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Context The 2020 Standards for the Accreditation of Professional Athletic Training Programs from the Commission on Accreditation of Athletic Training Education require programs to include at least one immersive clinical experience (ICE) in their clinical education curricula. Yet, it is unknown whether ICEs provide more opportunities and benefits than nonimmersive clinical experiences (N-ICEs). The purpose of this study was to compare characteristics of patient encounters (PEs) that occurred during ICEs and N-ICEs. Design Multisite panel design. Setting Twelve professional programs (5 undergraduate, 7 graduate). Patients or Other Participants Three hundred thirty-eight athletic training students logged PEs in the E*Value system. Main Outcome Measures For each PE, students reported clinical experience type (ICE, N-ICE), clinical site type, student role (observed, assisted, performed), diagnoses reported, and procedure(s) performed. Descriptive statistics were used to summarize PE characteristics. Generalized estimating equations were used to compare student role and clinical site type during PEs in ICEs and N-ICEs (P < .05). Results A total of 10 999 PEs occurred at ICEs and 18 228 PEs occurred at N-ICEs. Sixty-four percent of ICEs and 67.2% of N-ICEs occurred at collegiate settings. Students performed 70.6% of reported PEs during ICEs, and 72% of PEs at N-ICEs. Participants averaged 0.80 ± 0.64 diagnoses and 1.35 ± 1.12 procedures per PE during ICEs, compared with 0.82 ± 0.63 diagnoses and 1.33 ± 1.04 procedures per PE during N-ICEs. No significant differences between ICEs and N-ICEs were found in either student role (P = .50) or clinical site type (P = .71). Conclusion(s) Programs may intend to use ICEs later in their curricula to demonstrate progressive clinical autonomy; however, we found no statistically significant differences in student role for ICEs versus N-ICEs. The ICEs examined in this study may have been implemented without specific objectives, which may explain the lack of characteristic differences between the clinical experience types.

Context To enhance the quality of patient care, athletic training students (ATSs) should experience a wide variety of clinical practice settings, interact with diverse patient populations, and engage with patients who have a wide variety of conditions. It is unclear in what ways, if any, ATSs have diverse opportunities during clinical experiences. Objective To describe the characteristics of patient encounters (PEs) ATSs engaged in during clinical experiences. Design Multisite panel design. Setting Twelve professional athletic training programs (5 bachelor's, 7 master's). Patients or Other Participants A total of 363 ATSs from the athletic training programs that used E*Value software to document PEs during clinical experiences. Main Outcome Measure(s) During each PE, ATSs were asked to log the clinical site at which the PE occurred (college or university, secondary school, clinic, or other), the procedures performed during the PE (eg, knee evaluation, lower leg flexibility or range of motion, cryotherapy), and the patient's diagnosis, with the International Classification of Diseases, Tenth Revision code (eg, S83.512A knee sprain, anterior cruciate ligament). Results A total of 30 630 PEs were entered by 338 ATSs across 278 unique clinical settings. More than 80% of PEs occurred in college or university and secondary school settings. More than half of the diagnoses were categorized as affecting the lower body region. Examination and evaluation procedures and application of therapeutic modality procedures each contributed approximately 27% of procedures. Conclusions It was surprising that ATSs were not gaining experience in all clinical practice settings in which athletic trainers commonly practice. Our data suggest that students may be consigned to working with patients who have more frequently occurring injuries, which may not prepare them for the realities of autonomous clinical practice. These findings indicate that directed efforts are needed to ensure that ATSs are provided opportunities to engage with diverse patient populations who have a variety of conditions in an array of clinical site types during their clinical experiences.

Patient-centered care (PCC) is a core competency that should be required by all healthcare education programs, but little is known about its implementation in athletic training clinical experiences. Therefore, we examined characteristics of patient encounters documented by athletic training students implementing PCC behaviors. A multisite panel design was used to recruit 363 students from twelve professional athletic training programs (five undergraduate, seven graduate). Over 1.5 years, clinical experience patient encounter data were logged in E*Value Case Logs, including student role during the encounter, length of encounter, and clinical site. Generalized estimating equations models characterized the likelihood students included PCC behaviors in 30,522 encounters. Discussing patient goals was associated with student role (χ2(2) = 40.6, p < 0.001) and length of encounter (χ2(4) = 67.6, p < 0.001). Using patient-reported outcome measures was associated with student role (χ2(2) = 21.6, p < 0.001), length of encounter (χ2(4) = 34.5, p < 0.001), and clinical site (χ2(3) = 17.3, p = 0.001). Implementing clinician-rated outcome measures was affected by length of encounter (χ2(4) = 27.9, p < 0.001) and clinical site (χ2(3) = 8.6, p = 0.04). PCC behaviors were largely associated with student role and length of encounters; clinical site had less impact. Athletic training educators should emphasize progressive autonomous supervision with preceptors and encourage students to facilitate slightly longer patient visits, when possible, to incorporate more PCC behaviors.

Objective The objective of this systematic review was to investigate if a positive vestibular or oculomotor screening is predictive of recovery in patients following concussion. Data Sources Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to search through PubMed, Ovid Medline, SPORTDiscuss, and the Cochrane Central Register of Controlled Trials and hand searches of included articles. Study Selection Two authors evaluated all articles for inclusion and assessed their quality using the Mixed Methods Assessment Tool. Data Extraction After quality assessment was completed the authors extracted recovery time, vestibular or ocular assessment results, study population demographics, number of participants, inclusion and exclusion criteria, symptom scores, and any other outcomes of assessments reported in the included studies. Data Synthesis Data were critically analyzed by two of the authors and categorized into tables with respect to each article's ability to answer the research question. Many patients who have vision, vestibular, or oculomotor dysfunction appear to have longer recovery times than patients who do not. Conclusions Studies routinely report that vestibular and oculomotor screenings are prognostic of time to recovery. Specifically, a positive Vestibular Ocular Motor Screening test appears to predict longer recovery consistently.

While religious participation is positively associated with health, and faith traditions often promote wholesome behavior among followers, religious beliefs endorsing the notion of illness as punishment for sin can be negatively related to health. To date, little is known about the correlates of this belief. This study examined demographic characteristics and religiosity as predictors of the belief that illness occurs as punishment for sin in a national probability sample of African American adults. Of 3,173 participants completing a telephone survey, 2,172 (68.45%) moderately endorsed belief in illness as punishment for sin (mean of 16 [SD=4.59] out of possible 32). Spearman correlations and linear regression modeling were conducted. Findings suggested that participants who were men, less educated, with lower income levels, lower religious beliefs, greater religious participation, greater use of negative religious coping, and both active and passive spiritual health locus of control beliefs, reported significantly stronger belief in illness as punishment for sin. Age, employment, and positive religious coping were not significant predictors. Psychologists, counselors, and health professionals working with African Americans may consider these findings in helping clients find healthy ways to reflect on their illnesses in collaboration with clergy, that are client-centered and respectful of their faith traditions.

