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Objectives The aim of this systematic review is to assess the treatment effects (amount of distalization, distal tipping and vertical movement) of buccally versus palatally placed temporary skeletal anchorage devices (TSADs) on maxillary first molars during distalization. Materials and methods Medline and Scopus databases were searched up to September 2020 for randomized controlled trials (RCTs) and non-randomized prospective cohort studies on maxillary molar distalization using TSADs in patients with Class II malocclusion. After study selection, data extraction and risk of bias assessment, meta-analyses were performed for the amount of distalization, distal tipping and intrusion of first molars. Results Nine studies (2 RCTs and 7 prospective studies) were included. The risk of bias of the RCTs was low to unclear. The non-randomized studies were of moderate quality. In five studies, the TSADs were placed in the infrazygomatic process while in two studies, they were placed in the buccal inter-radicular spaces, and in two studies, they were placed in the midpalatal region. The first molar distalization was 2.75 mm when buccal inter-radicular TSADs were used, but 4.07 and 4.17 mm with palatal and infrazgomatic TSADs. The palatal appliances were associated with 11.17° of distal tipping of the first molar while infrazygomatic and buccal inter-radicular TSADs resulted in 3.99° and 1.70° of tipping, respectively. Conclusions Inter-radicular TSADs resulted in less distal tipping but also in less distalization. Palatal TSAD-supported appliances showed the greatest amount of distal tipping. Further RCTs or prospective studies on the effect of various designs of TSAD-supported distalization are warranted.

Background: Updated rates and patterns associated with patients with dance-related injuries reporting to US emergency departments (EDs) is needed. Hypothesis: Between the years 2014 and 2018, there will be an observed rise of patients with dance-related injuries seen within US EDs. Study Design: Retrospective analysis. Level of Evidence: Level 4. Methods: Utilizing the National Electronic Injury Surveillance System (NEISS) database, data were abstracted for all structured dance-related injuries for all people who presented to a NEISS participating hospital from January 1, 2014, to December 31, 2018. Data were abstracted on age, sex, race, disposition, location on the body where the injury happened, and free text box regarding the mechanism and nature of the injury. Each patient case was associated with a weight to provide national incidence rate (per 100,000) estimates. Descriptive statistics were used to summarize counts, percentages, and rates across patient cases. Results: Between years 2014 and 2018, 4152 patients reported to the NEISS EDs with a dance-related injury. Most injuries occurred in female patients (83.3%; n = 3459) and among those who were 10 to 18 years old (76.2%; n = 3164). The most common injuries were ankle sprain/strain (12.7%; n = 527) and knee sprain/strain (10.4%; n = 431). Almost all patients were treated and released (97.1%; n = 4033). These data yielded population-weighted estimates of 125,618 injuries for the study period, with an increasing trend over time (19.2% increase over 5 years). Incidence rates were over 4 times higher for female (12.4) than for male patients (3.0) and highest in the 10- to 18-year-old age group (incidence rate = 46.4). Conclusion: Patients with dance-related injuries reporting to EDs increased over a 5-year period from 2014 to 2018. The majority of dancers in the study were female patients, between the ages of 10 and 18 years, nearly half of the patients reported to the ED with a sprain/strain, and almost all patients were treated and released. Clinical Relevance: An increase in access to proper injury prevention medical services and education should be provided to female dancers between the ages of 10 and 18 years. Strength of Recommendation Taxonomy: B.

We have noticed an increase in the number of patients who go through the court-ordered evaluation (COE) process but are not placed on a court-ordered treatment, and who then return to the hospital on another COE petition within one year from their initial discharge. The aim of this study is to examine what factors might be involved in rehospitalization in this population of psychiatric patients. The records of 146 readmitted patients and 146 randomized patients not readmitted were compared for various risk factors. Data were analyzed using univariate and mutivariate procedures. All patients who had diagnoses of substance-induced mood or psychotic disorders were readmitted within one year. Other risk factors included younger age, seriously mentally ill (SMI) status, longer length of stay and having a psychotic or schizophrenia spectrum disorder. Substance-induced mood or psychotic disorder may play significant roles for patients who are rehospitalized within a year of initial COE.

Context COVID-19 caused a worldwide pandemic, and there are still many uncertainties about the disease. C-reactive protein (CRP) levels could be utilized as a prognosticator for disease severity in COVID-19 patients. Objectives This study aims to determine whether CRP levels are correlated with COVID-19 patient outcomes and length of stay (LoS). Methods A retrospective cohort study was conducted utilizing data obtained between March and May 2020. Data were collected by abstracting past medical records through electronic medical records at 10 hospitals within CommonSpirit Health. Patients were included if they had a positive COVID-19 test from a nasopharyngeal swab sample, and if they were admitted and then discharged alive or had in-hospital mortality and were ≥18 years. A total of 541 patients had CRP levels measured and were included in this report. Patient outcome and LoS were the endpoints measured. Results The 541 patients had their CRP levels measured, as well as the demographic and clinical data required for analysis. While controlling for body mass index (BMI), number of comorbidities, and age, the first CRP was significantly predictive of mortality (p Conclusions The results indicate that there is a positive correlation between the CRP levels of COVID-19 patients and their respective outcomes with regard to death and LoS.

Background Near point of convergence (NPC), a component of the Vestibular Ocular Motor Screening (VOMS) assessment, may be helpful in diagnosing concussion. The VOMS uses a standardized approach to measure NPC; however, methods of screening for NPC are not standardized. Purpose The purpose of this study was to determine whether four different methods of measuring NPC yielded different estimates. Study Design Descriptive within-subjects laboratory study. Level of Evidence Level 3. Methods Healthy recreational athletes participated in a comparison of 4 commonly used methods of measuring NPC: a 12-point font target, the VOMS (14-point font target), the tip of a black pen, and the Bernell VergelTM device (9-point font target). The order of the presentation of the 4 targets was randomized. Results Seventy-five participants (59 females, 16 males; mean [SD] age=21.0 [6.12] years) completed 3 trials. The mean (SD) of the 900 NPC measurements was 7.11 (3.67) cm. Measurements for all targets had excellent reliability (r=0.94 to 0.98). In a comparative analysis, participant age was associated with NPC (p, The purpose of this study was to determine whether four different methods of measuring near point of convergence yielded different estimates.

BACKGROUND Fear of falling (FOF) is associated with restricted activities, increased risk of falling, and decreased quality of life. A Matter of Balance (AMOB) is an evidence-based programme designed to decrease FOF. The current study investigated the influence of the AMOB on activity avoidance caused by FOF in older adults using the Fear of Falling Avoidance Behavior Questionnaire (FFABQ), health-related quality of life, and a question regarding concerns about falling. METHODS Participants of this quasi-experimental, one-group, pretest-post-test study design were older adults from community sites in the Phoenix, Arizona, metropolitan area. Participants attended the AMOB programme, which consisted of one weekly 2-h session for 8 weeks. At the beginning and end of the programme, participants completed the standard AMOB assessments, the FFABQ, the Centers for Disease Control Core Healthy Days Measure (CDC HRQOL-4), and a question regarding concerns about falling. RESULTS Sixty-three participants completed the study; their mean ± SD age was 75.3 ± 7.1 years (range: 60.0-90.0 years), and 84.1% were women. The FFABQ scores decreased from baseline (24.4 ± 12.7 points) to post-AMOB (20.1 ± 11.9 points; t = 2.62, P = 0.01). No changes in any of the CDC HRQOL-4 questions were noted (CDC HRQOL-4 question (Q)1 (z = -1.41, P = 0.16), CDC HRQOL-4 Q2 and Q3 summary index (z = -1.60, P = 0.11), and CDC HRQOL-4 Q4 (z = -0.97, P = 0.33)). Concerns about falling decreased from baseline (3.4 ± 0.9 points) to post-AMOB (2.8 ± 0.8 points; z = -4.09, P < 0.001). CONCLUSION Avoidance behaviour caused by FOF, as measured by the FFABQ, and concerns about falling decreased in community-dwelling older adults who participated in the AMOB. Findings support the efficacy of the AMOB for reducing both avoidance behaviour caused by FOF and concerns about falling through an approach that combines education and exercise.

