MEDICA@MUSC (Medical University of South Carolina)
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Variations in Implant Position Based Upon Planning Strategy
Get PDFObjective: To compare different techniques for the digital planning of dental implant placement using commercially available computed aided design software and assess the variability in planned implant position. Materials and methods: Eight dentists individually planned fifteen dental implants using SimPlant software. For each implant, the examiner planned the implant under four different conditions relating to the amount of digital reference data used: (1) no waxed up tooth, (2) pre-op intra-oral scan, (3) pre-op intraoral scan with a virtual tooth created by the examiner, and (4) pre-op intra-oral scan with wax up tooth in occlusion provided by the prosthodontist. . Implant sites included single tooth-bound, adjacent to a single tooth, and “stand alone” as in a distal abutment for an implant bridge. The implant placements were then compared against each other using analysis software in SimPlant. The outcome variables were angular deviation, horizontal placement, and vertical placement. Results: For all measured outcomes in angulation and horizontal distance, “stand alone” planned implants were significantly different from each other (p-value = \u3c 0.05). For vertical distance outcomes, single tooth-bound edentulous site planned implants were significantly different from each other (p-value=0.0057). Conclusion: The variability between digitally planned dental implants is indirectly proportional to the number and proximity of reference points to the surgical site. If there are many fixed reference points available in close proximity to the surgical site, the estimation is likely to be more accurate in angulation and axial position, but not depth (e.g., a one-tooth edentulous site with adjacent teeth on the mesial and distal surfaces). In situations where there are fewer references (sites with multiple missing teeth), the estimation is more challenging and is prone to variability, which appears to be on par with error created between guided and implant surgery
Improvement in the Rate of Full Implementation of Electronic Advanced Directives in Acute Care Hospitals after the HITECH Act
Get PDFThis report reviews the improvement in accessibility of POLST in United States hospitals since the implementation of the HITECH Act in 2009. An analysis and compilation of available information was conducted from all US acute care hospitals responding to the Information Technology Supplement to the annual American Hospital Association (AHA) survey. The survey was voluntary including non-members of the association. The total number of hospitals that participated in 2009 were 2903 while 2782 in 2018. From the results, there was slight increase in hospital beds in 2019 compared to 2018. In 2009, 64% of the hospitals were private nonprofit, 25% government hospitals and 11% were private for-profit hospitals while in 2018, most were private nonprofit at 66%, government at 22% and private for profit 12%. The report showed a significant improvement (42%) in the hospitals capability to fully implement advanced directive (DNR) across every unit by 2018. The study shows smaller hospitals recorded much improvements in DNR by 2018 as opposed to larger hospitals. This was similar to government and For-profit hospitals unlike nonprofit hospitals that realized insignificant improvements. Besides a hospitals intent to apply for CMS payments in 2009 had no significant effect in DNR availability in 2018. It was found that HITECH has greatly enhanced the availability of POLST information especially for emergency situations
The Role of Insulin-Like Growth Factor- Binding Protein 5 in Systemic Sclerosis- Associated Pulmonary Fibrosis
No full textPulmonary fibrosis is a hallmark of diseases such as systemic sclerosis (SSc, scleroderma) and idiopathic pulmonary fibrosis (IPF). SSc is a complex autoimmune disease that is characterized by progressive fibrosis of the skin and multiple visceral organs. Despites multiple studies, the etiology of this connective tissue disease is still unknown, causing high morbidity and mortality in the patients. To date, therapeutic options are limited, and organ transplantation remains the only viable option for SScassociated lung disease. Therefore, identifying novel therapeutic targets is critical for advancing the treatment of SSc. Insulin-like growth factor-binding protein-5 (IGFBP-5) is the most conserved member of the IGFBP family of proteins that is overexpressed in SSc and IPF. Some of the mechanisms mediating the effects of IGFBP-5 and downstream signaling pathways have been identified, the question to whether the promotion of fibrosis was directly mediated by IGFBP-5 or via other pro-fibrotic factors that may be downstream of IGFBP-5 had remained unanswered. Therefore, we investigated the role of IGFBP-5 in the pathophysiology of SSc using in vitro, ex vivo and in vivo models. Our data showed that both exogenous and adenovirally expressed IGFBP-5 promote fibrosis by increasing the production of extracellular matrix (ECM) genes and the expression