Context There is limited evidence regarding the assessment of single-item patient-reported outcomes when patients are medically cleared to return-to-sport following a lateral ankle sprain (LAS) injury. Objective To evaluate self-report of improvement in health status, pain, function, and disability at return-to-sport following a LAS. Design Descriptive study. Setting Sixty-nine athletic training facilities across 24 states. Patients or Other Participants Six hundred and thirty-seven patients (male=53.2%) were included in our final analysis. Patients were diagnosed with a LAS, restricted from sport following injury, and subsequently medically cleared to return-to-sport within 60 days were included. Main Outcome Measures Descriptive statistics were used to summarize scores for health status (Global Rating of Change), pain (Numeric Pain Rating Scale), function (Global Rating of Function), and disability (Global Rating of Disability). Mann-Whitney U Tests were used to compare score differences between sexes. A Kaplan-Meier analysis was performed to provide a visual depiction of sex differences in time to return-to-sport. Results Most patients sustained a LAS injury while participating in basketball, football, or soccer and cleared to return-to-sport 8 days following injury. Over two-thirds of patients reported a meaningful improvement in health status between time of injury and return-to-sport. However, many reported some level of deficits related to pain (65.1%), function (86.2%), and disability (35.8%) at return-to-sport. No differences were noted between males and females for pain (p=.90), function (p=.68), change (p=.45), or disability (p=.21) at return-to-sport. Males, however, returned to sport slightly sooner than females (p=.025). Conclusions Despite self-perceived improvements in health status from time of injury, patients typically return-to-sport with deficits in pain, function, and disability following a LAS. Patients may be returning to unrestricted sport participation before they feel their bodies have fully recovered from the injury. Level of Evidence Level III; retrospective cohort study.

There are conflicting reports on the efficacy of exercise in chronic venous insufficiency (CVI). Exercise in water or aquatic activity (AA) can have additional advantages. We sought to evaluate the clinical effects of AA in CVI in a randomized prospective open label fashion.A total of 201 patients with advanced CVI were randomized to receive AA vs no such treatment. In the Aquatic Group (AG), 91 patients reached the 24-month follow-up point, and in the Control Group (CG), 90 patients did. The primary efficacy end point was a predefined reduction of ≥4 points in the modified Venous Clinical Severity Score (VCSS) at 3 months. Instruments of venous disease severity and quality of life were compared at baseline, 3 months, and 24 months between and within the two groups. These included the modified VCSS, Villalta score, leg and thigh circumference, the Physical Health Component of the 36-Item Short Form Health Survey, and the Venous Insufficiency Epidemiological and Economic Study Quality of Life/Symptom scores. Aquatic activity consisted of a minimum of 15 minutes of walking in a swimming pool at 1 m/s, 3 times/wk for 3 months.The primary end point of 4-point reduction in the modified VCSS at 3 months was reached in 28% of AG and 3% of CG (odds ratio = 12.08; 95% confidence interval: 3.51, 41.59; P .001). Comparison of changes in secondary end points from baseline to 24 months between AG and CG demonstrated the following: modified VCSS -4.08 ± 2.08 vs -1.15 ± 1.26, Villalta score -4.00 ± 2.68 vs -1.01 ± 1.34, thigh circumference -3.40 ± 1.78 cm vs -1.40 ± 2.55 cm, leg circumference -1.27 ± 1.34 cm vs -0.49 ± 1.21 cm, Physical Health Component of the 36-Item Short Form Health Survey 3.82 ± 2.36 vs 1.16 ± 1.18, Venous Insufficiency Epidemiological and Economic Study Quality of Life 3.35 ± 1.67 vs 1.30 ± 1.43, and Venous Insufficiency Epidemiological and Economic Study Symptom 3.53 ± 1.71 vs 1.23 ± 1.26 (P .001 for all comparisons; ± denotes mean ± standard deviation).The addition of AA to the treatment of patients with advanced CVI is safe and effective, leading to a significant improvement in clinical status and quality of life. These beneficial changes occur rapidly within 3 months of initiation of AA and are continued at a slower rate of improvement from 3 months to 2 years.

To evaluate content validity and interrater reliability for acuity tools developed for the antepartum and neonatal intensive care unit (NICU) patient population.Antepartum and NICU acuity tools were developed to better evaluate nurse staffing assignment equity and patient needs. Following several iterations with staff nurses and nurse leaders, content validity of the acuity tools was established via a panel of experts in each substantive area using the Content Validity Index. The final tools were then evaluated for interrater reliability using Intraclass Correlation.Content validity for the Antepartum Acuity Tool was S-CVI/Ave = 0.87 and for the NICU Acuity Tool was S-CVI/Ave = 0.98. Interrater Reliability for the Antepartum Acuity tool was ICC = 0.88, and the NICU Acuity Tool was ICC = 0.95.These tools have established content validity and interrater reliability and are appropriate for use in the antepartum and NICU settings to determine patient acuity and promote appropriate nurse-to-patient assignments.

To estimate scale scores for patient-reported outcome (PRO) measures that classify patients as improved or unimproved at days 3 and 10 post-concussion.Data from 187 adolescent patients who sustained a concussion (150 males, 32 females, 5 not reported) were analyzed. Patients completed the Pediatric Quality of Life Inventory (PedsQL), PedsQL Multidimensional Fatigue Scale (MFS), Headache Impact Test (HIT-6), and Global Rating of Change (GROC) on days 3 and 10 post-concussion. Dependent variables: PedsQL total score, 3 MFS subscale scores [general (MFS-GF), sleep (MFS-SLF), cognitive (MFS-CF) fatigue], and HIT-6 total score. Higher scores on PedsQL and MFS indicate better health; lower scores on HIT-6 indicate less impact on headache-related health. GROC ascertained patient-perceived magnitude of change in health status since concussion. Receiver Operating Characteristic Curve analyses estimated PRO cut-point scores that classified patients as improved or unimproved.Day 3 PRO cut-points: PedsQL total = 90; MFS-GF = 73; MSF-CF = 85; MFS-SLF = 81; and HIT-6 total = 54. Day 10 PRO cut-points: PedsQL total = 91; MFS-GF = 85; MFS-CF = 85; MFS-SLF = 90; and HIT-6 total = 51.Our results define PedsQL, MFS, and HIT-6 scores as they relate to perceived improvement following concussive injuries. Cut-point scale scores help clinicians interpret concussion PROs and make informed decisions during the management of patients with concussion.

