Management of Medically Compromised Prosthodontic Patients

The medical evaluation of patients considering prosthodontic treatment is a vital step in the treatment planning. The prosthodontist should be able to assess the inherent risks associated with the treatment of patients with systemic conditions. Many factors are associated with evaluating the patient’s health status and risk including the patient’s current and past medical and dental history, current and past use of medications, type of treatment, length of treatment, invasiveness of treatment, and degree of urgency of treatment. In this article, some of the systemic diseases like arthritis, cardiovascular diseases, endocrine disorders, hematologic and oncologic disease, neurologic disorders, bone disorders, pulmonary diseases, liver diseases, and chronic kidney disease that commonly affect aged individuals are reviewed. The prosthodontic considerations that should be taken care of while managing patients with these systemic conditions will also be discussed.

4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes—2022

The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Telemedical percussion: objectifying a fundamental clinical examination technique for telemedicine

Purpose While demand for telemedicine is increasing, patients are currently restricted to tele-consultation for the most part. Fundamental diagnostics like the percussion still require the in person expertize of a physician. To meet today’s challenges, a transformation of the manual percussion into a standardized, digital version, ready for telemedical execution is required. Methods In conjunction with a comprehensive telemedical diagnostic system, in which patients can get examined by a remote-physician, a series of three robotic end-effectors for mechanical percussion were developed. Comprising a motor, a magnetic and a pneumatic-based version, the devices strike a pleximeter to perform the percussion. Emitted sounds were captured using a microphone-equipped stethoscope. The 84 recordings were further integrated into a survey in order to classify lung and non-lung samples. Results The study with 21 participants comprised physicians, medical students and non-medical-related raters in equal parts. With 71.4% correctly classified samples, the ventral motorized device prevailed. While the result is significantly better compared to a manual or pneumatic percussion in this very setup, it only has a small edge over the magnetic devices. In addition, for all ventral versions non-lung regions were rather correctly identified than lung regions. Conclusion The overall setup proves the feasibility of a telemedical percussion. Despite the fact, that produced sounds differ compared to today’s manual technique, the study shows that a standardized mechanical percussion has the potential to improve the gold standard’s accuracy. While further extensive medical evaluation is yet to come, the system paves the way for future uncompromised remote examinations.

Medical Experiences from a Consular Repatriation and Evacuation Operation from Afghanistan in August 2021: A Field Report

Following the Taliban influx in August 2021, several Western countries repatriated nationals and evacuated others from Kabul Airport in Afghanistan. This report aimed to describe medical experiences from the consular repatriation and evacuation operation. Memos from personal conversations with seven professionals involved in these operations formed the basis for this report. Minor trauma, gastrointestinal symptoms, dehydration, fever, and mental distress were common. Bandages, oral rehydration solution, and the administration of paracetamol were needed, in addition to medical evaluation of acuity. In consular repatriation and humanitarian evacuations, medical attendance should be prioritized to manage medical needs of individuals being evacuated, but also from a public health perspective. The medical needs covered a broad specter of infection disease symptoms, trauma, and mental health problems among patients of all ages. Since the nature of consular repatriations and evacuations can be challenging from safety and infrastructural aspects, general medical emergency awareness with an ability to effectively evaluate and manage both somatic and mental health emergencies on the ground and in the air, among both children and adults, is needed.

Developmental Training Model for the Sport Specialized Youth Athlete: A Dynamic Strategy for Individualizing Load-Response During Maturation

Context: Most available data on athletic development training models focus on adult or professional athletes, where increasing workload capacity and performance is a primary goal. Development pathways in youth athletes generally emphasize multisport participation rather than sport specialization to optimize motor skill acquisition and to minimize injury risk. Other models emphasize the need for accumulation of sport- and skill-specific hours to develop elite-level status. Despite recommendations against sport specialization, many youth athletes still specialize and need guidance on training and competition. Medical and sport professionals also recommend progressive, gradual increases in workloads to enhance resilience to the demands of high-level competition. There is no accepted model of risk stratification and return to play for training a specialized youth athlete through periods of injury and maturation. In this review, we present individualized training models for specialized youth athletes that (1) prioritize performance for healthy, resilient youth athletes and (2) are adaptable through vulnerable maturational periods and injury. Evidence Acquisition: Nonsystematic review with critical appraisal of existing literature. Study Design: Clinical review. Level of Evidence: Level 4. Results: A number of factors must be considered when developing training programs for young athletes: (1) the effect of sport specialization on athlete development and injury, (2) biological maturation, (3) motor and coordination deficits in specialized youth athletes, and (4) workload progressions and response to load. Conclusion: Load-sensitive athletes with multiple risk factors may need medical evaluation, frequent monitoring, and a program designed to restore local tissue and sport-specific capacity. Load-naive athletes, who are often skeletally immature, will likely benefit from serial monitoring and should train and compete with caution, while load-tolerant athletes may only need occasional monitoring and progress to optimum loads. Strength of Recommendation Taxonomy (SORT): B.

