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Effective teamwork remains a crucial component in providing high-quality care to patients in today’s complex healthcare environment. A prevalent ‘us’ versus ‘them’ mentality among professions, however, impedes reliable team function in the clinical setting. More importantly, its corrosive influence extends to health professional students who model the ineffective behaviour as they learn from practicing clinicians. Simulation-based training (SBT) of health professional students in team-based competencies recognized to improve performance could potentially mitigate such negative influences. This quasi-experimental prospective study will evaluate the effectiveness and impact of incorporating a multi-year, health science centre-wide SBT curriculum for interprofessional student teams. It targets health professional students from the Schools of Medicine, Nursing and Allied Health at Louisiana State University (LSU) Health New Orleans. The intervention will teach interprofessional student teams key team-based competencies for highly reliable team behaviour using SBT. The study will use the Kirkpatrick framework to evaluate training effectiveness. Primary outcomes will focus on the impact of the training on immediate improvements in team-based skills and attitudes (Level 2). Secondary outcomes include students’ perception of the SBT (Level 1), its immediate impact on attitudes towards interprofessional education (Level 2) and its impact on team-based attitudes over time (Level 3). The Institutional Review Board at LSU Health New Orleans approved this research as part of an exempt protocol with a waiver of documentation of informed consent due to its educational nature. The research description for participants provides information on the nature of the project, privacy, dissemination of results and opting out of the research.

Objective: An ideal local anesthetic would be effective, minimally reduce pulpal blood flow (PBF), and not require injection. This study compared the effects of 3% tetracaine plus 0.05% oxymetazoline nasal spray (Kovanaze; KNS) and injections using 2% lidocaine with 1:100,000 epinephrine (LE) or 3% mepivacaine plain (MP) on PBF, anesthetic efficacy, and participant preference. Methods: In a double-blind cross-over design, 20 subjects randomly received a test anesthetic and placebo at each of 3 visits (KNS/mock infiltration; mock nasal spray/LE; or mock nasal spray/MP). Nasal sprays and infiltration apical to a maxillary central incisor were delivered ipsilaterally. PBF was evaluated by laser Doppler flowmetry, and local anesthetic success was assessed with electric pulp testing. Postoperative pain levels, participant preference, and adverse events were also assessed. Results: LE injections demonstrated significant reductions in PBF at all time intervals compared with baseline (P < .05), whereas KNS and MP did not. Pulpal anesthesia success rates were higher for LE (85%) compared with MP (35%) and KNS (5%). Participants reported significantly higher postoperative pain levels for KNS compared with LE and MP. Additionally, KNS was the least preferred of the anesthetics administered and resulted in more reported adverse events. Conclusion: Although KNS showed no significant effect on PBF, it was not effective in achieving pulpal anesthesia as used in this study.

The purpose of this pilot randomized controlled trial was to analyze and compare the effects of advanced platelet-rich fibrin (A-PRF) and plasma rich in growth factors (PRGF) combined with deproteinized bovine bone mineral (DBBM) on bone regeneration outcomes in maxillary sinus augmentation (MSA) procedures. A total of 15 patients in need of MSA were consecutively recruited. Maxillary sinuses were grafted with DBBM alone (control group), DBBM mixed with A-PRF (PRF group), or DBBM mixed with PRGF (PRGF group). After a 6-month healing period, bone core biopsy samples were collected prior to implant placement for histologic and histomorphometric analyses. The mean percentage of mineralized tissue (MT) was 20.33 ± 11.50 in the control group, 32.20 ± 7.29 for the PRF group, and 34.80 ± 6.83 for the PRGF group, with no statistically significant differences across the three groups (P.05). The mean percentage of remaining bone grafting material (RBGM) was 24.00 ± 7.94 for the control group, 26.00 ± 7.78 for the PRF group, and 15.80 ± 8.23 for the PRGF group, with no statistically significant differences across the three groups (P.05). Finally, the mean percentage of nonmineralized tissue (NMT) was 55.66 ± 7.77 for the control group, 41.40 ± 8.32 for the PRF group, and 49.60 ± 5.68 for the PRGF group, with no statistically signifcant differences across the three groups (P.05). These findings suggest that the addition of A-PRF and PRGF to DBBM does not enhance new bone formation outcomes in maxillary sinus augmentation procedures. Neither of the two platelet concentrates were superior to the other in any of the variables assessed.