Background: Uncontrolled hypertension is a leading risk factor for cardiovascular disease. To ensure continuity of care, community health centers (CHCs) nationwide implemented virtual care (telehealth) during the pandemic. CHCs use the Centers for Medicare & Medicaid Services (CMS) 165v8 Controlling High Blood Pressure measure to report blood pressure (BP) control performance. CMS 165v8 specifications state that if no BP is documented during the measurement period, the patient’s BP is assumed uncontrolled. Objective: To examine trends in BP documentation and control rates in CHCs as telehealth use increased during the pandemic compared with pre-pandemic period. Methods: We assessed documentation of BP measurement and BP control rates from December 2019 - October 2021 among persons ages 18-85 with a diagnosis of hypertension who had an in-person or telehealth encounter in 11 CHCs. Rates were compared between CHCs that did and did not implement self-measured BP monitoring (SMBP). Results: The percent of patients with no documented BP measurement was 0.5% in December 2019 and increased to 15.2% (overall), 25.6% (non-SMBP CHCs), and 11.2% (SMBP CHCs) by October 2021. BP control using CMS 165v8 was 63.5% in December 2019 and decreased to 54.9% (overall), 49.1% (non-SMBP), and 57.2% (SMBP) by October 2021. When assessing BP control only in patients with documented BP measurements, CHCs largely maintained BP control rates (63.8% in December 2019; 64.8% (overall), 66.0% (non-SMBP), and 64.4% (SMBP) by October 2021). Conclusions: The transition away from in-person to telehealth visits during the pandemic likely increased the number of patients with hypertension lacking a documented BP measurement, subsequently negatively impacting BP control using CMS 165v8. There is an urgent need to enhance the flexibility of virtual care, improve EHR data capture capabilities for patient-generated data, and implement expanded policy and systems-level changes for SMBP, an evidence-based strategy that can build patient trust, increase healthcare engagement, and improve hypertension outcomes.

Context: Concussions are shown to hinder multiple health dimensions, including health-related quality of life (HRQOL), suggesting a need for a whole-person approach to assessment and treatment. Patient-reported outcome measures are one method to gather the patient’s perspective regarding their HRQOL. Objective: To evaluate perceived HRQOL using the Patient-Reported Outcomes Measurement Information System Pediatric-25 subscale in patients throughout concussion recovery. Design: Prospective cohort, descriptive survey. Setting: There were 9 high school athletic training facilities. Participants: A total of 70 patients with diagnosed concussions (51 males, 7 females, 12 unreported; age = 15.7 [0.9] y, height = 174.6 [8.4] cm, mass = 72.8 [14.8] kg, grade = 10.0 [0.9] level). Interventions: Patient-Reported Outcomes Measurement Information System Pediatric-25 was administered at 3 days, 10 days postconcussion, and return to play (RTP). Main Outcome Measures: Patient-Reported Outcomes Measurement Information System Pediatric-25 subscale T scores and self-reported concussion history (yes/no). Results: A total of 70 patients completed the study. For the Pediatric-25 subscales, the severity of problems associated with Physical Function Mobility, Anxiety, Depression, Fatigue, and Pain Interference were highest 3 days postconcussion, decreasing at 10 days and RTP (all p p p > .05). Ceiling and floor effects were present in all subscales throughout each timepoint, except for Physical Function Mobility (14.7%), and pain interference (11.8%) at day 3 postinjury. Conclusions: Patients who had suffered a concussion improved from day 3 through RTP on multiple health domains as demonstrated through the Pediatric-25 subscales. These findings highlight the need for health care professionals to serially monitor HRQOL and social factors that may affect the patient postconcussion as part of a multifactorial assessment. Ceiling effects in high functioning adolescent athletes were present; thus, efforts should be made to identify appropriate scales for use in managing recovery in athletic populations.

Identifying risk factors for prolonged recovery following concussion can assist clinicians with appropriate management strategies. It is thought that athletes who continue to participate following a hit to the head or body may take longer to recover following a concussion diagnosis. To systematically review the body of literature regarding the effect of delayed reporting and delayed presentation to medical providers on concussion recovery times. Systematic review with meta-analysis. PubMed, Ovid Medline, SPORTDiscus, Cochrane Central Register of Controlled Trials and hand searches of reference lists. All the searches were performed in April 2020. Studies included an investigation of immediate versus delayed reporting or early versus late presentation following a concussion, were published in the past ten years, and were level 4 evidence or higher. 12 studies were included. Patients who continued play or delayed reporting their concussion had significantly longer recovery times (standardized mean difference = 0.36 days (95%CI 0.066, 0.662) than those who immediately reported or were removed from play (p = 0.017). Expressed in raw scores, those who immediately reported recovered in 5.4 days (95% CI − 10.14, − 0.75) fewer than delayed reporters. Comparable results were found for post-concussion symptom scores (p = 0.034) with immediate reporters demonstrating lower symptom severity scores. Our qualitative synthesis found patients who presented earlier to a concussion specialist tended to recover faster than those who presented later. Patients who delayed reporting or continued play had longer recovery times compared to their immediately-reporting peers. Providers should ask concussion patients approximately how long they waited to report their injury, and also focus educational efforts on encouraging immediate reporting of concussion.

Background As the role of a health care system’s influence on nurse burnout becomes better understood, an under-standing of the impact of a nurses’ work environment on burnout and well-being is also imperative. Objective To identify the key elements of a healthy work environment associated with burnout, secondary trauma, and compassion satisfaction, as well as the effect of burnout and the work environment on nurse turnover. Methods A total of 779 nurses in 24 critical care units at 13 hospitals completed a survey measuring burnout and quality of the work environment. Actual unit-level data for nurse turnover during a 5-month period were queried and compared with the survey results. Results Among nurses in the sample, 61% experience moderate burnout. In models controlling for key nurse characteristics including age, level of education, and professional recognition, 3 key elements of the work environment emerged as significant predictors of burnout: staffing, meaningful recognition, and effective decision-making. The latter 2 elements also predicted more compassion satisfaction among critical care nurses. In line with previous research, these findings affirm that younger age is associated with more burnout and less compassion satisfaction. Conclusions Efforts are recommended on these 3 elements of the work environment (staffing, meaningful recognition, effective decision-making) as part of a holistic, systems-based approach to addressing burnout and well-being. Such efforts, in addition to supporting personal resilience-building activities, should be undertaken especially with younger members of the workforce in order to begin to address the crisis of burnout in health care.