Introduction: The androgen receptor (AR) regulates immune-related epithelial-to-mesenchymal transition (EMT), and prostate cancer (PCa) metastasis. Primary tumor-infiltrating lymphocytes (TILs) [CD3+, CD4+, and CD8+ TILs] are potential prognostic indicators in PCa, and variations may contribute to racial disparities in tumor biology and PCa outcomes. Aim: To assess the technical feasibility of tumor microarray (TMA)-based methods to perform multi-marker TIL profiling in primary resected PCa. Methods: Paraffin-embedded tissue cores of histopathologically-confirmed primary PCa (n = 40; 1 TMA tissue specimen loss) were arrayed in triplicate on TMAs. Expression profiles of AR, CD3+, CD4+, and CD8+ TILs in normal prostate, and the center and periphery of both the tumor-dominant nodule and highest Gleason grade were detected by IHC and associated with clinical and pathological data using standard statistical methodology. An independent pathologist, blinded to the clinical data, scored all samples (percent and intensity of positive cells). Results: TMAs were constructed from 21 (53.8%) Black and 18 (46.2%) White males with completely-resected, primarily pT2 stage PCa [pT2a (n = 3; 7.7%); pT2b (n = 2; 5.1%); pT2c (n = 27; 69.2%); pT3a (n = 5; 12.8%); mean pre-op PSA = 8.17 ng/ml]. The CD3, CD4, CD8, and CD8/CD3 cellular protein expression differed from normal in the periphery of the dominant nodule, the center of the highest Gleason grade, and the periphery of the highest Gleason grade (P < 0.05). Correlations between TIL expression in the center and periphery of the dominant nodule, with corresponding center and periphery of the highest Gleason grade, respectively, were robust, and the magnitude of these correlations differed markedly by race (P < 0.05). Conclusions: Multi-marker (AR, CD3, CD4, CD8) profiling with IHC analysis of TMAs consisting of primary, non-metastatic resected prostate cancer is technically feasible in this pilot study. Future studies will evaluate primary tumor immunoscore using semi-quantitative, IHC-based methodology to assess differences in the spectrum, quantity, and/or localization of TILs, and to gain insights into racial disparities in PCa tumor biology and clinical outcomes.

Introduction Growing up with disfigurement and functional limitations resulting from childhood burns can be challenging. Initial stages of care involve painful surgeries/dressing changes, strenuous physical & occupational therapy, pressure garments and time away from family/school activities. Few studies have examined the voiced issues faced by youth while maturing with burns. This study’s purpose was to determine if experiences in the post-injury phase differed between currently burn-injured youth vs. young adults burned as children. Methods A prior study asked Child Burn Survivors (CBS -10–16 yrs.) and Young Adults (YAs -17-25yrs.) to answer the statement: “The hardest thing about being burned is…” The most common issues included: People Staring, Getting Unwanted Questions, Being Bullied, Remembering When I Was Burned, Having Additional Surgeries and My Scars. The current study asked participants to rate items on a 4-point scale from (1) Not at all to (4) Really a lot. The YAs were asked to consider issues they encountered maturing with burns. Results Child Survivors (CBS, n=147) mean age 13.4 years, male (n=46%) female (n=54%), and YA Survivors (YA, n = 81) male(n=39%) female (n=61%) mean age =19.1 yrs. and were predominately racial/ethnic minorities (CBS=67%; YA = 58%). No differences existed for age burned (CBS=6 yrs. vs. YA = 6.4 yrs.) hidden & visible scars (CBS=55% vs. YA=68%) and TBSA > 50% (CBS=19% vs. YA =20%). Top mean scores for CBS’s included: Remembering the Burn (2.05) & Getting Unwanted Questions (2.0). The YA group’s top mean scores included Being Bullied (2.10) & People Staring (2.0). The CBS group reported that Getting Unwanted Questions was more problematic than the YA Group (p =003). YAs shared that Being Bullied was their biggest problem vs. CVS, significantly more so (p=.01). Conclusions Bullying appears to be less of a problem for current child burn survivors than those previously burned. The difference may be due to a recent emphasis placed on anti-bullying in US schools. Findings highlight an ongoing need to address the psycho/social issues related to burns. Teaching interventions like the Phoenix Society’s Rehearse Your Response can help youth address unwanted questions and staring. Providing children an opportunity to process the injury event may also improve their ability to cope with burn stressors.

Introduction The potential consequences of vitamin D insufficiency/deficiency (I/D) in critically ill patients include: increased ICU length of stay, organ dysfunction, infectious complications, and mortality. Burn patients, in particular, may be at increased risk of vitamin D I/D due to bleeding, systemic inflammatory response syndrome, increased utilization of vitamin D by injured tissues, compromised vascular integrity, fluid shifts, and leakage of vitamin D binding protein (VDBP) and albumin. The purpose of this study is to determine the incidence of vitamin D I/D and evaluate the institutional vitamin D dosing regimen. Methods A retrospective chart review was performed on all adult patients from January 1, 2018 through December 31, 2019 who received cholecalciferol and had at least one 25-hydroxy vitamin D level during their hospitalization. Vitamin D level was drawn on admission, then weekly thereafter. Patients found to be I/D were initiated on high dose vitamin D supplementation and then adjusted based on the weekly levels. The therapeutic goal for vitamin D supplementation was set at 50 ng/ml. Results Three hundred and sixteen patients met criteria for review. Of those patients, 293 patients (93%) were vitamin D I/D. The magnitude of vitamin D deficiency was strongly negatively correlated with increasing % total body surface area (TBSA) burn size (p< 0.001). Mean time to reach therapeutic vitamin D levels following initiation of supplementation was 19 days, requiring an average of 116,125 units cholecalciferol weekly. Time to reach therapeutic levels was also positively correlated with increasing burn size (p< 0.05). Many patients, however, were discharged prior to reaching therapeutic levels. Conclusions Vitamin D I/D is present in over 90% of burn center patients and the degree of I/D was profound. Additionally, vitamin D I/D was not easily corrected, taking almost 3 weeks to reach therapeutic levels using an aggressive supplementation regimen. Further studies documenting the consequences of vitamin D I/D and development of evidence-based supplementation dosing regimens are warranted. Applicability of Research to Practice This study documents common and severe vitamin D deficiency in burn patients, and difficulty in correcting this deficiency.