Introduction: Although smoking prevalence has recently declined, the smoking prevalence in China remains high. Extensive research has demonstrated ways that social media can assist in quitting smoking. WeChat is the most commonly used social media platform in China but has not been used for smoking cessation. A process evaluation of a novel WeChat-based smoking cessation intervention was conducted to measure its efficacy of content delivery, participant satisfaction, engagement, and likelihood of recommendation to others. Methods: A three-week, three-arm, single-blind randomized control trial was established. WeChat was used to recruit 403 participants and to deliver intervention messages and process evaluation surveys to them. Recruitment advertisements were posted on an official WeChat account and were forwarded to WeChat Moments. Intervention messages were delivered once a day during weekdays, using the WeChat broadcasting messages function, with two messages being sent each time. Process evaluation surveys were organized using Wenjuanwang and were delivered via WeChat. Process assessments were conducted every Friday to assess intervention message receipt, satisfaction level, engagement level, and recommendation to others. The receipt of intervention messages was measured by a self-reported question indicating which messages were read each week. Satisfaction was measured by a five-item Likert scale survey. Engagement was measured by a one-item Likert scale survey. Recommendation to others was measured by one self-reported question. Results: Participants read an average of 4.76 (out of 10), 5.80 (out of 10), and 4.25 (out of 6) messages at week 1, week 2, and week 3, respectively. The second messages were less likely to be read compared to the first messages (52.3% vs. 61.6%, respectively). Moreover, within each single week, the number of participants who read the intervention messages gradually decreases over time. Picture-based intervention messages tended to be less likely to be read than video-based intervention messages. Total program satisfaction scores ranged between 5 and 25, and the overall scores for satisfaction for each week were 21.55, 22.27, and 22.76, respectively. No significant differences were found in all the satisfaction indicators between groups. More than 60% of participants reported being either highly engaged or somewhat engaged each week. In addition, most participants (93.0% at week 1, 95.8% at week 2, and 96.2% at week 3) reported that they were willing to recommend our program to others. Discussion: A WeChat-based smoking cessation intervention for Chinese smokers was implemented and evaluated. For future studies, one should consider sending messages of a higher importance as the first message of a given day. Smokers had a higher rate of reading intervention messages at the beginning part of each week, during which, relatively important messages should be prioritized. One might also consider alternating the topics and formats of the messages for a better engagement of the users in future studies.

China is the largest tobacco producer and has the highest number of tobacco consumers in the world. Extensive research has demonstrated the utility of social media for smoking cessation. WeChat is the most commonly used social media platform in China, but has not yet been utilized for smoking cessation interventions. The objectives of this study are (1) to evaluate the efficacy of a WeChat-based smoking cessation intervention; and (2) to examine a possible additive effect of integrating oral health and smoking-related information into a tailored, Transtheoretical Model (TTM) guided smoking cessation intervention.Eligible adults were recruited through WeChat from July 1 to August 6, 2019, to participate in a 3-arm, single-blinded, randomized controlled trial. We enrolled and randomized 403 participants into three groups: the Standard Group, Enhanced Group, or a Waitlist-Control Group. Participants in the Standard Group received 20 smoking cessation-related messages for 2 weeks; participants in the Enhanced Group received this same protocol plus 6 oral health-related messages over an additional week. Participants in the Control Group received smoking cessation-related messages, after the post-intervention assessment. The primary outcome was TTM Stage of Change, and the secondary outcomes were 7-day Point Prevalence Abstinence (PPA), 24-h PPA, daily cigarette use, and nicotine dependence at 4 weeks follow-up post intervention, comparing intervention groups with the control group. The overall program attrition rate was 46%. PairedParticipants in the Enhanced Group (β = -1.28, 95%CI: -2.13, -0.44) and the Standard Group (β = -1.13, 95%CI: -1.95, -0.30) reported larger changes in nicotine dependence scores, compared to participants in the Waitlist Group. No statistically significant differences were found between the Enhanced Group and the Standard Group.This WeChat-based intervention was effective for smoking cessation overall. The addition of oral health information did not significantly improve the intervention.