Statins are an important but underutilized therapy to prevent cardiovascular events, particularly in high-risk patients. To increase use of statin therapy in high-risk patients, the Centers for Disease Control and Prevention funded a project led by the National Association of Community Health Centers to discover reasons for statin underuse in health centers and identify possible leverage points, particularly among vulnerable and underserved patients. The project further sought to develop training and educational materials to improve statin prescribing for and acceptance in eligible high-risk patients. As a first step, investigators implemented a questionnaire to clinical providers (n = 45) at health centers participating in the project to obtain their perspective on barriers to optimal statin use. We used the practical robust implementation and sustainability model (PRISM) domains to frame the overall project and guide the development of our questionnaire. This paper summarizes top perceived barriers to patient and health system/provider statin initiation and sustainment, as well as facilitators to prescribing, using PRISM as an organizing framework. Our questionnaire yielded important suggestions related to public awareness, education materials, health information technology (HIT)/data solutions, and clinical guidelines as key factors in optimizing statin use. It also informed the design of patient education resources and provider training tools. Future directions include using the full application of the PRISM implementation science model to assess how well our educational and training resources help overcome barriers to statin use in high-risk patients, including evaluating how key contextual factors influence successful implementation.

OBJECTIVE To systematically review the effects of cortical bone thickness (CBT) and bone mass density (BMD) on miniscrew success rates. METHODS MEDLINE, the Cochrane Library and Scopus were searched up to June 2020. Of a total of 5734 articles, seven studies were finally selected for the review. RESULTS The overall mean success rate weighted by the number of miniscrews was 87.21% (89.87% in the maxilla and 79.24% in the mandible). There was a significantly higher success rate for miniscrews placed in the maxilla compared with those in the mandible (P < .05). CBT showed small positive effect on the success rate of the miniscrews although it failed to reach a statistical significance. The cortical BMD had a minimal effect on the success of the miniscrews. The cancellous BMD demonstrated a very strong effect on the success of the miniscrews in the maxilla, whereas it showed a moderately negative effect in the mandible. LIMITATIONS Because of the small number and clinical heterogeneity of the included studies, the results should be interpreted with caution. Further randomized clinical studies with a large sample size are recommended.

PURPOSE Being swamped is defined as "when you are so overwhelmed with what is occurring that you are unable to focus on the most important thing." The purpose of this study was to explore the experience of being swamped in the clinical setting among nurses who are members of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) and the relationship of the level of being swamped to adherence to the nurse staffing guidelines. STUDY DESIGN AND METHODS A 25-item survey was sent to ~21,000 AWHONN members by email in the Fall of 2018. It was completed by 1,198 members, representing 49 states and the District of Columbia. Questions explored timing and causes of being swamped, its effect on health care team members and patients, what helps when a nurse feels swamped, and nurses' reports of their hospital following the AWHONN nurse staffing guidelines. RESULTS Twenty-eight percent of nurses reported being swamped daily or multiple times per day. Situations that contribute to being swamped include assignments that are too heavy, interruptions, critical patient situations, and mistakes made by others that nurses are expected to catch and fix. Teamwork and someone stepping in to help without being asked were identified as most helpful when a nurse feels swamped. Nurses practicing in hospitals following the AWHONN nurse staffing guidelines always or most of the time reported less frequency of being swamped as compared with those in hospitals that followed the guidelines some of the time, or rarely (p < 0.001). CLINICAL IMPLICATIONS Being swamped is a common phenomenon among AWHONN members responding to the survey. The reported incidence of being swamped daily is significantly associated with the extent to which hospitals follow the AWHONN nurse staffing guidelines. Nurse leaders, hospital administrators, and staff nurses must work together to identify and initiate timely, feasible nurse staffing solutions that support the safety of patients and nurses.

Accurately measuring tongue space is challenging, but this information can be useful to many dental specialties. This study was intended to estimate the reliability of using cone-beam computed tomography (CBCT) to measure tongue space, which includes tongue volume and the oral cavity air capacity. For this preliminary study, CBCT images from ten participants (five females and five males, mean age of 29.8 ± 3.3 years) were available for evaluation. Each participant was radiographed two times (T0 and T1). The average time between T0 and T1 was 15.8 ± 3.7 days. CBCT scans were standardized to reduce variability. Three-dimensional landmarks were established to identify tongue space and 3D image analysis software (SimPlant® 17 Pro; Materialise Dental, Leuven, Belgium) was used to measure the volume circumscribed by the landmarks. Two investigators independently calculated airway, tongue dimensions, and total tongue space for CBCT image T0 twice (day 1 and day 14), and T1 once. Intraclass correlation coefficients (ICCs) were used to estimate intra-rater and inter-rater reliability. Bland–Altman charts were constructed to demonstrate agreement within and between raters. The intra-rater and inter-rater ICCs of the CBCT measurements at T0 were excellent (> 0.90). Measurements for T0 vs. T1 show good (0.75–0.90) intra-rater and excellent (> 0.90) inter-rater reliability. Bland–Altman charts show that 90–95% of the total measurements fall within the 95% limits of agreement for both intra- and inter-rater pairs The results of this preliminary study suggest that the landmarks chosen to measure the overall tongue space are reproducible and can be measured clearly using CBCT.

Context Federally funded Community, Migrant, and Homeless Health Centers provide health services to the most vulnerable communities in the United States. However, little is known about their capabilities and processes for providing vaccinations to adults. Program We conducted the first national survey of health centers assessing their inventory, workflow, capacity for, and barriers to provision of routinely recommended adult vaccines. In addition, we asked health center leaders' perceptions regarding best practices and policy recommendations for adult vaccinations. Implementation A survey was developed on the basis of domains elicited from advisory panels and focus groups and was sent electronically to leaders of 762 health centers throughout the United States and its territories; data were collected and analyzed in 2018. Evaluation A total of 319 survey responses (42%) were obtained. Health centers reported stocking most routinely recommended vaccines for adults; zoster vaccines were not stocked regularly due to supply and storage issues. Respondents most commonly reported adequate reimbursement for vaccination services from private insurance and Medicaid. Most vaccinations were provided during primary care encounters; less than half of health centers reported providing vaccines during specialist visits. Vaccines administered at the health center were most commonly documented in an open field of the electronic health record (96%) or in an immunization information system (72%). Recommendations for best practices related to better documentation of vaccinations and communication with immunization information systems were provided. Discussion Health centers provide most adult vaccines to their patients despite financial and technological barriers to optimal provisioning. Further studies at point of care could help identify mechanisms for system improvements.