of pro-fibrotic genes in primary human lung fibroblasts and tissues. IGFBP-5 also increased expression of the pro-fibrotic growth factor CTGF and levels of the matrix crosslinking enzyme lysyl oxidase (LOX). IGFBP-5 promotes its own expression, generating a positive feedback loop. This suggests that IGFBP-5 likely acts in concert with other growth factors to drive fibrosis and tissue remodeling. Further, our findings demonstrated that LOX expression and activity correlated with fibrosis in vitro, ex vivo, and in vivo. LOX induced ECM production via upregulation of IL-6 and nuclear localization of c-Fos. Thus, LOX has a direct pathogenic role in SSc-associated fibrosis that is independent of its crosslinking function. The pro-fibrotic effects of IGFBP-5 was further examined in transgenic mice overexpressing human IGFBP-5. Our data show that the heterozygous and homozygous mice are viable and express human IGFBP-5 (hIGFBP-5). Transgenic mice had increased expression of extracellular matrix (ECM) genes, especially Col3a1, Fn and Lox in lung and skin tissues of mice expressing higher transgene levels. Histologic analysis of the skin tissues showed increased dermal thickness, and the lung histology showed subtle changes in the heterozygous and homozygous mice compared to the wild-type mice. These changes were more pronounced in animals expressing higher levels of hIGFBP-5. Bleomycin increased ECM gene expression in wild-type and accentuated the increase in ECM gene expression in transgenic mice, suggesting that transgene expression exacerbates bleomycin-induced pulmonary fibrosis. Primary lung fibroblasts cultured from lung tissues of homozygous transgenic mice showed significant increases in ECM gene expression and protein levels, further supporting the observation that IGFBP-5 results in a fibrotic phenotype in fibroblasts. Primary lung fibroblasts cultured from lung tissues of transgenic mice showed increased ECM production, suggesting that the effects of IGFBP-5 are cell-type and tissue-specific. In conclusion, these studies capitalize on knowledge gained about the impact of IGFBP-5 and LOX playing a direct pathogenic role in SSc. Our findings from the study provide a new platform for developing therapies targeting IGFBP-5 and/or LOX function to treat SSc and other fibrotic disorders
The Anesthesia Continuing Education Market and the Value Creation From a Sustainable Unified Platform
Get PDFPracticing anesthesia professionals in the United States are all governed by various profession-specific regulatory bodies that mandate continuing education (CE) requirements. To date, no unified resource exists for anesthesia professionals (i.e., Anesthesiologists, Certified Registered Nurse Anesthetists, and Anesthesiologist Assistants) to explore the CE offerings available within the marketplace. This study endeavored to convey the potential value of a unified anesthesia CE resource. It investigated how to cultivate a sustainable platform to potentially improve how anesthesia professionals search available CE offerings and to potentially enhance how anesthesia CE providers reach anesthesia professionals. This qualitative study was conducted utilizing an integrative review of the literature. The key concepts identified and investigated were network effect, segmentation, first to market, best of breed, search costs, transaction costs, minimally viable product, evolutionary phases of platforms, platform theory, platform business model, platform economy, and types of platforms. Inductive content analysis was chosen as the organizational method for the resultant qualitative data. The goal of the analysis was to create a conceptual, practical, and strategically applicable platform paradigm for the anesthesia CE marketplace driven by the insights and amalgamations from the literature. The analyzed concepts, dimensions, and indicators of platform successes and their applications potentially facilitate anesthesia professionals’ CE explorations and CE providers’ marketing efforts, as well as contextualize the overarching impacts and implications onto the anesthesia CE industry and beyond. The conclusion portrays these impacts and implications
GDF-15 Cytokine Promotes an Immunosuppressive Tumor-Microenvironment That Contributes to PDAC Development
No full textStudies indicate that growth and differentiation factor 15 (GDF15) is elevated in pancreatic ductal adenocarcinoma (PDAC). However, the relationship between increasing level and function in PDAC development are only beginning to be revealed. Our lab previously showed that GDF15 promotes the initiation of PDAC by functioning as an immunosuppressive factor of inflammatory, anti-tumor macrophages. We report here that GDF15 is also capable of influencing other immune cells within the tumor-microenvironment (TME), specifically T cells. In vitro, we found that when T cells are incubated with conditioned media (CM) from pancreatic tumor cells containing GDF15, both CD4+ and CD8+ T cells proliferation was inhibited. The opposite effect was observed when T cells were grown in CM lacking GDF15. This GDF15 immune suppressive activity was reversed when GDF15 in the CM was inhibited with a neutralizing antibody. In vivo, the conditional ablation of GDF15 in a GEMM of pancreatic cancer led to a reduction in PDAC initiation, which was associated with increased macrophage infiltration. We have also showed that the absence of GDF15 in this setting led to greater survival. Together, these data lead us to speculate that increasing levels of GDF15 in PDAC is relevant to the initiation of tumorigenesis by functioning to immunosuppress both anti-tumor macrophages and CD8+ T cells