Third variable effect refers to the effect from a third variable that explains an observed relationship between an exposure and an outcome. Depending on whether there is causal relationship, typically, a third variable takes the format of a mediator or a confounder. A moderation effect is a special case of the third-variable effect, where the moderator and other variables have an interactive effect on the outcome. In this paper, we extend the R package 'mma' for moderation analysis so that third-variable effects can be reported at different levels of the moderator. The proposed moderation analysis use tree-structured models to automatically detect moderation effects and can handle both categorical and numerical moderators. We propose algorithms and graphical methods for making inference on moderation effects and illustrate the method under different scenarios of moderation effects. Finally, we apply the proposed method to explore the trend of racial disparities in the use of Oncotype DX recurrence tests among breast cancer patients. We found that the unexplained racial differences in using the tests have decreased from 2010 to 2015.

Background. The use of sports and energy drinks has drastically increased in the adolescent population. This population often is in orthodontic treatment, and the use of such drinks with poor oral hygiene promotes the development of white spot lesions (WSLs). Quantifying the degree of the lesion has been limited in the past. The hypothesis was that the Canary Caries Detection System could be used to quantify the degree of WSLs caused by different commercial beverages. Methods. A total of 105 extracted human premolars were divided into seven groups (n=15). Each group was tested in one of six beverages or a phosphate-buffered solution (control). The teeth were exposed to its beverage three times a day for 15 minutes for 28 days. Canary numbers and ambient light and fluorescent photographs were collected at baseline (T0 ) and on days 14 (T1 ) and 28 (T2 ). Results. The paired t test and one-way ANOVA found that T0 to T1 measurements were statistically significant (P

We propose an adaptive design for variable selection in Bayesian modeling process. First randomly select some models to evaluate (e.g. by posterior model probability). Using these models, we predict the performance of all models in the candidate pool, based on which more models are selected and evaluated, in which models with good predicted performance or large prediction variances have high probabilities of being selected. Newly sampled models are used to update the performance predictions of candidate models. Repeat the process until informative models are not likely to be left unsampled in terms of the preset model selection criterion. When there are high-dimensional variables, we propose the use of highest-resolution-minimum-aberration-fractional-factorial design to select candidate-model sets to enable inferences on main effects and low-level interactions of variables. Simulations and a real data example have shown that the proposed adaptive design is efficient in finding informative models compared with other variable selection procedures.

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 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.

OBJECTIVES The purpose of this study was to determine and compare nickel and chromium ion release from traditional stainless steel and nickel titanium wires and newer esthetic archwires under different pH conditions, for different time intervals. METHODS Ten pieces of 10-mm segments of five different orthodontic archwires were submerged in buffer solutions of pH 4.0, 5.5, and 7.0, for 4 and 13 weeks. The sample solutions were analyzed using ICP-MS. First, the results were analyzed by three-way ANOVA to determine any significant differences in metal concentration (ppb) between the different groups. Then, a post-hoc multiple pairwise comparison by Tukey's Studentized Range (HSD) Test was conducted to further compare the different materials and pH conditions. RESULTS For nickel, uncoated NiTi had the highest nickel ion release (ppb), while AO Iconix had the lowest average nickel ion release, with a significant difference (p

Third-Variable effect refers to the intervening effect from a third variable (called mediators or confounders) to the observed relationship between an exposure and an outcome. The general multiple third-variable effect analysis method (TVEA) allows consideration of multiple mediators/confounders (MC) simultaneously and the use of linear and non-linear predictive models for estimating MC effects. Previous studies have found that compared with non-Hispanic White population, Blacks and Hispanic Whites suffered disproportionally more with obesity and related chronic diseases. In this paper, we extend the general TVEA to deal with multivariate/multicategorical predictors and multivariate response variables. We designed algorithms and an R package for this extension and applied MMA on the NHANES data to identify MCs and quantify the indirect effect of each MC in explaining both racial and ethnic disparities in obesity and the body mass index (BMI) simultaneously. We considered a number of socio-demographic variables, individual factors, and environmental variables as potential MCs and found that some of the ethnic/racial differences in obesity and BMI were explained by the included variables.

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.

