Evaluating components of dental care utilization among adults with diabetes and matched controls via hurdle models

Background

About one-third of adults with diabetes have severe oral complications. However, limited previous research has investigated dental care utilization associated with diabetes. This project had two purposes: to develop a methodology to estimate dental care utilization using claims data and to use this methodology to compare utilization of dental care between adults with and without diabetes.

Methods

Data included secondary enrollment and demographic data from Washington Dental Service (WDS) and Group Health Cooperative (GH), clinical data from GH, and dental-utilization data from WDS claims during 2002–2006. Dental and medical records from WDS and GH were linked for enrolees continuously and dually insured during the study. We employed hurdle models in a quasi-experimental setting to assess differences between adults with and without diabetes in 5-year cumulative utilization of dental services. Propensity score matching adjusted for differences in baseline covariates between the two groups.

Results

We found that adults with diabetes had lower odds of visiting a dentist (OR = 0.74, p < 0.001). Among those with a dental visit, diabetes patients had lower odds of receiving prophylaxes (OR = 0.77), fillings (OR = 0.80) and crowns (OR = 0.84) (p <  0.005 for all) and higher odds of receiving periodontal maintenance (OR = 1.24), non-surgical periodontal procedures (OR = 1.30), extractions (OR = 1.38) and removable prosthetics (OR = 1.36) (p < 0.001 for all).

Conclusions

Patients with diabetes are less likely to use dental services. Those who do are less likely to use preventive care and more likely to receive periodontal care and tooth-extractions. Future research should address the possible effectiveness of additional prevention in reducing subsequent severe oral disease in patients with diabetes.

     

Three-Dimensional Model-Based Segmentation in Echocardiography Using High Temporal Tissue and Blood Flow Information

Accurate 3-D surface segmentation is a challenging task in echocardiography because of the relatively low image quality. We introduce a new method for 3-D segmentation of the endocardium involving temporal decorrelation of echo signals originating from tissue and blood using radiofrequency (RF) signals acquired in 3-D Doppler mode. Temporal features were extracted in 3-D Doppler mode, where a sequence of RF lines is recorded for each image line. Each set of RF lines is highly correlated because of the high pulse repetition frequency. However, for high blood flow, the RF signals will decorrelate over time in contrast to the endocardium, which will remain relatively highly correlated over time. These decorrelation features permit differentiation between myocardial tissue and blood flow. We describe an implementation of a 3-D segmentation model in which temporal information is used as external constraint. The model was validated in a phantom and in vivo in healthy volunteers (n = 5). The phantom study revealed that the model successfully segmented the artificial blood lumen even for low flow velocity and illustrated the sensitivity of the segmentations to flow rate. In healthy volunteers, high Dice similarity indices indicate that 3-D segmentation of the endocardial border in vivo is feasible.     

Are conventional microbiological diagnostics sufficiently expedient in the era of rapid diagnostics? Evaluation of conventional microbiological diagnostics of orthopedic implant-associated infections (OIAI)

Background and purpose — In a time when rapid diagnostics are increasingly sought, conventional procedures for detection of microbes causing orthopedic implant-associated infections (OIAI) seem extensive and time-consuming, but how extensive are they? We assessed time to (a) pathogen identification, (b) antibiotic susceptibility patterns, and (c) targeted antibiotic treatment using conventional microbiological diagnostics of OIAI in a consecutive series of patients.Patients and methods — Consecutive patients aged ≥18 years undergoing first revision surgery for acute OIAI, including prosthetic joints, fracture, and osteotomy implants, in 2017–2018 at Akershus University Hospital (Ahus), Norway were included. Information regarding microbiological diagnostics and clinical data was collected retrospectively from the hospital’s diagnostic and clinical databases.Results — 123 patients fulfilled the inclusion criteria. Median time to pathogen identification was 2.5 days and to antibiotic treatment recommendations was 3.5 days. The most common pathogens were S. aureus (52%) and S. epidermidis (15%). Cultures were inconclusive in 11% of the patients. Of the 109 patients with culture-positive results, antibiotic treatment was changed in 66 (61%) patients within a median of 4 days (0–24) after the recommendation was given.Interpretation — Conventional microbiological diagnostics of OIAI is time-consuming, taking days of culturing. Same-day diagnostics would vastly improve treatment efficacy, but is dependent on rapid implementation by clinicians of the treatment recommendations given by the microbiologist.