Introduction The use of oxygen is a key component of acute burn resuscitation, particularly when there is concern for carbon monoxide toxicity or inhalation injury. Prior studies of critically-ill patients have shown an association between early hyperoxia and increased mortality. There are no studies to date evaluating outcomes related to excessive oxygen administration in burn patients. Methods We conducted a retrospective analysis of 219 severely burned patients to quantify the average amount of oxygen given during initial resuscitation, the level of carbon monoxide exposure, and to determine if early exposure to supratherapeutic oxygen was associated with increased hospital mortality or ventilator-associated pneumonia (VAP). The models were adjusted for inhalation injury and total body surface area (TBSA) burned. Results Early hyperoxia in severely burn patients is common and possibly associated with increased overall mortality, although the results were inconclusive and after adjusting for burn-specific scoring systems, we found a negative correlation between hyperoxia and mortality. Confirmed carbon monoxide poisoning was relatively uncommon, but also associated with increased mortality. Patients with elevated carboxyhemoglobin did not receive more oxygen compared to others within the cohort. Conclusions Burn patients are exposed to higher concentrations of pure oxygen compared to other critically-ill patients, presumably for empiric treatment of carbon monoxide poisoning. Our data showed a liberal use of oxygen therapy across all patients. Considering the potentially negative effects of hyperoxia, this study exposes either a gap in clinical research or need for clearer indications.

This study retrospectively compared the outcomes of patients who received ultrasound facilitated catheter-directed thrombolysis (UFCDT) versus systemically administered ‘half-dose’ thrombolysis (HDT) in 97 patients with PE. The outcomes assessed included changes in baseline pulmonary artery systolic pressure (PASP), right ventricle/left ventricle ratio (RV/LV), cost and duration of hospitalization, death, bleeding, and recurrent venous thromboembolism in the short and intermediate term follow-up. Analyses were performed using a covariance adjustment propensity score approach to address baseline differences between groups in variables associated with PASP and RV/LV, covarying baseline scores. The baseline mean ± SE PASP dropped from 49.3 ± 1.1 to 32.5 ± 0.3 mmHg at 36 hours in the HDT group, and from 50.6 ± 1.2 to 35.1 ± 0.4 mmHg in the UFCDT group; group × time interaction p-value = 0.007. Corresponding drops in the RV/LV were from a baseline of 1.26 ± 0.05 to 1.07 ± 0.01 in the HDT group and from 1.30 ± 0.05 to 1.14 ± 0.01 in the UFCDT group at 36 hours; group × time interaction p-value = 0.269. Statistically significant decreases were noted in PASP and RV/LV for both the HDT and UFCDT at 36 hours and follow-up. PASP through follow-up was significantly lower in the HDT than the UFCDT group. Likewise, RV/LV was lower in the HDT group. The duration and cost of hospitalization were lower in the HDT group (6.2 ± 1.4 days vs 1.9 ± 0.3 days, p < 0.001; US$12,000 ± $3000 vs $74,000 ± $6000, p < 0.001). We conclude that both UFCDT and HDT lead to rapid reduction of PASP and RV/LV, whereas HDT leads to a lower duration and cost of hospitalization.

Purpose: The purpose of this study was to estimate the prevalence of white spot lesions (WSLs) in various practice settings and patient populations, and to gather information about the treatment timing and modalities used by pediatric dentists in the United States. Study design: A fourteen question, multiple choice, electronic survey was developed and distributed to 6,092 active American Academy of Pediatric Dentistry (AAPD) members. Results: A total of 625 active members responded, garnering a 9.7% response rate. Before treatment, there were significantly more WSLs reported in Corporate practice than Multi-Doctor Practice (P=0.002), and significantly more WSLs in Academics/Hospital-Based Practices than in Multi-Doctor Practices (P=0.002). For WSLs after treatment, there were significantly more WSLs in Academic/Hospital-Based practices than in single-practitioner settings (P=0.003). Approximately 38% of pediatric dentists preferred to treat WSLs before, during or after orthodontic treatment, while 23% treat only before and 20% treat only after treatment. The three most common treatment modalities for WSLs, were prescription fluoride toothpaste (5000 ppm), fluoride varnish, and fluoride rinse. Approximately 47% of respondents reported they were “very comfortable” treating WSLs and 31.0% felt “comfortable.” Conclusions: The prevalence of WSLs differed across types of practice. There is no agreement among pediatric dentist as to timing and treatment modalities for WSLs.

Introduction There is a paucity of research regarding the challenges faced by young adults (YA) who matured with burns. It is well documented that acute burn care is laden with painful surgeries/dressing changes, gruesome physical/occupational therapies, anxiety and time away from family & friends. However, the specific issues young adults burned as children find most challenging remain largely unknown. This study sought to provide YA survivors with an opportunity to describe the difficult issues they endured. Methods Burn surviving youth responded to the open-ended statement “The hardest thing about being burned is…” Seven themes were derived from their responses: People Staring at Me, Being Bullied, Remembering When I was Burned, Having Additional Surgeries, My Scars, Getting Questions About My Burns,& the Pain & Itching, Young adult survivors were asked to rate each item on a 4-point scale from (1) Not at all to (4) Really a lot. Results Participants were YA survivors (n=64) mean age 19.1 years, female (62%) male (38%), average age at burn of 6.4 yrs. Sixty-eight percent reported both visible & hidden scars; 25% had a TBSA > 50%., Sixty-six percent were minority race/ethnicity. More than half of respondents reported issues with My Scars (65%), Remembering the Burn (52%) and Pain & Itching (50%). People Staring and Bullying has been bothersome for over 70%, 72% reported Being Bullied and 71% noted People Staring. The highest 5 means among YA subgroups included: Participants with hand scars- Being Bullied (2.6), those with visible scars - My Scars (2.6). Those reporting both facial & hand scars endorsed People Staring (2.4), youth with a TBSA ≥ 50% - Being Bullied (2.4) and with visible scars - Remembering the Burn – (2.4). Girls were bothered significantly more by My Scars (p=.02). Youth with both facial & hand scars had greater issues with Pain/Itch (p=.03). Conclusions This study provides insight into problems encountered by maturing burn survivors and discloses the more challenging issues they endured. These data can assist burn centers, camps, and psychotherapists in discussing potential survivor issues and suggest interventions to help burn-injured youth respond to challenges. Special consideration should be given to girls, those with facial/hand scars, large TBSAs and visible scarring.

Pulseless electrical activity (PEA) during cardiac arrest portends a poor prognosis. There is a paucity of data in the use of thrombolytic therapy in PEA and cardiopulmonary arrest due to confirmed pulmonary embolism (PE). We evaluated the outcome of low-dose systemic thrombolysis with tissue plasminogen activator (tPA) in patients presenting with PEA due to PE.During a 34-month period, we treated 23 patients with PEA and cardiopulmonary arrest due to confirmed massive PE. All patients received 50 mg of tPA as intravenous push in 1 minute while cardiopulmonary resuscitation was ongoing. The time from initiation of cardiopulmonary resuscitation to administration of tPA was 6.5 ± 2.1 minutes.Return of spontaneous circulation occurred in 2 to 15 minutes after tPA administration in all but 1 patient. There was no minor or major bleeding despite chest compression. Of the 23 patients, 2 died in the hospital, and at 22 ± 3 months of follow-up, 20 patients (87%) were still alive. The right ventricular/left ventricular ratio and pulmonary artery systolic pressure dropped from 1.79 ± 0.27 and 58.10 ± 7.99 mm Hg on admission to 1.16 ± 0.13 and 40.25 ± 4.33 mm Hg within 48 hours, respectively (P.001 for both comparisons). There was no recurrent venous thromboembolism or bleeding during hospitalization or at follow-up.Rapid administration of 50 mg of tPA is safe and effective in restoration of spontaneous circulation in PEA due to massive PE leading to enhanced survival and significant reduction in pulmonary artery pressures.