Premedication with Hydrocortisone Increases Risk of Adverse Drug Events and Return to Medical Care Among Pediatric Patients with ITP Treated with IVIG

Immune Thrombocytopenia (ITP) is one of the most common acquired bleeding disorders affecting children. While 75-80% of these children will develop only mild bleeding symptoms, others can experience more severe bleeding, including rare intracranial hemorrhage (ICH), and may require platelet-directed therapy. Intravenous immunoglobulin (IVIG), a commonly utilized and effective first-line therapy, may be associated with adverse drug events (ADEs). The most commonly reported ADEs include headache (approximately 30% of treated patients) and nausea/vomiting, however the exact rates of these events and relationship to premedication strategies are poorly classified. These ADEs often result in emergent medical evaluation and additional diagnostic testing, including computed tomography (CT) of the head, to evaluate for ICH in children with severe thrombocytopenia. In order to identify rates of IVIG-associated ADEs and subsequent emergent medical evaluations in pediatric patients with ITP, we completed an retrospective observational cohort study of all pediatric patients with ITP who were treated with one-time IVIG infusion utilizing Gamunex-C ® 10% at a dose of 1g/kg across 4 large pediatric centers from 2010 to 2019. Included patients were between the ages of 0 and 21 years. Among the 563 patients receiving single IVIG infusions across all 4 centers, patients reported headache, nausea/vomiting, or both following 203 infusions (36%). Excluding those patients who remained hospitalized at the time of symptom development, 16% (84 of 513) of all patients returned for urgent medical evaluation following IVIG infusion. Nine percent of all patients receiving a single IVIG infusion underwent head CT to rule out ICH. All 51 CTs were negative for ICH. In order to determine if specific patient characteristics were associated with the development of IVIG-associated ADEs and return to medical care, univariable logistic regression was performed. Multiple logistic regression was used to determine whether the associations identified in the univariable analysis persisted after adjusting for other significant factors. Older age at administration (Adjusted Odds Ratio [adj OR] 1.07 for each additional year of age; 95% Confidence Interval [CI] 1.03, 1.11; p<0.001) and premedication with hydrocortisone (adj OR 2.36; 95% CI 1.38, 4.07; p=0.002) were associated with increased odds of IVIG-associated ADEs. Patients who received premedication with hydrocortisone were more likely to re-present for medical evaluation than patients who did not receive hydrocortisone (OR 1.90; 95% CI 0.98, 3.54; p=0.049). No associations were identified between ADEs and gender, race/ethnicity, premedication with diphenhydramine or ondansetron, pre-treatment serum IgG levels, or concurrent glucocorticoid administration. In summary, the rate of ADEs among pediatric patients with ITP treated with IVIG is remarkably high. Thirty-six percent of patients in our multi-institutional cohort reported headache, nausea/vomiting, or both following single IVIG infusion, consistent with our previous single institution experience. This again highlights the need for proper balance of risks and benefits when considering treatment for children with ITP. Patients who received premedication with acetaminophen were less likely to develop IVIG-associated ADEs, but those who received premedication with diphenhydramine or concurrent glucocorticoid therapy were no more or less likely to develop ADEs. Interestingly, however, patients who received premedication with hydrocortisone were more likely to develop IVIG-associated ADEs. Despite only a small subset of our cohort being premedicated with hydrocortisone (12%, n=66), this premedication strategy was significantly associated with an increased rate of return to medical care following IVIG infusion. Patients returning for emergent medical evaluation frequently underwent repeat laboratory studies or CT imaging, resulting in unnecessary radiation exposure and increased healthcare-related costs. These findings will help to inform IVIG premedication strategies in an attempt to reduce both ADEs and re-presentation to medical care among pediatric patients with ITP receiving IVIG therapy. Figure 1 Figure 1. Disclosures Kirk: Biomarin: Honoraria. Grace: Novartis: Research Funding; Principia: Membership on an entity's Board of Directors or advisory committees; Dova: Membership on an entity's Board of Directors or advisory committees, Research Funding; Agios: Research Funding. Neunert: Novartis: Research Funding. Lambert: Bayer: Consultancy; ClinGen, ISTH, ASH, GW University: Honoraria; Novartis: Consultancy, Honoraria, Research Funding; Astra Zeneca: Research Funding; Argenx: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Principia: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Dova: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Shionogi: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Rigel: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; PDSA: Research Funding; Sysmex: Research Funding; Octapharma: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Despotovic: UpToDate: Patents & Royalties: Royalties; Apellis: Consultancy; Novartis: Consultancy, Research Funding; Agios: Consultancy.