The majority of orthopedic procedures include the use of implants, which increase the risk of infection due to the reduced number of bacteria needed to establish an infection (Zimmerli et al. 1982). Orthopedic implant-associated infections (OIAI) are infrequent per se, with an overall surgical site infection rate following implant surgery of 3% (Skråmm et al. 2012). However, the number of patients undergoing orthopedic implant surgery is high and increasing (Norwegian National Advisory Unit on Arthroplasty and Hip Fractures 2020).A microbiological diagnosis is vital for providing the best treatment, with regards to both surgical options and providing targeted and narrow-spectrum antimicrobial therapy (Beam and Osmon 2018). Today’s conventional diagnostics include microbiological culturing of 5 biopsies from each infected patient on several different media for at least 5 days dependent on growing and dividing bacteria (Bergh et al. 2011, Osmon et al. 2013). More rapid diagnostic tools are being developed, but with varying degrees of sensitivity and specificity (Bonanzinga et al. 2017, Jun and Jianghua 2018, Aamot et al. 2019).We assessed time to (a) pathogen identification, (b) antibiotic susceptibility patterns, and (c) targeted antibiotic treatment using conventional microbiological diagnostics of OIAI in a consecutive series of patients.     

A cautious iodization programme bringing iodine intake to a low recommended level is associated with an increase in the prevalence of thyroid autoantibodies in the population

Autoantibodies against the thyroid gland with thyroid peroxidase antibody (TPO‐Ab) and thyroglobulin antibody (Tg‐Ab) as the most common can often be demonstrated in serum. The effect of public iodization programmes on antibody prevalence is uncertain. Aim To measure the concentrations of thyroid autoantibodies in the Danish population before and after mandatory iodization of salt. Methods Two identical cross‐sectional population studies were performed before (Cohort 1 (C1), year 1997–1998, n = 4649, median urinary iodine 61 μg/l) and 4–5 years after (Cohort 2 (C2), year 2004–2005, n = 3570, median urinary iodine 101 μg/l) mandatory iodine fortification of salt was implemented in Denmark. Blood tests were analysed for TPO‐Ab and Tg‐Ab using sensitive assays. Results Antibodies were more frequent in C2 than in C1: TPO‐Ab > 30 U/ml, C1 vs C2: 14·3 vs 23·8% (P < 0·001) and Tg‐Ab > 20 U/ml, C1 vs C2: 13·7 vs 19·9% (P < 0·001). The C2 vs C1 effect was confirmed in multivariate regression models (C1 reference): TPO‐Ab: OR (95% CI): 1·80 (1·59–2·04) and Tg‐Ab: 1·49 (1·31–1·69). The increase in the frequency of thyroid antibodies was most pronounced in young women and especially observed at low concentrations of antibodies. Conclusion The prevalence of both TPO‐Ab and Tg‐Ab was higher 4–5 years after a cautious iodine fortification of salt was introduced in Denmark. The increase was most pronounced in young women and in the low concentrations of antibody. Further studies are needed to evaluate the long‐term effects of increased iodine intake on thyroid autoimmunity in the population.     

Development of a home visitation programme for the early detection of health problems in potentially frail community-dwelling older people by general practices

The integration within existing health care systems of preventive initiatives to maintain independent living among older people is increasingly emphasized. This article describes the development and refinement of the [G]OLD home visitation programme: an eight-step programme, including a comprehensive geriatric assessment, for the early detection of health and well-being problems among older people (≥75 years) by general practices. A single group post-test study using a mixed model design is performed to evaluate (a) the feasibility of the home visitation programme in general practice, (b) the practical usefulness of the geriatric assessment instrument, and (c) programme implementation with respect to reinventions introduced by general practitioners (GPs) and practice nurses (PNs). Within 3 months time, 22 PNs of 18 participating general practices visited 240 community-dwelling older people (mean age = 82.0 years; SD 4.2) who had not been in contact with their general practice for more than 6 months. Mean time investment of the programme per older person was 118.1 min (SD 27.0) for GPs and PNs combined. Evaluation meetings revealed that GPs and PNs considered the home visitation programme to be feasible in daily practice. They judged the geriatric assessment to be useful, although minor adjustments are needed (e.g., lay-out, substitution of tests). PNs often failed to register follow-up actions for detected problems in a care and treatment plan. Future training for PNs should address this issue. No reinventions were introduced that threatened fidelity of implementation. The findings are used to improve the home visitation programme before its evaluation in a large-scale controlled trial.     