Introduction There is a paucity of research regarding the challenges faced by young adults (YA) who matured with burns. It is well documented that acute burn care is laden with painful surgeries/dressing changes, gruesome physical/occupational therapies, anxiety and time away from family & friends. However, the specific issues young adults burned as children find most challenging remain largely unknown. This study sought to provide YA survivors with an opportunity to describe the difficult issues they endured. Methods Burn surviving youth responded to the open-ended statement “The hardest thing about being burned is…” Seven themes were derived from their responses: People Staring at Me, Being Bullied, Remembering When I was Burned, Having Additional Surgeries, My Scars, Getting Questions About My Burns,& the Pain & Itching, Young adult survivors were asked to rate each item on a 4-point scale from (1) Not at all to (4) Really a lot. Results Participants were YA survivors (n=64) mean age 19.1 years, female (62%) male (38%), average age at burn of 6.4 yrs. Sixty-eight percent reported both visible & hidden scars; 25% had a TBSA > 50%. Sixty-six percent were minority race/ethnicity. More than half of respondents reported issues with My Scars (65%), Remembering the Burn (52%) and Pain & Itching (50%). People Staring and Bullying has been bothersome for over 70%, 72% reported Being Bullied and 71% noted People Staring. The highest 5 means among YA subgroups included: Participants with hand scars- Being Bullied (2.6), those with visible scars - My Scars (2.6). Those reporting both facial & hand scars endorsed People Staring (2.4), youth with a TBSA ≥ 50% - Being Bullied (2.4) and with visible scars - Remembering the Burn – (2.4). Girls were bothered significantly more by My Scars (p=.02). Youth with both facial & hand scars had greater issues with Pain/Itch (p=.03). Conclusions This study provides insight into problems encountered by maturing burn survivors and discloses the more challenging issues they endured. These data can assist burn centers, camps, and psychotherapists in discussing potential survivor issues and suggest interventions to help burn-injured youth respond to challenges. Special consideration should be given to girls, those with facial/hand scars, large TBSAs and visible scarring. Applicability of Research to Practice This research can help burn care professionals better understand the major difficulties burn-injured youth experience. Supportive strategies should be developed to augment surgical/medical treatment with constructive psycho/social interventions. Providing survivors with constructive coping strategies can help to improve their social interactions and quality of life.

Background Oculomotor function is impaired when an individual has a concussion and as such, it is important to identify tests that are able to assess oculomotor impairment. The King-Devick (K-D) test assesses horizontal saccadic eye movement and attention. The Developmental Eye Movement (DEM) test is designed to identify oculomotor dysfunction in children. It measures both horizontal and vertical saccades. The K-D test shows promise as a concussion-screening tool and part of a multifactorial assessment. The DEM has not been tested as a concussion assessment tool, but the neuroanatomical control of horizontal and vertical saccades originates from different areas of the brain, so one might expect to see differences in performance on the K-D and DEM tests when administered to concussed patients. First, it is important to determine if performance on the DEM and K-D tests, particularly with respect to the measurement of vertical and horizontal saccades, is similar in a healthy population.Hypothesis/Purpose: The primary purpose was to evaluate the relationship between horizontal and vertical saccade tests over repeated trials in normal, healthy subjects. A secondary purpose of this study was to determine the number of trials needed to reach a performance plateau for both the DEM and K-D tests.Study Design: This study used a prospective cohort research design. Methods Forty-two healthy non-concussed participants (22 males, 20 females; mean age, 24.2 ± 2.92 years) completed six repeated trials of both the DEM, and then six trials of the K-D test in a single testing session. Trials within each test were performed in random order and participants were offered short rest breaks as needed between test administrations. Results Results indicated strong correlations, r=.67, or greater, between measurements of horizontal and vertical saccades. Performance plateaued on the K-D at trial three and on the DEM at trial two for both horizontal and vertical saccades. Conclusion It appears that the DEM and K-D tests measure similar constructs in healthy individuals and that no additional information is provided by assessment of vertical saccades. Additional studies are required to investigate the usefulness of the DEM in concussed individuals. Level of evidence 3: Laboratory study with repeated measures.

Post-thrombotic syndrome (PTS) is a common complication of deep venous thrombosis (DVT) of the iliofemoral venous system leading to significant morbidity and high health care costs. It has been recently shown that percutaneous endovenous intervention (PEVI) can effectively reduce the incidence of PTS. The role of new oral anticoagulants (NOACs) in combination with PEVI in the reduction of PTS has not been previously studied. This report sought to evaluate the role of PEVI plus NOACs in the reduction of PTS in acute symptomatic femoropopliteal and iliac DVT. We studied 127 patients with acute lower extremity DVT who had undergone PEVI plus administration of NOACs. All had received a minimum of 3 months of anticoagulation with a NOAC following PEVI. The mean follow-up was 22±5 months. The patients were evaluated for development of PTS, bleeding, recurrent venous thromboembolism (VTE), duration of hospitalization and mortality. There was no in-hospital bleeding. The mean duration of hospitalization was 46±9 hours. DVT occurred in two patients who had been later switched to warfarin. There were four non-VTE-related deaths. PTS developed in five patients (3%), two of whom were those who had been switched to warfarin. Their mean Villalta score was 6.2±0.9. We conclude that the combination of PEVI plus NOAC and low dose aspirin is associated with a very low rate of PTS with the severity being only mild. This approach leads to very low rates of bleeding and recurrent VTE and promotes early discharge.

Unresolved pediatric pain, both acute and chronic, has been associated with negative short- and long-term physical and mental health outcomes. This study sought to determine whether an association existed between self-reported pain coping skills and anxiety levels in a cohort of pediatric burn patients, and whether gender would influence their responses. The sample comprised burn-injured children in attendance at one of three mature burn camp sites. The self-report measures utilized included the 41-item Screen for Child Anxiety Related Disorders Child Version and the 39-item Pain Coping Questionnaire. Parental consent was obtained. A psychologist administered the measures. Participants included 187 youth, mean age 12.4 ± 2.4 years, girls (n = 89) boys (n = 98) with 67% reporting visible burn scars. Among boys, the use of Internalizing Coping Strategies was moderately correlated with elevated scores on Panic Disorder symptoms (r = .42, P.001). Among girls, the use of Internalizing Coping Strategies was associated with elevated Generalized Anxiety (r = .51, P.001), Panic Disorder (r = .46, P.001), and Total Anxiety Symptom Scores (r = .49, P.001). Those children who reported using Behavioral Distraction Strategies did not have any elevated anxiety scores. These findings suggest that burn-injured children, who employ Internalization as their pain coping strategy, may be more vulnerable to the development of long-term anxiety disorder, which, if left untreated may result in a negative psycho/social outcome. Applicability to Practice: Assessment of in-patient pediatric patients with the Pain Coping Questionnaire may help to identify children who are more likely to experience long-term anxiety. Future studies should seek to confirm these findings and determine whether improved pain management and early treatment of anxiety can help to diminish the long-term implications of unhelpful pain strategies and increased anxiety in burn-injured children.