Background: Studies on symptomatic osteoarthritis suggest that Black patients report worse pain and symptoms compared with White patients with osteoarthritis. In this study, we aimed to quantify the relationship among variables such as overall health and socioeconomic status that may contribute to disparities in patient-reported outcomes. Methods: A total of 223 patients were enrolled. A mediation analysis was used to evaluate cross-sectional associations between race and the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire, which was administered to patients prior to undergoing primary total knee arthroplasty. Results: Black patients had worse KOOS pain, symptoms, and activities of daily living subscale scores than White patients. In our cohort, Black patients were younger, more likely to be female, and more likely to report lower educational status. We identified age, sex, Charlson Comorbidity Index, and education as partial mediators of racial disparities in KOOS subscale scores. Insurance status, deformity, radiographic (Kellgren-Lawrence) grade, C-reactive protein level, marital status, body mass index, and income did not show mediating effects. We found that, if age and sex were equal in both cohorts, the racial disparity in KOOS symptom scores would be reduced by 20.7% and 9.1%, respectively (95% confidence intervals [CIs], −5.1% to 47% and −5.5% to 26.3%). For KOOS pain scores, age and education level explained 18.9% and 5.1% of the racial disparity (95% CIs, −0.6% to 37% and −10.8% to 22.9%). Finally, for KOOS activities of daily living scores, education level explained 3.2% of the disparity (95% CI, −19.4% to 26.6%). Conclusions: No single factor in our study completely explained the racial disparity in KOOS scores, but our findings did suggest that several factors can combine to mediate this disparity in outcome scores. Quantification of variables that mediate racial disparity can help to build models for risk adjustment, pinpoint vulnerable populations, and identify primary points of intervention. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Mediation analysis is widely used to identify significant mediators and estimate the mediation (direct and indirect) effects in causal pathways between an exposure variable and a response variable. In mediation analysis, the mediation effect refers to the effect transmitted by mediator intervening the relationship between an exposure variable and a response variable. Traditional mediation analysis methods, such as the difference in the coefficient method, the product of the coefficient method, and counterfactual framework method, all require several key assumptions. Thus, the estimation of mediation effects can be biased when one or more assumptions are violated. In addition to the traditional mediation analysis methods, Yu et al. proposed a general mediation analysis method that can use general predictive models to estimate mediation effects of any types of exposure variable(s), mediators and outcome(s). However, whether this method relies on the assumptions for the traditional mediation analysis methods is unknown. In this paper, we perform series of simulation studies to investigate the impact of violation of assumptions on the estimation of mediation effects using Yu et al.’s mediation analysis method. We use the R package mma for all estimations. We find that three assumptions for traditional mediation analysis methods are also essential for Yu et al.’s method. This paper provides a pipeline for using simulations to evaluate the impact of the assumptions for the general mediation analysis.

BackgroundThe evidence for the conventional wisdom that debriefing quality determines the effectiveness of learning in simulation-based training is lacking. We investigated whether the quality of debriefing in using simulation-based training in team training correlated with the degree of learning of participants.MethodsForty-two teams of medical and undergraduate nursing students participated in simulation-based training sessions using a two-scenario format with after-action debriefing. Observers rated team performance with an 11-item Teamwork Assessment Scales (TAS) instrument (three subscales, team-based behaviours (5-items), shared mental model (3-items), adaptive communication and response (3-items)). Two independent, blinded raters evaluated video-recorded facilitator team prebriefs and debriefs using the Objective Structured Assessment of Debriefing (OSAD) 8-item tool. Descriptive statistics were calculated, t-test comparisons made and multiple linear regression and univariate analysis used to compare OSAD item scores and changes in TAS scores.ResultsStatistically significant improvements in all three TAS subscales occurred from scenario 1 to 2. Seven faculty teams taught learners with all scores ≥3.0 (except two) for prebriefs and all scores ≥3.5 (except one) for debriefs (OSAD rating 1=done poorly to 5=done well). Linear regression analysis revealed a single statistically significant correlation between debrief engagement and adaptive communication and response score without significance on univariate analysis.ConclusionsQuality of debriefing does not seem to increase the degree of learning in interprofessional education using simulation-based training of prelicensure student teams. Such a finding may be due to the relatively high quality of the prebrief and debrief of the faculty teams involved in the training.