A Mixed Methods Study to Investigate Barriers and Enablers to Nurses’ Implementation of Nonpharmacological Interventions for Infants with Neonatal Abstinence Syndrome (NAS)
Get PDFThe national burden of Neonatal Abstinence Syndrome on individuals, families, and the healthcare system has reached epidemic proportion. The rising incidence of Neonatal Abstinence Syndrome significantly impacts healthcare utilization and costs due to increases in Neonatal Intensive Care Unit admissions and length of hospitalization, to the possible detriment of maternal-infant bonding. Because nonpharmacologic nursing care is not complicated by the potentially harmful side effects of pharmacological treatment, it should be considered the standard of care for opioid-exposed infants; therefore, a comprehensive understanding of the barriers and enablers to nurses’ implementation of nonpharmacological interventions for infants with Neonatal Abstinence Syndrome is needed. This dissertation examines the benefits and factors associated with breastfeeding (a key nonpharmacological intervention) for the opioid-dependent maternal-infant dyad, factors associated with influencing healthcare providers’ behaviors in the care of infants with Neonatal Abstinence Syndrome, and barriers and enablers to nurses’ implementation of nonpharmacological interventions for infants with Neonatal Abstinence Syndrome. Findings from this study will inform the development of programs to improve nurses’ implementation of nonpharmacological interventions and health and utilization outcomes in infants with Neonatal Abstinence Syndrome
In Vitro Assessment of Dynamic Guidance in Endodontic Microsurgical Osteotomy & Root-End Resection
Get PDFIntroduction: Dynamic guidance is a technology that uses CBCT images and an array of cameras & sensors to guide the operator’s dental handpiece along a pre-determined path in real-time. It has been used in implant surgery, non-surgical endodontics, as well as in a few reported clinical cases of endodontic microsurgery to improve the accuracy of these procedures. However, no study has been published which quantitatively evaluates its ability to improve accuracy and reduce osteotomy size in endodontic microsurgery. Therefore, the aim of this in-vitro study was to compare dynamically guided endodontic microsurgery to freehand surgery in terms of osteotomy window, osteotomy volume, apical bevel, apical resection length and depth of osteotomy past the target root. Materials and Methods: Thirty-six human mandibular posterior teeth were cast into stone models containing three teeth each (one premolar, two molars), and those models were subsequently divided equally into freehand and guided groups. In the freehand group, an experienced operator performed osteotomies and root-end resections. In the guided group, the X-Guide System was used to assist in the execution of similar osteotomies and resections. Post-operative CBCT images were taken of both groups and the aforementioned parameters were evaluated using software native to the imaging system. Results: Significant differences were found between the freehand and guided groups in terms of osteotomy window area, osteotomy volume, depth of osteotomy past the target root and amount of resection. Most notably, the window area in the guided group (15.7mm2 ± 3.85) was significantly (p\u3c0.05) smaller than in the freehand group (37.6mm2 ± 5.02), and the osteotomy volume in the guided group (0.111cm3 ± 0.04) was significantly (p\u3c0.05) smaller than in the freehand group (0.226cm3 ± 0.05). Conclusions: The results of this study show that implementing dynamic guidance in endodontic microsurgery has the potential to significantly reduce the osteotomy window area and osteotomy volume as compared to freehand surgery, which subsequently can result in improved healing. It can also ensure that critical structures such as adjacent non-target roots and the mandibular canal are avoided while attempting to locate the target root
Development and Evolution of a Statewide Outpatient Consultation Service: Leveraging Telemedicine to Improve Access to Specialty Care