Intervention Characteristics that Facilitate Return to Work After Sickness Absence: A Systematic Literature Review

Introduction In many Western countries, a vast amount of interventions exist that aim to facilitate return to work (RTW) after sickness absence. These interventions are usually focused on specific target populations such as employees with low back pain, stress-related complaints or adjustment disorders. The aim of the present study is to detect and identify characteristics of RTW interventions that generally facilitate return to work (i.e. in multiple target populations and across interventions). This type of knowledge is highly relevant to policy makers and health practitioners who want to deliver evidence based care that supports the employee??s health and participation in labour. Methods We performed a keyword search (systematic literature review) in seven databases (period: 1994?C2010). In total, 23 articles were included and assessed for their methodological quality. The characteristics of the interventions were evaluated as well. Results Early interventions, initiated in the first 6?weeks of the RTW process were scarce. These were effective to support RTW though. Multidisciplinary interventions appeared effective to support RTW in multiple target groups (e.g. back pain and adjustment disorders). Time contingent interventions in which activities followed a pre-defined schedule were effective in all physical complaints studied in this review. Activating interventions such as gradual RTW were effective in physical complaints. They have not been studied for people with psychological complaints. Conclusions Early- and multidisciplinary intervention and time-contingent-, activating interventions appear most effective to support RTW.     

Optimizing implantable cardioverter-defibrillator treatment of rapid ventricular tachycardia: Antitachycardia pacing therapy during charging

BACKGROUND: Previous studies in implantable cardioverter-defibrillator (ICD) patients demonstrated the efficacy and safety of antitachycardia pacing (ATP) for rapid ventricular tachycardias (VT). To prevent shock delay in case of ATP failure, a new feature (ATP during charging) was developed to deliver ATP for rapid VT while charging for shock. OBJECTIVE: The purpose of this study was to determine the efficacy and safety of this new feature. METHODS: In a prospective, nonrandomized trial, patients with standard ICD indication received an EnTrust ICD. VT and ventricular fibrillation (VF) episodes were reviewed for appropriate detection, ATP success, rhythm acceleration, and related symptoms. RESULTS: In 421 implanted patients, 116 VF episodes occurred in 37 patients. Eighty-four (72%) episodes received ATP during or before charging. ATP prevented a shock in 58 (69%) of 84 episodes in 15 patients. ATP stopped significantly more monomorphic (77%) than polymorphic VTs (44%, P = .05). Five (6%) episodes accelerated after ATP but were terminated by the backup shock(s). No symptoms were related to ATP during charging. In four patients, 38 charges were saved by delivering ATP before charging. Of 98 induced VF episodes, 28% were successfully terminated by ATP versus 69% for spontaneous episodes (P <.01). CONCLUSION: Most VTs detected in the VF zone can be painlessly terminated by ATP delivered during charging, with a low risk of acceleration or symptoms. ATP before charging allows delivery of two ATP attempts before shock in the same time that would otherwise be required to deliver only one ATP plus a shock. It also offers potential battery energy savings.     

New CFSE-based assay to determine susceptibility to lysis by cytotoxic T cells of leukemic precursor cells within a heterogeneous target cell population

For the clinical evaluation of the efficacy of cellular immunotherapy it is necessary to analyze the effector functions of T cells against primary leukemic target cell populations which are usually considerably heterogeneous caused by differential maturation stages of the leukemic cells. An appropriate assay should not only allow the quantitative analysis of rapid cell death induction as measured by the conventional 51Cr release assay but also of the more slowly executing pathways of T-cell-induced apoptosis occurring within days instead of hours which cannot be measured using this method. Furthermore, it should dissect the differential susceptibility to T-cell-induced cell death of various target cell subpopulations and characterize the malignant precursor cells capable of producing malignant progeny. To fulfill these requirements we developed a new assay based on carboxyfluorescein diacetate succinimidyl ester (CFSE) labeling of the target cell population combined with antibody staining of specific cell populations and addition of fluorescent microbeads to quantitatively monitor target cell death occurring within a longer time frame up to at least 5 days. This new assay facilitates the analysis of differential recognition of distinct cell types within a heterogeneous target cell population and allows simultaneously evaluation of the proliferative status of surviving target cells in response to relevant cytokines.