Context Recently, calls to conduct comparative effectiveness research (CER) in athletic training to better support patient care decisions have been circulated. Traditional research methods (eg, randomized controlled trials [RCTs], observational studies) may be ill suited for CER. Thus, innovative research methods are needed to support CER efforts. Objectives To discuss the limitations of traditional research designs in CER studies, describe a novel methodologic approach called the point-of-care clinical trial (POC-CT), and highlight components of the POC-CT (eg, incorporation of an electronic medical record [EMR], Bayesian adaptive feature) that allow investigators to conduct scientifically rigorous studies at the point of care. Description Practical concerns (eg, high costs and limited generalizability of RCTs, the inability to control for bias in observational studies) may stall CER efforts in athletic training. In short, the aim of the POC-CT is to embed a randomized pragmatic trial into routine care; thus, patients are randomized to minimize potential bias, but the study is conducted at the point of care to limit cost and improve the generalizability of the findings. Furthermore, the POC-CT uses an EMR to replace much of the infrastructure associated with a traditional RCT (eg, research team, patient and clinician reminders) and a Bayesian adaptive feature to help limit the number of patients needed for the study. Together, the EMR and Bayesian adaptive feature can improve the overall feasibility of the study and preserve the typical clinical experiences of the patient and clinician. Clinical Advantages The POC-CT includes the basic tenets of practice-based research because studies are conducted at the point of care, in real-life settings, and during routine clinical practice. If implemented effectively, the POC-CT can be seamlessly integrated into daily clinical practice, allowing investigators to establish patient-reported evidence that may be quickly applied to patient care decisions. This design appears to be a promising approach for CER investigations and may help establish a “learning health care system” in the sports medicine community.

Context: Ankle sprains are common during sport participation and associated with long-term deficits in self-report of function. However, little is known of short-term changes in self-report of function following injury. The authors aimed to assess statistical and clinically meaningful changes in self-report of function, as measured by the Foot and Ankle Ability Measure (FAAM), during the first 2 weeks after an ankle sprain injury. Design: A retrospective analysis of electronic medical records. Methods: Eighty-eight patients, who were diagnosed with an ankle sprain injury by an athletic trainer, received usual care from an athletic trainer, and completed the FAAM during treatment at weeks 1 and 2 postinjury. The authors calculated the percentage of patients who reported clinically meaningful changes and used Wilcoxon signed-rank tests to compare differences in FAAM scores between time points. Results: Between weeks 1 and 2, significant differences were noted for the FAAM Activities of Daily Living (FAAM-ADL) (P P Conclusions: Patients report statistically significant and meaningful improvements in self-report of function during the first 2 weeks following ankle sprain injury. However, almost half of patients still report deficits in sport function at 2 weeks postinjury. Patient-reported outcome measures such as the FAAM, can help capture the patient’s perception of function and inform patient care decisions. Research efforts should explore individual response patterns to treatment.

This study assesses the effect of a nurse-designed SMART educational intervention on goal attainment, patient empowerment, and satisfaction.A mixed-methods study design was used.68 adults with cancer were recruited from an oncology research center and randomized to the immediate or waitlist control group. Empowerment was measured using the Patient Empowerment Scale, and health literacy was measured using the Cancer Health Literacy Test.Measures were completed by the immediate group at enrollment and by the waitlist control group after an eight-week waiting period to establish an updated baseline. Participants received four learning modules on goal setting and coaching to facilitate learning and activation of knowledge. Visit data were collected by nurses based on participants' written and oral responses.Goal attainment ranged from 67% to 100%. Patient empowerment scores were high at baseline and throughout. No significant differences were noted among the groups on goal attainment, empowerment, or satisfaction.RNs can deliver a SMART educational intervention using a universal health literacy approach to support adults with cancer in creating symptom management strategies and attaining self-care goals.

The purpose of this study was to evaluate midpalatal bone density (BD) by using cone-beam computed tomography (CBCT) according to gender, age, and vertical and horizontal skeletal patterns. CBCT images from 126 subjects (64 females and 62 males) were reoriented and analyzed in order to attain BD values at the midpalatal suture. Four age groups were used for classification (adolescence, 10 ≤ early < 14 years, 14 ≤ middle ≤ 17 years, and 17 < late ≤ 21 years; adult > 21 years). Vertical skeletal pattern categories were differentiated by the Frankfort horizontal line to mandibular plane angle (hypodivergent < 22°, 22° ≤ normovergent ≤ 28°, and 28° < hyperdivergent). Horizontal skeletal pattern differentiation was defined by ANB angle (Class III < 0°, 0° ≤ Class I ≤ 4°, and 4° < Class II). Females showed significantly higher BD than males (p < 0.001). As age increased, BD increased significantly (p < 0.001). There were no significant differences between vertical skeletal patterns. Class II showed significantly less BD than Class III (p < 0.05). With this information, clinicians can better understand BD trends of the midpalatal suture and, thus, better understand our patient’s anatomy and potential hurdles in successful treatment.

Cheryl Modica,1 Joy H Lewis,2 R Curtis Bay3 1National Association of Community Health Centers, Bethesda, MD, USA; 2Medicine and Public Health, SOMA Department of Public Health, School of Osteopathic Medicine in Arizona, A.T. Still University, Meza, AZ, USA; 3Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, Mesa, AZ, USACorrespondence: Cheryl ModicaNational Association of Community Health Centers, Inc., 7501 Wisconsin Avenue, Suite 1100W, Bethesda, MD, 20814, USATel +1 301 310 2250Email cmodica@nachc.orgIntroduction: Diabetes and pre-diabetes impact more than 114 million Americans. Federally qualified health centers (FQHCs) provide care to some of the most high-risk and underinsured individuals throughout the US, twenty-one percent of whom report being told they have diabetes, compared to 11% of the general adult population. It is widely agreed our health care system requires a transformation to effectively address diabetes and its complications.Objective: By applying the Value Transformation Framework (VTF) in health centers, the National Association of Community Health Centers (NACHC) aims to show improvements in diabetes control. This systematic strategy to transform the way health centers operate can lead to improvements in health outcomes, patient and staff experiences, costs, and equity (Quintuple Aim). Special attention is paid to the health centers’ infrastructure, people systems and care delivery systems.Methods: Evidence-based diabetes interventions, the learning community model, and the VTF were used together to drive system improvements and activate proven diabetes control practices within eight health centers. Multidisciplinary teams at select health centers in Georgia and Iowa, with their partner primary care associations, participated in this NACHC-led quality improvement project.Results: During the one-year intervention (January 2017–December 2017), the mean raw percentage of patients with HbA1c Poor Control decreased from 50.9% (range, 23.7– 70.4%) in January to 27.5% (range, 13.6– 37.4%) in December. This represents a relative improvement in diabetes control of 46%. The 1-year-intervention data also showed trends in the desired direction with statistically significant improvements related to the following interventions: a formal written clinical policy, standing orders, patient recall/outreach, performance data shared at the provider/team-level, and performance data shared at the site/organization level.Conclusion: A conceptual model focused on transforming health center systems, organized by the NACHC Value Transformation Framework and supported by a strong learning community, can lead to better diabetes control outcomes among patients seen at health centers.Keywords: vulnerable populations, hemoglobin A1c, quality improvement, health systems, interdisciplinary care