Objective Native Americans (NAs) have worse healthcare outcomes over some measures than non-Native Americans (non-NAs) (i.e., lower life expectancy, higher heart disease and psychiatric disease rates). Little data exists to show if there are differences in the hospital course of burned NAs versus non-NA patients. The purpose of this study is to analyze the epidemiology, clinical course, and outcomes of NA burn injury in Arizona. Methods We conducted a retrospective database review of all burn center burn admissions from 2000 to 2015. This initial dataset of 12,724 patients included all initial presentations for burns, non-burns, and readmissions. From this database, we extracted all patients who were new admissions for burn injuries only. This resulted in 10,521 patients of which 9555 patients were non-NA patients and 966 were NA patients. The burn center collects sixty-eight data points to populate our burn database; of these data points, we reviewed twenty-nine to assess if differences existed. Results Statistically significant differences exist between the two groups with regard to age, geographic locality at time of burn, circumstances surrounding the injury, etiology of the injury, method of transport to the regional burn center, total length of stay, Injury Severity Score on admission, total percent total body surface area burned, month of year of burn injury, hospital charges, payor source for medical costs, and the final disposition. NA burn patients were more often burned at recreational than occupational sites and while participating in non-work related activities. Burn etiologies in NA patients were more frequently due to contact and flame. NA burn patients tended to have greater hospital length of stays and greater charges, and were less likely to be discharged home. Conclusions Our data demonstrate that NAs have a different experience with the healthcare system than non-NAs after a burn injury. The majority of these issues revolve around socioeconomic differences between the two groups.

ObjectiveSport-related concussions are considered a public health issue due to the number of athletes who sustain concussions.BackgroundThe Vestibular Ocular Motor Screening (VOMS) Assessment appears to be useful in evaluating concussion. Investigators have reported that abnormal near point of convergence (NPC), a component of the VOMS, is associated with prolonged concussion recovery. The purpose of this study was to compare four commonly used approaches to estimating NPC.Design/MethodsFour methods of measuring NPC were evaluated (tip of a pen, 12-point font, 14-point font, and the Bernell Vergel™ 9-point font). A generalized estimating equations approach was used to compare NPC measurements with the four methods, employing one practice trial, followed by three test trials. A sequential Bonferroni adjustment was used for pairwise comparisons. NPC estimate was modestly correlated with age of the subject, so age was included as a covariate. Significance was set at p = 0.05, a priori.ResultsSeventy-five healthy adults (16 males, 59 females; mean age, 21 ± 6.12 years, range, 18-58 years) were tested. The mean (standard error) for NPC was 7.13 ± 0.36 (95% CI, 6.45, 7.88). The smaller targets (Bernell Vergell™ and pen) yielded significantly larger estimates of NPC than both the 12- and 14-point font targets, p < 0.001). The Bernell Vergell™ and pen NPC did not differ (p = 0.134), and the 12- and 14-point font NPC’s did not differ (p = 0.794).ConclusionsEvaluation of NPC in the clinical environment uses non-standardized items of convenience that vary in size. The results of this study suggest that size is an important consideration when measuring NPC. Multiple disciplines are investigating NPC because of its relationship with concussion. Using evidence-based assessment tools such as the VOMS requires a systematic approach. Precision is required in clinical assessment, so it is suggested that clinicians use one standard approach to estimate NPC.

233 Background: Pancreatic cancer has significant mortality at five years, even in resectable disease. Recent effort has been dedicated to identify a more specific tumor marker for screening and assessing tumor response, in part because 10% of the population does not produce CA19-9. Detection and quantification of circulating tumor DNA (ctDNA) in the bloodstream is a novel concept for screening and treatment response assessment. This study examined possible correlations between ctDNA levels and various aspects of pancreatic cancer in a total of 17 patients receiving treatment at Banner MD Anderson Cancer Center. Methods: Present study is approved by our local IRB. Research was conducted according HIPPA regulation. Subjects on the present study were obtained from the list of patients participating in our ctDNA trial. A total of 17 subjects were identified from the list. Their ctDNA index levels were obtained from the sponsor (Chronyx) at baseline and following each cycle of the treatment. For each CT scan and each ctDNA study, they are considered the same time if they are obtained within 4 weeks of each other. The sizes of the primary tumor and the largest metastatic lesion were on a transverse image at the largest extent of the lesion. Data was analyzed with Spearman's correlation. Results: Baseline ctDNA levels did not correlate with patient demographic data (N = 17; gender, p = 0.63; age, p = 0.82), baseline size of primary mass on CT scan (N = 16; p = 0.85), baseline vessel involvement on CT Scan (N = 17; p = 0.58), presence of metastasis on CT scan (N = 17; p = 0.78), size of largest metastasis on CT scan (N = 17; p = 0.85), presence of peripancreatic lymph nodes on CT scan (N = 17; p = 0.45), or overall survival (N = 8; p = 0.6). However, there is a trend toward correlating the change in ctDNA and change in size on CT scan following treatment (N = 7; p = 0.12). Conclusions: ctDNA at baseline appears to be secreted independent of the primary tumor size, location, or presence of metastasis. However, changes in ctDNA does seem to correlate with changes in tumor size following treatment. Although our data was not statistically significant, this may be related to the low sample size. With larger sample size, it is expected that changes in ctDNA may prove to correlate with changes in tumor size.

Background Thrombolysis, though very effective, has not been embraced as routine therapy for symptomatic pulmonary embolism (PE) except in very severe cases. Rivaroxaban recently has been approved for the treatment of venous thromboembolism (VTE). There are no data on the combined use of thrombolysis and rivaroxaban in PE. Hypothesis “Safe dose” thrombolysis (SDT) plus new oral anticoagulants are expected to become an appealing, safe and effective approach in the treatment of moderate and severe PE in the near future, thereby drastically reducing hospitalization time. Methods Over a 12-month period, 98 consecutive patients with symptomatic PE were treated by a combination of SDT and rivaroxaban. The SDT was started in parallel with unfractionated heparin and given in 2 hours. Heparin was given for a total of 24 hours and rivaroxaban started at 15 or 20 mg daily 2 hours after termination of heparin infusion. Results There was no bleeding due to SDT. Recurrent VTE occurred in 3 patients who had been switched to warfarin. No patient on rivaroxaban developed VTE. Two patients died of cancer at a mean follow-up of 12 ± 2 months. The pulmonary artery systolic pressure dropped from 52.8 ± 3.9 mm Hg before to 32 ± 4.4 mm Hg within 36 hours of SDT (P < 0.001). The duration of hospitalization for patients presenting primarily for PE was 1.9 ± 0.2 days. Conclusions “Safe dose” thrombolysis plus rivaroxaban is highly safe and effective in the treatment of moderate and severe PE, leading to favorable early and intermediate-term outcomes and early discharge.

Catheter-directed thrombolysis (CDT) is a highly effective approach in the treatment of deep venous thrombosis (DVT). There are no data on the primary use of CDT with argatroban and tissue plasminogen activator (tPA) in patients without heparin-induced thrombocytopenia (HIT). The aim of this study was to evaluate the efficacy and safety of the combined administration of argatroban and tPA during CDT for massive DVT in patients without HIT. Thirty-three patients with massive symptomatic iliac and femoropopliteal DVT underwent CDT with tPA and argatroban within 28 ± 6 h of presentation. The dose of tPA was 0.75–1 mg/h through the infusion port and that of argatroban at 0.3–1 μg/kg/min through the side port of the sheath. The patients were evaluated for the efficacy and safety of CDT and recurrent symptomatic venous thromboembolism (VTE) at a mean follow-up of 22 months. There was no bleeding or iatrogenic pulmonary embolism with the CDT regimen we used. Grade III lysis (complete resolution of thrombus on venography) was achieved in 30 patients (91 %). In 3 patients with additional inferior vena cava filter thrombosis, further thrombectomy of the filter was required. No patient developed recurrent VTE. Concomitant administration of argatroban and tPA is a highly safe and effective regimen for CDT for massive DVT.