Get PDFDespite a robust health care system in the United States, many Americans experience health care disparities as a result of poor access to medical care. Academic medicine plays an important role in addressing health care disparities by providing primary and specialty care for the poor and uninsured. In South Carolina, 43 of its 46 counties are designated as fully or partially Medically Underserved Areas (MUAs), defined as areas with a shortage of medical providers, high infant mortality, and either high elderly population or high poverty rates. To address these health care disparities, an academic medical center in South Carolina created a hub-and-spoke specialty care model using telemedicine in partnership with primary care providers across community settings. Initial private foundation grant funding enabled the development and dissemination of technology to provide remote teleconsultations by physicians at the academic medical center (hub) to patients in their primary care offices (spoke). This model, now supported by recurring state funding and professional billing, provides much-needed services, including psychiatry, nutrition counseling, and various surgical and medical subspecialties, to rural and underserved populations in the state. This manuscript provides a narrative review of the development of this statewide telemedicine service, with an emphasis on identification of stakeholders, technology issues, barriers to implementation, and future directions
DCHS1 Regulated miRNA Processing and its Effects on Valve Endocardium Stabilization
Get PDFMitral valve prolapse (MVP) is one of the most common forms of cardiac valve disease and affects 1 in 40 individuals worldwide. MVP can lead to arrhythmias, heart failure, and sudden cardiac death and 1 in 10 patients will require valve surgery. Surgery for MVP is now the fastest growing cardiovascular intervention in the Western world. As such, MVP carries a significant burden of morbidity and mortality. Our lab was the first to identify a cause for non-syndromic MVP using a combination of linkage analyses, as well as capture sequence of the linkage interval, to identify loss of function mutations in the cadherin gene, DCHS1. Two-hybrid screens were undertaken to further understand DCHS1 function and the RNA binding protein, LIX1L was identified as the only interacting protein. LIX1L binds and promotes miRNA processing through interactions as an RNA-binding protein and miRNAs. This leads us to the hypothesis: DCHS1-regulated miRNA processing stabilizes the valve endocardium. Expression studies have corroborated this theory as DCHS1, LIX1L, and the microprocessor proteins are expressed in endothelial cells in the mitral valve. Cell culture data shows that a loss of DCHS1 compromises processing of target miRNAs through the microprocessor leading to a significant decrease in miRNA expression. Expression studies have also shown that loss of Dchs1 reduces valve endocardial stability, which may be caused by the loss of miRNAs. These studies illustrate the importance of DCHS1 effects on valve endocardium stabilization in MVP. Uncovering how these changes lead to clinically significant pathology later in life is crucial to the characterization of MV
Is a Shortage of Specialist Physicians Disproportionately Affecting Access to Care in Rural Counties with Federally Qualified Health Centers: Trends in Texas from 2012 & 2017?
Get PDFObjective: This study utilized Medicare 5% limited Data sets to compare total specialty care referral consultations for Medicare patients seen at FQHCs in Harris County to those seen at FQHCs in rural Texas counties. Currently, no published data is examining the changes in specialty referral rates for FQHC patients in the state of Texas. Evaluating these trends will allow system executives, public health officials, and patients alike to understand the magnitude of differences in specialty provider coverage in Texas. Methods: A retrospective cross-sectional study was conducted using CPT codes for patients living in selected rural and urban counties across Texas who have completed visit (s) with a specialist provider between 2012-2017. The primary aim of the study is to describe the population health impact of changes in specialty referral practices across the state of Texas. The selected CPT codes measured all defined specialty visits across the state of Texas. Results: The study found a change in the use of specialty referral consultations when comparing the two data years. Study results showed a significant reduction in the usage of specialty services for patients living in rural counties. The reduction may be attributed to a few changes currently happening in the state. Several researchers have indicated that the state is not producing or recruiting enough residents and practicing physicians to meet the growing population demand (Merrit Hawkins, 2018). Conclusion: The population in Texas continues to grow at one of the fastest paces in the U.S. As the population grows, residency programs in the state will need to adapt by creating more spots for residents. More focus will need to be placed in rural settings, possibly offering providers more incentives to work in these environments. As it stands today, many Texas counties have less than two specialists living in them. Hospital systems in these rural counties will also benefit by partnering with FQHCs in the area to ensure that specialty services are rendered by the FQHCs within the communities they serve. Lastly, The Resident Physician Shortage Act, if passed, will provide a much-needed boost of new physicians to the workforce. A boost of physicians in underserved areas, such as the rural counties in Texas, may provide a solution to the physician shortages in these areas