PURPOSE The purpose of this study was to evaluate potential benefits of use of an abdominal binder after cesarean birth. STUDY DESIGN AND METHODS A randomized controlled trial was conducted at a Magnet-designated, academic medical center in the southwest United States. English- and Spanish-speaking adult women scheduled for an elective cesarean birth were randomized to the intervention or control group. Outcomes were measured for the first 48 hours postoperatively, including pain, medication use, and self-reported symptom distress. RESULTS Randomization resulted in balanced groups. Women who used the abdominal binder after cesarean birth reported a decrease in pain after ambulation, whereas women in the control group reported an increase in pain after ambulation (p < .001). Women in the binder group reported less distress on the Breathe and Cough items of the Symptom Distress Scale than those in the control group. On postoperative day 2, women in the binder group used more ibuprofen (p = .002) and acetaminophen (p = .027) than the control group. CLINICAL IMPLICATIONS Use of an abdominal binder by women after cesarean birth can decrease pain, potentially enhancing speed of postoperative recovery. As a nursing intervention, abdominal binders may offer women a safe nonpharmacologic option to provide postoperative comfort.

Context:Altered diaphragm function is linked to decreased core stabilization, postural changes, and decreased function. Two clinical tests used to assess breathing are the Hi-lo and lateral rib expansion (LRE) tests. It is currently unknown how breathing classification based on these tests differ and how their results are affected by varying test positions.Objective:To compare the results of breathing tests when conducted in varying test positions.Design:Prospective cross-sectional study.Setting:University laboratory.Participants:A total of 50 healthy adults (females 31 and males 29; age 29.3 [4.1] y; height 170.0 [10.4] cm; weight70.7 [15.1] kg).Intervention(s):Hi-lo and LRE tests in supine, seated, standing, and half-kneeling body positions. All tests were recorded and later scored by a single examiner. A generalized estimating equations approach with breathing test and body position as factors was used for analysis. Pairwise comparison with Bonferroni correction was used to adjust for multiple tests. Statistical significance was set atP = .05, 2 tailed.Main Outcome Measures:Hi-lo and LRE tests were scored based on the presence or absence of abdominal excursion, LRE, and superior rib cage migration. Following scoring, results were classified as functional or dysfunctional based on observation of these criteria.Results:A significant breathing test × test position interaction (P P P P P = .52). In the LRE test, all positions were similar (P > .99) except for half-kneeling, which was significantly different from all other positions (P Conclusions:The Hi-lo test and LRE tests assess different breathing mechanics. Clinicians should use these tests in combination to gain a comprehensive understanding of a person’s breathing pattern. The Hi-lo test should be administered in multiple testing positions.

OBJECTIVE Our purpose was to determine the association between concussion recovery and health-related quality of life (HRQOL). SETTING Secondary school athletic training facilities. PARTICIPANTS Patients (N = 122) with a concussion. STUDY DESIGN Prospective, longitudinal cohort. MAIN MEASURES The Pediatric Quality-of-Life Inventory (PedsQL), PedsQL Multidimensional Fatigue Scale (MFS), and Headache Impact Test-6 (HIT-6) were completed at preseason and days 3 (D3), 10 (D10), and 30 (D30) postconcussion. The independent variable was the recovery group. RESULTS Interactions between group and time (P < .001) were noted for all PedsQL subscales, except Social Functioning (P = .75). Significantly lower scores were found among Prolonged than in Short on D3 (P < .05). Significant interactions (P < .001) were also noted for all MFS subscales. Pairwise comparisons for General and Sleep subscales revealed Prolonged had lower scores than Short and Moderate on D3 and D10. A group by time interaction was found for the HIT-6 (P < .001), with scores being higher (P < .01) in Prolonged than in Short on D3 and D10. CONCLUSIONS Adolescents with a prolonged recovery demonstrated lower HRQOL in the immediate days postinjury, particularly in physical and school functioning, fatigue, and headache. There was a strong association between recovery length and school functioning. Additional research is needed to understand how to minimize the impact of concussion on HRQOL.

Concussion symptoms are important self-reported indicators of recovery. The purpose of this study was to describe the symptom burden in the first 3 weeks postconcussion and estimate the strength of relationship between symptomatology and days postconcussion. Headache was the most commonly endorsed symptom during weeks 1 (71.1%), 2 (37.6%), and 3 (32.6%). Severity scores were negatively correlated with days postconcussion, p

We aimed to assess whether perceived pressure predicts concussion reporting intentions and behavior in youth, high school, and collegiate ice hockey athletes, and, secondarily, whether perceived pressure from stakeholders differed between sex or level of play.Online survey.One hundred fifty-two ice hockey athletes (males: n = 96, 63.2%; females: n = 55, 36.2%; missing: n = 1, 0.7%; age = 14.04 ± 3.6 years).Cross-sectional.Respondents answered a survey that elicited information about demography, perceived pressure from 6 stakeholders, and concussion reporting intentions and behavior. For the first aim, we used a generalized linear model to determine whether perceived pressure from any stakeholder predicted intention (symptom reporting, concussion reporting, and intention beliefs) or behavior ("all concussions," "not obvious concussions"; α.05) while controlling for level of play. To determine whether pressure from any stakeholder predicted symptom reporting behavior, we used logistic regression while controlling for level of play. For the second aim, to examine sex differences in perceived pressure from each stakeholder, we employed Mann-Whitney tests and to examine level of play differences, we used Kruskal-Wallis tests.Controlling for level of play, a 1-point increase in perceived pressure from parents and athletic administrators decreased concussion reporting intentions by 0.92 (P = .004) and 1.09 (P = .005) points, respectively. Perceived pressure from a sports medicine professional decreased intention beliefs by 0.17 (P = .029) points. Perceived pressure from stakeholders did not predict symptom reporting (P = .440) or "not obvious concussion" reporting (P = .655) behavior. We observed no difference in perceived pressure across stakeholders (all P values.05); however, collegiate ice hockey respondents perceived greater pressure from coaches than youth or high school athletes (P.001). We noted no other differences in perceived pressure across levels of play (all P values.05).Concussion reporting intentions were negatively influenced by perceived pressure from parents, athletic administrators, and sports medicine professionals, but these findings did not translate to reporting behavior.