Immunoglobulin A nephropathy (IgAN) is a leading cause of chronic kidney disease, frequently associated with hypertension and renal inflammation. ω-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in fish oil (FO) improve kidney function in animal models, but have inconsistent metabolic effects in humans. Oxylipin profiles in serum from IgAN patients supplemented with either FO or corn oil (CO) placebo were analyzed by liquid chromatography coupled to tandem mass spectrometry. EPA cyclooxygenase and lipoxygenase metabolites, and EPA and DHA epoxides and diols were increased in response to FO supplementation, as were total epoxides and epoxide/diol ratios. Several of these metabolites were drivers of separation as assessed by multivariate analysis of FO patients pre- vs. post-supplementation, including 17,18-dihydroxyeicosatrienoic acid, prostaglandin D3, prostagalandin E3, Resolvin E1, 12-hydroxyeicosapentaenoic acid, and 10(11)-epoxydocosapentaenoic acid. In patients whose proteinuria improved, plasma total oxylipins as well as several hydroxyoctadecadienoic acids, hydroxyeicosatetraenoic acids, and leukotriene B4 metabolites were among the metabolites that were significantly lower than in patients whose proteinuria either did not improve or worsened. These data support the involvement of oxylipins in the inflammatory component of IgAN as well as the potential use of oxylipin profiles as biomarkers and for assessing responsiveness to ω-3 fatty acid supplementation in IgAN patients.

To present midterm results from a randomized study comparing the safety and efficacy of percutaneous endovenous intervention (PEVI) + anticoagulation vs. anticoagulation alone in the reduction of venous thromboembolism (VTE) and post-thrombotic syndrome (PTS) in acute symptomatic proximal deep venous thrombosis (DVT).The TORPEDO trial was a randomized study to demonstrate superiority of PEVI in the reduction of the VTE and PTS at 6 months; in that trial, 183 patients (103 men; mean age 61 ± 11 years) with symptomatic proximal DVT were randomized to receive PEVI + anticoagulation (n = 91) or anticoagulation alone (n = 92). PEVI consisted of one or more of a combination of thrombectomy, balloon venoplasty, stenting, and/or local low-dose thrombolytic therapy.At 6 months, recurrent VTE developed in 2.3% of the PEVI + anticoagulation group vs. 14.8% in the anticoagulation only group (p = 0.003); PTS developed in 3.4% vs. 27.2% (p0.001), respectively. At a mean follow-up of 30 ± 5 months (range 12-41), 88 patients in the PEVI + anticoagulation group and 81 patients in the anticoagulation only group reached target follow-up. Recurrent VTE developed in 4 (4.5%) of the 88 PEVI + anticoagulation patients vs. 13 (16%) of the 81 patients receiving anticoagulation only (p = 0.02). PTS developed in 6 (6.8%) of the PEVI + anticoagulation group vs. 24 (29.6%) of the anticoagulation only group (p0.001).In patients with proximal DVT, PEVI is superior to anticoagulation alone in the reduction of VTE and PTS. This benefit, which appears early in the course of treatment, extends to2.5 years.

The purpose of this study was to evaluate the necessity of and recommend indications for inferior vena cava (IVC) filter implantation during percutaneous endovenous intervention (PEVI) for deep venous thrombosis (DVT).PEVI has emerged as a powerful tool in the management of acute proximal DVT. Instrumentation of extensive fresh thrombus is potentially associated with iatrogenic pulmonary embolism (PE). The true frequency of this complication has not been studied in a randomized fashion. We evaluated IVC filter implantation during PEVI for DVT.A total of 141 patients with symptomatic proximal DVT undergoing PEVI for symptomatic DVT were randomized to receive an IVC filter (70 patients) or no filter (71 patients; control group). The anticoagulation and PEVI regimen were similar between the two groups. Patients with development of symptoms suggestive of PE underwent objective testing for PE.PE developed in 1 of the 14 symptomatic patients in the filter group and 8 of the 22 patients in the control group (P = 0.048). There was no mortality in any group. Three patients (4.2%) in the control group had transient hemodynamic instability necessitating resuscitory efforts. Predictors of iatrogenic PE were found to be PE at admission; involvement of two or more adjacent venous segments with acute thrombus; inflammatory form of DVT (severe erythema, edema, pain, and induration); and vein diameter of ≥7 mm with preserved architecture.IVC filter implantation during PEVI reduces the risk of iatrogenic PE by eightfold without a mortality benefit. A selective approach may be exercised in filter implantation during PEVI.

OBJECTIVE: The long-term outcome of patients treated with gamma knife radiosurgery (GKRS) for typical trigeminal neuralgia has not been fully studied. We evaluated 185 patients who underwent their first GKRS treatment between 1997 and 2003 at the Barrow Neurological Institute. METHODS: Follow-up was obtained by surveys and review of medical records. Outcomes were assessed by the Barrow Neurological Institute Pain Intensity Score and Brief Pain Inventory. The most common maximum dose was 80 Gy targeted at the root entry zone. Outcomes are presented for the 136 (74%) patients for whom more than 4 years of clinical follow-up data were obtained. RESULTS: Treatment failed in 33% of the cohort within 2 years, but only an additional 1% relapsed after 4 years. Actuarial analysis demonstrated that 32% of patients were pain-free off medication and 63% had at least a good outcome at 7 years. When GKRS was used as the primary treatment, 45% of the patients were pain-free at 7 years. In contrast, 10% of patients in whom previous treatment had failed were pain-free. When needed, salvage therapy with repeat GKRS, microvascular decompression, or percutaneous lesioning was successful in 70%. Posttreatment facial numbness was reported as very bothersome in 5%, most commonly in patients who underwent another invasive treatment. After GKRS, 73% reported that trigeminal neuralgia had no impact on their quality of life. CONCLUSION: GKRS is a reasonable long-term treatment option for patients with typical trigeminal neuralgia. It yields durable pain control in a majority of patients, as well as improved quality of life with limited complications and it does not significantly affect the efficacy of other surgical treatments, should they be needed.

METHODS A sample of patients with HIV completed a questionnaire identifying their demographic characteristics and risk factors for hepatitis C virus (HCV). A chart review was conducted to confirm the information obtained using the questionnaire. Risk factors associated with coinfection status at alpha level of 0.1 in univariate analysis were entered into a multivariate Cox regression model. RESULTS Of the 242 HIV-positive patients analyzed, 168 were HIV-infected and 74 were HIV/HCV-coinfected. Risk factors that were significantly different between HIV-monoinfected and HIV/HCV-coinfected subjects included intravenous drug use, snorting drugs, sharing razors or toothbrushes, being in prison, the presence of one or more tattoos, sex for money or drugs, sex with an intravenous drug user and man who has sex with men. In a multivariate regression model, only intravenous drug use remained as a significant risk factor/predictor of HCV/HIV coinfection. A subanalysis identified risk factors more prevalent among coinfected men who have sex with men, including intravenous drug use, sharing razors/toothbrushes, tattoos, sex for money or drugs, sex with an intravenous drug user, and a history of having 11 or more sexual partners. A history of having had a sexually transmitted disease and 11 or more sex partners was more prevalent among HIV-monoinfected men who have sex with men. CONCLUSIONS HIV/HCV coinfection was associated with intravenous drug use but not with sexual risk factors.