Frequency, etiologies, risk factors, and sequelae of falls among patients with brain metastases: a population- and institutional-level analysis

Background Falls in patients with cancer harbor potential for serious sequelae. Patients with brain metastases (BrM) may be especially susceptible to falls but supporting investigations are lacking. We assessed the frequency, etiologies, risk factors, and sequelae of falls in patients with BrM using two data sources. Methods We identified 42,648 and 111 patients with BrM utilizing Surveillance, Epidemiology, and End Results (SEER)-Medicare data (2008-2016) and Brigham/Dana Farber (BWH/DFCI) institutional data (2015), respectively, and characterized falls in these populations. Results Among SEER-Medicare patients, 10,267 (24.1%) experienced a fall that prompted medical evaluation, with cumulative incidences at 3, 6, and 12 months of 18.0%, 24.3%, and 34.1%, respectively. On multivariable Fine/Gray’s regression, older age (>81 or 76-80 vs. 66-70 years, hazard ratio [HR] 1.18 [95% CI, 1.11-1.25], p<0.001 and HR 1.10 [95% CI, 1.04-1.17], p<0.001, respectively), Charlson comorbidity score of >2 vs. 0-2 (HR 1.08 [95% CI, 1.03-1.13], p=0.002) and urban residence (HR 1.08 [95% CI, 1.01-1.16], p=0.03) were associated with falls. Married status (HR 0.94 [95% CI, 0.90-0.98], p=0.004) and Asian vs. white race (HR 0.90 [95% CI, 0.81-0.99], p=0.03) were associated with reduced fall-risk. Identified falls were more common among BWH/DFCI patients (N=56, 50.4% of cohort), resulting in emergency department visits, hospitalizations, fractures, and intracranial hemorrhage in 33%, 23%, 11%, and 4% of patients, respectively. Conclusions Falls are common among patients with BrM, especially older/sicker patients, and can have deleterious consequences. Risk-reduction measures, such as home safety checks, physical therapy, and medication optimization, should be considered in this population.

A Data Augmentation Method for War Trauma Using the War Trauma Severity Score and Deep Neural Networks

The demand for large-scale analysis and research of data on trauma from modern warfare is increasing day by day, but the amount of existing data is not sufficient to meet such demand. In this study, an integrated modeling approach incorporating a war trauma severity scoring algorithm (WTSS) and deep neural networks (DNN) is proposed. First, the proposed WTSS, which uses multiple non-linear regression based on the characteristics of war trauma data and the medical evaluation by an expert panel, performed a standardized assessment of an injury and predicts its trauma consequences. Second, to generate virtual injury, based on the probability of occurrence, the injured parts, injury types, and complications were randomly sampled and combined, and then WTSS was used to assess the consequences of the virtual injury. Third, to evaluate the accuracy of the predicted injury consequences, we built a DNN classifier and then trained it with the generated data and tested it with real data. Finally, we used the Delphi method to filter out unreasonable injuries and improve data rationality. The experimental results verified that the proposed approach surpassed the traditional artificial generation methods, achieved a prediction accuracy of 84.43%, and realized large-scale and credible war trauma data augmentation.