Context: Plantar fasciitis (PF) is a common condition in active individuals. The lack of agreement on PF etiology makes treatment challenging and highlights the importance of understanding risk factors for preventive efforts. Objective: The purpose of this systematic review and meta-analysis was to determine what factors may put physically active individuals at risk of developing PF. Data Sources: CENTRAL, CINAHL, EMBASE, Gray Lit, LILACS, MEDLINE (PubMed), ProQuest, Scopus, SPORTDiscus, and Web of Science were searched through April 2018 and updated in April 2020. Study Selection: Studies were included if they were original research investigating PF risk factors, compared physically active individuals with and without PF, were written in English, and were accessible as full-length, peer-reviewed articles. Study Design: Systematic review and meta-analysis. Level of Evidence: Level 3, because of inconsistent definitions and blinding used in the included observational studies. Data Extraction: Data on sample characteristics, study design and duration, groups, PF diagnosis, and risk factors were extracted. The methodological quality of the studies was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology statement. When means and standard deviations of a particular risk factor were presented 2 or more times, that risk factor was included in the meta-analysis. Results: Sixteen studies were included in the systematic review and 11 risk factors in the meta-analysis. Increased plantarflexion range of motion (weighted mean difference [MD] = 7.04°; 95% CI, 5.88-8.19; P < 0.001), body mass index (MD = 2.13 kg/m2; 95% CI, 1.40-2.86; P < 0.001; I2 = 0.00%), and body mass (MD = 4.52 kg; 95% CI, 0.55-8.49; P = 0.026) were risk factors for PF. Conclusion: Interventions focused on addressing a greater degree of plantarflexion range of motion, body mass index, and body mass and their load on the force-absorbing plantar surface structures may be a good starting point in the prevention and treatment of active individuals with PF.

Context To enhance the quality of patient care, it is important that athletic trainers integrate the components of the core competencies (CCs; evidence-based practice [EBP], patient-centered care [PCC], health information technology [HIT], interprofessional education and collaborative practice [IPECP], quality improvement [QI], professionalism) as a part of routine clinical practice. In what ways, if any, athletic training students (ATSs) are currently integrating CCs into patient encounters (PEs) during clinical experiences is unclear. Objective To describe which professional behaviors associated with the CCs were implemented by ATSs during PEs that occurred during clinical experiences. Design Multisite panel design. Setting A total of 12 professional athletic training programs (5 bachelor's, 7 master's level). Patients or Other Participants A total of 363 ATSs from the athletic training programs that used E*Value software to document PEs during clinical experiences participated. Main Outcome Measure(s) During each PE, ATSs were asked to report whether professional behaviors reflecting 5 of the CCs occurred (the professionalism CC was excluded). Summary statistics, including means ± SDs, counts, and percentages were tabulated for the professional behaviors of each CC. Results Data from 30 630 PEs were collected during the study period. Professional behaviors related to EBP were the most frequently incorporated during PEs (74.3%, n = 22 773), followed by QI (72.3%, n = 22 147), PCC (56.6%, n = 17 326), HIT (35.4%, n = 10 857), and IPECP (18.4%, n = 5627). Conclusions It is unsurprising that EBP and PCC behaviors were 2 of the most frequently incorporated CCs during PEs due to the emphasis on these competencies during the past several years. However, it is surprising that ATSs did not incorporate behaviors related to either HIT (in 65% of PEs) or IPECP (in 82% of PEs). These findings suggest that directed efforts are needed to ensure that ATSs are provided opportunities to incorporate professional behaviors related to the CCs during clinical experiences.

Supplemental material, sj-docx-3-sph-10.1177_1941738120970976 for Risk Factors for Plantar Fasciitis in Physically Active Individuals: A Systematic Review and Meta-analysis by Karrie L. Hamstra-Wright, Kellie C. Huxel Bliven, R. Curtis Bay and Burcu Aydemir in Sports Health: A Multidisciplinary Approach

Supplemental material, sj-docx-2-sph-10.1177_1941738120970976 for Risk Factors for Plantar Fasciitis in Physically Active Individuals: A Systematic Review and Meta-analysis by Karrie L. Hamstra-Wright, Kellie C. Huxel Bliven, R. Curtis Bay and Burcu Aydemir in Sports Health: A Multidisciplinary Approach

Supplemental material, sj-docx-4-sph-10.1177_1941738120970976 for Risk Factors for Plantar Fasciitis in Physically Active Individuals: A Systematic Review and Meta-analysis by Karrie L. Hamstra-Wright, Kellie C. Huxel Bliven, R. Curtis Bay and Burcu Aydemir in Sports Health: A Multidisciplinary Approach

Objective: The objective of this retrospective study was to investigate the relationship between mandibular symphysis bone density (BD) and mandibular growth direction in adolescent patients by facilitating the measurement of cortical and cancellous BDs at the mandibular symphysis using cone beam computed tomography (CBCT). Study Design: 224 adolescent patients (98 males and 126 females) were categorized by sex, age, and mandibular growth direction. Cortical and cancellous BDs were measured along with a sagittal slice at multiple locations. Results: Females exhibited higher cortical BD than males at menton (Me, P =0.002). Patients with a posterior growth direction exhibited a higher cortical BD than those with anterior and normal growth direction at Me (P

Background Many studies have analyzed treatment effects on the airway using CBCT scans of the airway as evidence, but no study to date has been published that validates a repeatable protocol for acquiring CBCT airway measurements. Our objective is to evaluate a protocol for standardization of CBCT volume acquisition of the airway. Methods Ten participants (6 females and 4 males, median age 30.03 ± 3.53 years) were radiographed 2 times each (T1 and T2, the average time between T1-T2 was 15.8 ± 3.65 days), for a total of 20 CBCT scans. The participants’ head position was placed so that the Frankfort horizontal plane was parallel to the floor. Participants were given specific instructions regarding jaw position, tongue position, swallowing and breathing before each of the 2 scans. Minimum cross-sectional area (MCA) and total volume (TV) of each airway scan were measured between the distal most point of the hard palate (superior limit) and the superior most point of the epiglottis (inferior limit). T1 and T2 were compared to determine the repeatability of our proposed protocol for CBCT airway acquisition. Results There was no statistically significant difference between T1 and T2 measurements for TV and MCA. The average difference between T1 and T2 MCA and TV measurements for each participant was 34.18 ± 30.55 mm2 and 2.51 ± 2.05 cc, respectively. Conclusions Using our proposed standardization protocol, the measurements of MCA and TV of the airway were reliable to within 34.18 ± 30.55 mm2 and 2.51 ± 2.05 cc, respectively.