Study Objectives The aim of this study was to determine the use of Boehler's angle (BA) and the critical angle of Gissane (CAG) in diagnosing calcaneus fractures in the ED. Design The study was conducted as a randomized, blinded, case-control trial. Cases One hundred thirty-three patients older than 15 years were included in the study. Sixty-five patients with computed tomography–verified calcaneus fractures (gold standard) and 68 ED patients with lateral foot or ankle x-rays without calcaneus fractures were included in the study. Methods One second-year emergency medicine resident, 1 third-year emergency medicine resident, 2 board-certified emergency medicine attending physicians, and 1 board-certified radiologist prospectively reviewed all films using the Picture Archival and Communication System digital radiology system. Cases and controls were randomized and the participants were blinded to final radiographic diagnoses. Participants determined whether there was a fracture on each x-ray and measured BA and the CAG using the digital angle tool in the Picture Archival and Communication System. Results Emergency physicians were 97.9% accurate in diagnosing calcaneus fractures (range, 97% to 99%). The mean κ value for emergency physicians was 0.96 (range, 0.94-0.985). Receiver operating characteristic curves were constructed for BA and the CAG. When compared with the gold standard, the area under the curve for BA ranged from 0.82 to 0.88. The area under the curve for the CAG ranged from 0.45 to 0.67. BA had an interclass correlation coefficient of 0.84 (95% confidence interval, 0.79-0.87). The CAG interclass correlation was 0.52 (95% confidence interval, 0.43-0.60). One fracture was missed by the radiologist and all of the emergency physicians because it was only visible on computed tomography. Conclusion BA is somewhat helpful and the CAG is not useful in diagnosing calcaneus fractures in the ED. Interrater reliability for BA is excellent, but for the CAG, it is poor. Emergency physicians were 97.9% accurate in making the diagnosis by reviewing the plain films without "assistance" of the angle measurements.

Research that exclusively focuses on oral health competencies for physician assistant (PA) and nurse practitioner (NP) education is scarce. Purpose: A study was conducted to determine PAs’ and NPs’ perspectives and self-perceived levels of skill in performing a set of oral health competencies. Method: Following e-mail notifications of professional and educational associations and an announcement placed in Clinician Reviews, an online survey of PAs and NPs was conducted between December 2005 and February 2006. The survey listed a number of oral health competencies and asked respondents (1) whether PAs and NPs should have the competencies and (2) to rate their own competency in each area. Results: A sample of 106 PAs (46%) and 127 NPs (54%) self-selected to participate in this survey. The largest percentage of respondents (37%) had been in clinical practice 1-5 years, 24% had been in practice greater than 15 years, and 23% had been in practice 6-10 years. Thirty-five percent of the respondents listed family medicine as the area most closely resembling their practice, 12% were in education, 10% in internal medicine (specialty), 8% in internal medicine (general), and 8% in obstetrics/gynecology/ women’s health. Eighty-two percent of respondents, on average, agreed that PAs and NPs should have the competencies listed (ranging from 45% for “apply fluoride varnish” to 96% for “recognize common diseases”). For the eight competencies as a whole, 40.3% of the respondents, when asked if they felt competent in these areas, listed “competent” as their choice, while 59.7% felt “somewhat competent” or “not competent.” Conclusions: Overall, respondents agreed that the defined oral competencies were important skills for practicing PAs and NPs. On the other hand, fewer than half of the respondents felt competent in their skills in these areas. This small survey demonstrates a need for additional training of PAs and NPs in oral health care.

This study sought to identify which commonly experienced burn-related issues parents/caregivers of burn-injured youth deemed most stressful, difficult, and disruptive during their child's initial acute burn care hospitalization, and following the child's discharge. Parents completed an 11-item survey, asking them to rate the difficulty of items regarding their child's burn injury. The scale was created by burn doctors, nurses, and psychologists with an average of 10.5 (SD ± 4.8) years of experience. Items selected were among common parental problems reported in the burn literature. Respondents included 69 parents/caregivers of previously hospitalized, burn-injured youth. The majority were mothers, n = 51 (74%), and n = 34 (49%) were Caucasian. The most represented age group was 37 to 45 years, n = 31 (45%). Children were on average, 6.04 years out from their initial injury. All parents reported their child's pain as the most difficult part of the injury, n = 69 (100%). The second most common issue was the child's first hospital stay. The other two items found to be "very hard" or "pretty hard" were the time spent away from their other children, and feelings of hopelessness in being unable to fix everything for their child. In this study, key parental problems occurred during the child's initial hospitalization. Burn staff cannot alleviate all problems, however, staff education regarding distressing problems faced by parents, as well as possible solutions, can be made available.

Objective: To compare rates of motor vehicle crash (MVC) fatalities among different race/ethnic groups in urban and rural Arizona. Method: Using the Fatality Analysis Reporting System and the National Center for Health Statistics Multiple Cause of Death file, MVC fatalities in Arizona from 1990–96 inclusive were classified by gender, race/ethnicity, and urban or rural residence. Age adjusted rates of total, occupant, pedestrian, and alcohol related fatalities were calculated. The total MVC fatality rate for each race/ethnic group was then adjusted for proportion of rural residence. Results: Compared with non-Hispanic whites (NHWs), American Indians had raised relative risks for MVC fatality in all gender and residence subgroups. Hispanic females and rural Hispanic males had lower relative risks, as did rural African-American men. Raised relative risks for American Indian men and women included all subgroups: total, occupant, pedestrian, and alcohol related. Hispanic and African-American men both had raised relative risks of pedestrian related fatalities, and Hispanic men had a slightly higher relative risk while Hispanic women had a lower relative risks, for alcohol related fatality. Hispanic men and women and African-American men had lower occupant fatality rates. Close to half (45%) of the excess MVC fatality among American Indians can be attributed to residence in rural areas, where MVC fatality rates are higher. There were 1.85 occupants in crashes involving NHW deaths compared with 2.51 for Hispanics and 2.71 for American Indians (p

Aims: The aim of this study was to assess how individuals in three rural communities in Ecuador self-rate their oral health status. Materials and Methods: This was a cross-sectional descriptive study that utilized a survey to assess the community awareness of risk factors for oral health. Because fluorosis is an issue that affects these communities, local water systems were tested for excess fluoride. Results: One hundred and eighty-five individuals aged 18 years and older participated in the study. Two-thirds of the participants described the state of their teeth as average or poor and more than half stated that they had sought dental care due to pain and need for treatment during the past year. Age and education had a statistically significant effect on how people described the state of their teeth. Significant associations were found between number of years of education and age and number of natural teeth the participants had (rs = 0.43, n = 177, P ≤ 0.001; rs= −0.53, n = 178, P ≤ 0.001). Likewise, significant associations were found between number of years of education and age and how participants described the state of their teeth (rs= −0.228, n = 177, P ≤ 0.001; −0.617, n = 177; P

BackgroundA growing number of patients who are on systemic anticoagulation with warfarin require endovenous thermal ablation for reflux disease in the great saphenous vein (GSV). Little is known about the effects of anticoagulation on periprocedural bleeding and long-term closure rates of the treated veins. This study evaluated the effects of uninterrupted anticoagulation in patients undergoing endovenous thermal ablation.MethodsIn this prospective observational study, 88 limbs of patients on warfarin (anticoagulation group [AG]) who underwent endovenous thermal ablation for GSV reflux disease were compared with 92 limbs in patients receiving no anticoagulation or antiplatelet agents (control group [CG]). Forty percent of AG patients were also receiving antiplatelet therapy. Periprocedural bleeding and closure rate at 1 year were evaluated.ResultsNo major bleeding occurred in either group. Minor bleeding was noted in 8 of 88 procedures in the AG vs 4 of 92 in the CG (P = 0.24); all in patients receiving radiofrequency ablation. Four of the eight minor bleeds in the AG were noted in patients receiving “triple therapy” with warfarin, aspirin, and clopidogrel or ticlopidine. Triple therapy in the AG was associated with a higher risk of minor bleeding compared with the CG (relative risk, 13.0; 95% confidence interval, 4.10-41.19, P < .001). All treated venous segments remained closed at the 1-year follow-up in both groups.ConclusionsIn this relatively small, nonrandomized study comparing endovenous thermal ablation in patients with and without warfarin, no differences were found in periprocedural risk of major bleeding or closure rate of the treated venous segments. Minor bleeding was increased in patients receiving triple therapy with warfarin, aspirin, and a thienopyridine who underwent radiofrequency ablation.

