiple Additive Regression Trees. Therefore, more complicated variable transformations and interactions can be considered in analyzing the mediation effects. The proposed method is realized by the R package 'mma'. We illustrate in this paper the proposed method and how to use 'mma' to estimate mediation effects and make inferences.