BACKGROUND China is the largest tobacco producer and has the highest number of tobacco consumers in the world. Extensive research has demonstrated ways that social media can assist in quitting smoking. WeChat is the most commonly used social media platform in China; however, it has not yet been used for smoking cessation interventions. OBJECTIVE The objectives of this study are (1) to evaluate the effectiveness of a WeChat-based smoking cessation intervention; and (2) to examine a possible synergistic effect of integrating oral health and smoking-related information into a tailored, Transtheoretical Model (TTM) guided smoking cessation intervention. METHODS Eligible adults were recruited through WeChat from July 1 to August 6, 2019, to participate in a 3-arm, single-blinded, randomized controlled trial. 403 participants were enrolled and randomized into three groups: Standard Group (smoking cessation intervention only, n=136), Enhanced Group (smoking cessation + oral health education interventions, n=136), or Waitlist Group (delayed smoking cessation intervention, n=132). The intervention was delivered through WeChat with total of three weeks. Participants were asked to complete questionnaires at baseline and follow-up assessments as well as process evaluation at each intervention week. The primary outcome was Stage of Change, and the secondary outcomes were 7-day Point Prevalence Abstinence (PPA), 24-hour PPA, daily cigarette use, and nicotine dependence at 4 weeks follow-up after intervention comparing intervention groups and control group. The overall attrition rate was 46%. Paired t-tests, McNemar tests, and linear and logistic regression were used to examine differences in smoking cessation outcomes within and between groups. RESULTS Compared to baseline, at follow-up, all groups experienced smokers had significantly greater reduction in nicotine dependence scores (Standard: 1.8; Enhanced: 1.9, and Waitlist: 0.4). At 4-week follow-up, compared to the Waitlist Group, smokers from the Enhanced Group and the Standard Group had significantly lower nicotine dependence scores, lower daily cigarette use, and were more likely to have stage of change progression movement. Participants in Enhanced Group (β=-1.28, 95%CI: -2.13, -0.44) and the Standard Group (β=-1.13, 95%CI: -1.95, -0.30) also reported larger change in nicotine dependence score, compared to participants in the Waitlist Group. CONCLUSIONS This WeChat-based intervention was overall effective for smoking cessation, with enhanced cessation when additionally incorporating an oral health education intervention. Future smoking cessation programs should consider inclusion of oral health education. More broadly, in light of continued social distancing, WeChat could be considered as a platform for smoking cessation and other behavioral interventions.

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.

Mediation analysis refers to the process of making inferences on effects of third variables that intervene in the relationship between an exposure and response variable. The relationships among variables can be modelled by generalized linear models (GLM). However, GLM are not sufficient to describe relationships among variables when there are nonlinear relationships and potential interaction effects. A general mediation analysis method was developed using not only GLMs, but also multiple additive regression trees and smoothing splines by Yu and Li (2017). The method is implemented in the R package, mma. In this paper, we developed SAS macros so that functions in the mma package can be called and the mediation analysis performed in the SAS environment. Funding statement: Research reported in this publication was supported by the National Institute On Minority Health And Health Disparities of the National Institutes of Health under Award Number R15MD012387. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Background: The objective of this study was to determine the effect of an adhesive layer and its photopolymerization on the microleakage of sealants. Study design: 0.5mm-deep standardized fissurectomies were performed on extracted molars (n = 72). Teeth were randomly assigned to 3 different sealant materials (n = 24/group). Teeth were further divided to receive sealants with or without an adhesive layer. Each sealant with adhesive was also divided into two groups: adhesive was light-cured separately or light cured together with the sealant. Following thermocycling, microleakage was assessed using dye penetration and image analysis. Data was analyzed using ANOVA and Tukey's studentized ranged HSD tests. Results: Microleakage was not affected by type of sealant material (p>0.05) but was significantly influenced by application (p0.05). Conclusion: An adhesive layer should be placed beneath sealants, but whether it should be light cured or left uncured before sealant placement varies by the sealant type.

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.

Objective: The purpose of this study was to determine if changes in dental development are associated with Attention Deficit Hyperactivity Disorder (ADHD) or ADHD medications. Study Design: This retrospective chart review evaluated the dental age of 128 patients between 6 and 16 years of age using the Demirjian method from the following two groups a) children with ADHD b) unaffected children. The ADHD group was further stratified into four groups according to the medication type. The impact of ADHD on dental age difference (the difference between dental age and chronologic age) was analyzed using T-test and the association between medication type and dental age difference was analyzed through one way ANOVA. Results: The mean difference between estimated dental age and chronologic age (dental age difference) for all subjects was 0.80 years. There was no significant dental age difference in subjects with ADHD and the control group (0.78±1.28vs. 0.84 ±1.09 years respectively; P=0.75) and there was no significant difference in dental age difference and type of medication (P=0.84). Conclusion: No significant difference was found between children with ADHD and unaffected children with respect to dental age difference. No significant differences were found in dental age difference in the four medication groups.

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.