Background Heparin induced thrombocytopenia (HIT) is a potentially catastrophic syndrome with a high incidence of vascular thrombosis. There are little data on the efficacy of new oral anticoagulants (NOAC) in this setting. This study reports on the outcome of patients with HIT, treated with NOAC. Materials and Methods We retrospectively identified 22 patients with HIT who were treated by our group with a combination of NOAC and a short course of argatroban. These patients were evaluated in a prospective fashion for development of outcomes at a mean follow up of 19 ± 3 months. Results There were a total of 5 deep and 2 superficial vein thromboses diagnosed at index hospitalization. No patient developed arterial thrombosis. All patients tolerated NOAC and their platelet count normalized before discharge. At 19 months of follow-up, 6 patients had died of non-thrombotic causes. There was no bleeding, limb loss or recurrent venous thromboembolism in any patient. Conclusions In patients with HIT, a short course of parenteral treatment with argatroban followed by administration of a NOAC is highly safe and effective in prevention of thrombosis and normalization of platelet count. Development of HIT however, portends a poor prognosis independent of vascular thrombosis.

Medial tibial stress syndrome (MTSS) is a common injury in runners and military personnel. There is a lack of agreement on the aetiological factors contributing to MTSS, making treatment challenging and highlighting the importance of preventive efforts. Understanding the risk factors for MTSS is critical for developing preventive measures. The purpose of this systematic review and meta-analysis was to assess what factors put physically active individuals at risk to develop MTSS. Selected electronic databases were searched. Studies were included if they contained original research that investigated risk factors associated with MTSS, compared physically active individuals with MTSS and physically active individuals without MTSS, were in the English language and were full papers in peer-reviewed journals. Data on research design, study duration, participant selection, population, groups, MTSS diagnosis, investigated risk factors and risk factor definitions were extracted. The methodological quality of the studies was assessed. When the means and SDs of a particular risk factor were reported three or more times, that risk factor was included in the meta-analysis. There were 21 studies included in the systematic review and nine risk factors qualified for inclusion in the meta-analysis. Increased BMI (weighted mean difference (MD)=0.79, 95% CI 0.38 to 1.20, p

Safe dose thrombolysis (SDT) has been shown to be highly effective in the treatment of moderate and severe pulmonary embolism (PE) while eliminating bleeding risks. The combination of SDT plus rivaroxaban has been recently reported to be a potent strategy in treating PE thereby drastically reducing

Extensive acute deep venous thrombosis (DVT) responds favorably to catheter directed thrombolysis (CDT). Argatroban is an effective parenteral direct thrombin inhibitor which makes it an attractive drug for DVT treatment. There is a paucity of data on the utilization of argatroban in combination

Objective: The purpose of this case series was to examine the feasibility of using an in-home robotic therapy telerehabilitation device to produce quality outcomes in functional ability and mood, while satisfying patient need for access to post-stroke rehabilitation at low cost to the client. Methods: Thirteen chronic stroke survivors with motor impairments of at least one upper or lower extremity were instructed in a home rehabilitation regimen using a robotic device designed for either the hand or the foot. Assessments of function and depression were made prior to initiation and at the end of 3 months of in-home use to determine any change in outcomes. Satisfaction with the device and access to therapy were determined using written and verbal surveys. Cost analysis was performed to compare the economics of the in-home delivery method to the cost of clinic-based physical or occupational therapy. A licensed physical therapist remotely monitored participant progress throughout the treatment period via weekly telephone calls and a secure database. Results: Compared to baseline, participants showed improvements in depressive symptoms, functional independence, use of the upper extremity in functional tasks, distance walked, and gait speed at final assessment. Participants indicated satisfaction with the device and with their outcomes at the end of the 3 month treatment period. Using the device in the home expanded access to post-stroke rehabilitation for all participants with a reduced cost compared to clinic-based therapy. Conclusion: Individuals were able to make functional improvements in the use of their impaired extremities poststroke using a robotic telerehabilitation device in the home. The in-home service delivery regimen reduced the cost of therapy while expanding access to a rehabilitation modality for individuals who would not otherwise have received services. A small sample of mostly males and no comparison group limits the statistical analysis and generalizability of results.

The role of low-dose thrombolysis in the reduction of pulmonary artery pressure in moderate pulmonary embolism (PE) has not been investigated. Because the lungs are very sensitive to thrombolysis, we postulated that effective and safe thrombolysis might be achieved by a lower dose of tissue plasminogen activator. The purpose of the present study was to evaluate the role of this “safe dose” thrombolysis in the reduction of pulmonary artery pressure in moderate PE. During a 22-month period, 121 patients with moderate PE were randomized to receive a “safe dose” of tissue plasminogen activator plus anticoagulation (thrombolysis group [TG], n [ 61 patients) or anticoagulation alone (control group [CG], n [ 60). The primary end points consisted of pulmonary hypertension and the composite end point of pulmonary hypertension and recurrent PE at 28 months. Pulmonary hypertension and the composite end point developed in 9 of 58 patients (16%) in the TG and 32 of 56 patients (57%) in the CG (p

Objectives. We compared the efficacy and safety of percutaneous endovenous intervention (PEVI) plus anticoagulation with anticoagulation alone in the reduction of venous thromboembolism (VTE) and post-thrombotic syndrome (PTS) in acute proximal deep venous thrombosis (DVT). Background. Recurrent VTE and PTS are common complications of DVT. There are no randomized trials investigating the efficacy of PEVI in the reduction of the above complications. Methods. Patients with symptomatic proximal DVT were randomized to receive PEVI plus anticoagulation or anticoagulation alone. Anticoagulation consisted of intravenous unfractionated heparin or subcutaneous low-molecular weight heparin plus warfarin. PEVI consisted of one or more of a combination of thrombectomy, balloon venoplasty, stenting, or local low-dose thrombolytic therapy. Results. At 6 months follow-up, recurrent VTE developed in 2 of 88 patients of the PEVI plus anticoagulation group versus 12 of 81of the anticoagulation-alone group (2.3% vs. 14.8%, P = 0.003). PTS developed in 3 of 88 patients of the PEVI plus anticoagulation Group and 22 of 81 of the anticoagulation-alone group (3.4% vs. 27.2%, P < 0.001). Conclusions. In patients with symptomatic proximal DVT, PEVI plus anticoagulation may be superior to anticoagulation—alone in the reduction of VTE and PTS at 6 months. © 2010 Wiley-Liss, Inc.