This study evaluated the trends in orthodontic practitioner choice over the past 15 years and explored the lay public's understanding of different orthodontic practitioner options in the U.S., specifically, orthodontists compared with general dentists.A survey was distributed to a representative sample of laypersons in the U.S. The response rate was 90.2%, and 727 completed responses were analyzed.A 28.2% shift away from orthodontists toward general dentists over the last 15 years was significant (P 0.001). The 2 most frequently endorsed ways respondents found their orthodontic practitioners were a recommendation from another dentist (54.2%) and their family's general dentist who offered orthodontic treatment in-house (22.9%). Respondents' knowledge of orthodontists was limited; 85.0% believed that dentists who perform orthodontic treatment are also orthodontic specialists. Only 17.1% of respondents disagreed with the statement that "a dentist who advertises orthodontic treatment is an orthodontic specialist." In addition, 89.7% were not aware that a dentist could not be called an orthodontist without separate training from an accredited residency program. Finally, 64.2% of respondents did not know that an orthodontist must complete more education than a general dentist.Over the past 15 years, the percentage of orthodontic patients treated by general dentists has increased significantly. The public's ability to differentiate between different types of orthodontic practitioners is poor, showing substantial confusion about orthodontists' qualifications. Most respondents believed that orthodontists are best suited for their orthodontic treatment, but they rely heavily on their general dentists for orthodontic practitioner decisions.

Background: Preventive training programs (PTPs) reduce injury risk in youth athletes. Corrective verbal feedback is an integral component of PTP implementation; however, too many cues delivered at once may be too complicated for youth athletes. PTPs with simplified cues may be more effective as traditional PTPs to improve athlete injury risk. Hypothesis/Purpose: The purpose of this study was to evaluate changes in movements associated with injury risk youth athletes participating in a season-long PTP: with simplified feedback cues, with traditional feedback cues, or in a warm-up of the coaches’ choosing. Methods: A cluster-randomized controlled trial was utilized. Youth soccer teams were randomized into: simplified or traditional PTP, or the control group. Simplified and traditional PTPs were the same duration (10-15 minutes) with the same exercises, but the simplified PTP only provided sagittal plane feedback cues (e.g., “get low”) and the traditional PTP provided feedback in all planes of motion (e.g., “don’t let your knees cave inward”). Teams in the control group performed their coach’s warm-up. Participants completed two test sessions (PRE-season, POST-season) with three trials of a jump-landing task evaluated using the Landing Error Scoring System (LESS). The LESS is a valid and reliable clinical movement assessment. Participants jumped off a 30-cm high box to a distance half their height and immediately rebounded straight in the air for maximum vertical height. A single, reliable rater graded all trials. Three trials were averaged together for one composite LESS score at each time point. A generalized linear model was used to evaluate differences in composite LESS score between warm-up (Simplified, Traditional, Control) over time (PRE, POST) while controlling for team. All data were analyzed using SPSS Version 21.0 (pResults: There were no significant differences between Simplified and Traditional PTPs (P>0.05) so the PTPs were combined into a single group (Intervention) and compared to Control from PRE to POST. Four-hundred and twenty athletes (Intervention n=291 athletes, Control n=129 athletes) participated. The Intervention group improved LESS scores ((Mean±SE [95% CI]) Intervention PRE:6.32±0.17 [5.99,6.67], Intervention POST: 5.36±0.16 [5.05,5.69], Control PRE: 6.58±0.35 [5.94,7.30], Control POST: 6.09±0.34 [5.47,6.79])(P=.04). Conclusion: Regardless of PTP, athletes improved movement technique. These findings suggest that simplified corrective feedback is as effective as more complex feedback. Future studies should look to train coaches to focus on simplified cues and evaluate impact on PTP implementation.

Accurately measuring tongue space is challenging, but this information can be useful to many dental specialties. This study was intended to estimate the reliability of using cone-beam computed tomography (CBCT) to measure tongue space, which includes tongue volume and the oral cavity air capacity.For this preliminary study, CBCT images from ten participants (five females and five males, mean age of 29.8 ± 3.3 years) were available for evaluation. Each participant was radiographed two times (T0 and T1). The average time between T0 and T1 was 15.8 ± 3.7 days. CBCT scans were standardized to reduce variability. Three-dimensional landmarks were established to identify tongue space and 3D image analysis software (SimPlantThe intra-rater and inter-rater ICCs of the CBCT measurements at T0 were excellent ( 0.90). Measurements for T0 vs. T1 show good (0.75-0.90) intra-rater and excellent ( 0.90) inter-rater reliability. Bland-Altman charts show that 90-95% of the total measurements fall within the 95% limits of agreement for both intra- and inter-rater pairs CONCLUSIONS: The results of this preliminary study suggest that the landmarks chosen to measure the overall tongue space are reproducible and can be measured clearly using CBCT.

The aim of this study was to evaluate the bone density of mandibular condyles in adolescents with varying skeletal patterns using cone-beam computed tomography. The null hypothesis was that there is no difference in the bone density of mandibular condyles in adolescents across various facial height ratios, ANB angle classifications, sexes, and age categories.We divided 120 adolescent patients, 56 boys and 64 girls, into 3 groups according to 3 criteria: (1) age (early, 10 to 14 years; middle, 14 to 17 years; late, 17 to 20 years); (2) facial height ratio or Jarabak quotient (hyperdivergent: facial height ratio, 62%; normovergent: facial height ratio, 62% to ≤65%; and hypodivergent: facial height ratio, 65%); and (3) ANB angle classification (Class I, 1° to ≤4°; Class II, (4°); and Class III, 1°). The total, cortical, and cancellous bone densities were measured and compared on the axial slice with the largest mediolateral diameter of the mandibular condyle using C-mode cone-beam computed tomography.Cortical bone density increased as age increased and showed statistically significant differences between the early and middle (P = 0.041) and the early and late adolescent groups (P = 0.031). Condylar bone density increased as facial height ratio decreased, and cancellous bone density showed statistically significant differences between the hyperdivergent and hypodivergent groups (P = 0.038). The cortical, cancellous, and total bone densities increased as ANB angle increased and showed statistically significant differences between the Class II and Class III groups (P = 0.022, P = 0.006, and P = 0.003, respectively).The null hypothesis was rejected. Condylar bone density increased as facial height ratio decreased and ANB angle increased. These findings may be useful in predicting the vertical and horizontal skeletal growth patterns of growing adolescents.