Recent Publications by CFE Educators

Advances in precision medicine portend similar progress in orthodontics and will be increasingly harnessed to achieve customized treatment approaches and enhance treatment efficiencies. Our goal is to provide a background on emerging advances in computer technologies and biomedicine and highlight their current and likely future applications to precision orthodontics. A review of orthodontically relevant technologies and advances in pertinent biological research was undertaken. Innovations in computer hardware and software, and 3D imaging technologies offer the ability for customized treatment and biomechanical planning that will be more fully realized within the next few decades. These technologies combined with 3D printing are already being applied to customized appliance fabrication such as aligners and retainers. The future prospects for custom fabrication of orthodontic brackets of appropriate material properties and smart devices are highly desirable and compelling goals. Within biomedicine, the fundamental understanding of cartilage growth and bone biology is currently being tested in animal models to modify mandibular growth and modulate tooth movement, respectively. Some of these discoveries will ultimately have clinical applications in orthodontics including for growth modification, accelerating orthodontic tooth movement, and enhancing anchorage or retention of teeth. Additional genomic and proteomic information will add to further customization of orthodontic diagnosis and treatments. Over the coming decades, precision orthodontics will continue to benefit from advances in many fields and will require the integration of advances in technology, and biomedical and clinical research to deliver optimal, efficient, safe, and reproducible personalized orthodontic treatment.

OBJECTIVES

The RASopathies are a group of syndromes that have in common germline mutations in genes that encode components of the Ras/mitogen-activated protein kinase (MAPK) pathway and have been a focus of study to understand the role of this pathway in development and disease. These syndromes include Noonan syndrome (NS), Noonan syndrome with multiple lentigines (NSML or LEOPARD syndrome), neurofibromatosis type 1 (NF1), Costello syndrome (CS), cardio-facio-cutaneous (CFC) syndrome, neurofibromatosis type 1-like syndrome (NFLS or Legius syndrome) and capillary malformation-arteriovenous malformation syndrome (CM-AVM). These disorders affect multiple systems, including the craniofacial complex. Although the craniofacial features have been well described and can aid in clinical diagnosis, the dental phenotypes have not been analysed in detail for each of the RASopathies. In this review, we summarize the clinical features of the RASopathies, highlighting the reported craniofacial and dental findings.

METHODS

Review of the literature.

RESULTS

Each of the RASopathies reviewed, caused by mutations in genes that encode different proteins in the Ras pathway, have unique and overlapping craniofacial and dental characteristics.

CONCLUSIONS

Careful description of craniofacial and dental features of the RASopathies can provide information for dental clinicians treating these individuals and can also give insight into the role of Ras signalling in craniofacial development.

Fears and worries are normal feelings that help us adapt to the ups and downs of life. Those ups and downs are especially normal as children and adolescents grow up and try to find where they fit in the world. With changing relationships at home and in social circles, they are establishing their worldview and solidifying their identity. These feelings of fear and worry can sometimes become overwhelming, and anxiety disorders can develop. Anxiety disorders are the most common psychiatric disorders with onset in childhood. Pediatricians are often a trusted confidant for children and adolescents, and they may be the first people to hear when normal stress becomes overwhelming and progresses into an anxiety disorder. This article is intended for primary care pediatricians to help them identify normal stresses versus anxiety disorders, and help their patients move, through psychotherapy and pharmacotherapy, toward wellness. [Pediatr Ann. 2017;46(6)e213-e216.].

BACKGROUND

Vascular malformations manifest with pain, bleeding, disability, and disfigurement in a subset of children. There are scant data available on the utility and tolerability of laser surgery for symptomatic or disfiguring non-port-wine stain vascular malformations in children.

OBJECTIVE

The objective of this study was to determine the utility and tolerability of the 1064-nm long-pulsed neodymium:yttrium-aluminum-garnet (LP Nd:YAG) laser for treatment of symptomatic or disfiguring vascular malformations in children.

METHODS

We conducted a retrospective review of 29 pediatric patients with non-port-wine stain vascular malformations who were treated with the LP Nd:YAG laser at our institution. We report patient characteristics, treatment parameters, outcomes, and complications.

RESULTS

Blinded assessment of clinical efficacy revealed good to excellent results in 66.7% of patients treated and poor to fair results in 25%. The overall rate of complications was 27%, with minor skin breakdown and blistering being the most common.

LIMITATIONS

Our conclusions are limited by small sample size, pretreatment and posttreatment photographs in only a subset of patients, and lack of long-term follow-up.

CONCLUSION

The LP Nd:YAG laser is a well-tolerated and effective treatment modality for a variety of non-port-wine stain vascular malformations in children.

IMPORTANCE

Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. As systemic therapies improve, patients with lung cancer live longer and thus are at increased risk for brain metastases. Understanding how prognosis varies across this heterogeneous patient population is essential to individualize care and design future clinical trials.

OBJECTIVE

To update the current Diagnosis-Specific Graded Prognostic Assessment (DS-GPA) for patients with non-small-cell lung cancer (NSCLC) and brain metastases. The DS-GPA is based on data from patients diagnosed between 1985 and 2005, and we set out to update it by incorporating more recently reported gene and molecular alteration data for patients with NSCLC and brain metastases. This new index is called the Lung-molGPA.

DESIGN, SETTING, AND PARTICIPANTS

This is a multi-institutional retrospective database analysis of 2186 patients diagnosed between 2006 and 2014 with NSCLC and newly diagnosed brain metastases. The multivariable analyses took place between December 2015 and May 2016, and all prognostic factors were weighted for significance by hazard ratios. Significant factors were included in the updated Lung-molGPA prognostic index.

MAIN OUTCOMES AND MEASURES

The main outcome was survival. Multiple Cox regression was used to select and weight prognostic factors in proportion to their hazard ratios. Log rank tests were used to compare adjacent classes and to compare overall survival for adenocarcinoma vs nonadenocarcinoma groups.

RESULTS

The original DS-GPA was based on 4 factors found in 1833 patients with NSCLC and brain metastases diagnosed between 1985 and 2005: patient age, Karnofsky Performance Status, extracranial metastases, and number of brain metastases. The patients studied for the creation of the DS-GPA had a median survival of 7 months from the time of initial treatment of brain metastases. To design the updated Lung-molGPA, we analyzed data from 2186 patients from 2006 through 2014 with NSCLC and newly diagnosed brain metastases (1521 adenocarcinoma and 665 nonadenocarcinoma). Significant prognostic factors included the original 4 factors used in the DS-GPA index plus 2 new factors: EGFR and ALK alterations in patients with adenocarcinoma (mutation status was not routinely tested for nonadenocarcinoma). The overall median survival for the cohort in the present study was 12 months, and those with NSCLC-adenocarcinoma and Lung-molGPA scores of 3.5 to 4.0 had a median survival of nearly 4 years.

CONCLUSIONS AND RELEVANCE

In recent years, patient survival and physicians' ability to predict survival in NSCLC with brain metastases has improved significantly. The updated Lung-molGPA incorporating gene alteration data into the DS-GPA is a user-friendly tool that may facilitate clinical decision making and appropriate stratification of future clinical trials.

OBJECTIVE

To determine if age is an independent predictor of surgical success in patients undergoing urethroplasty. Urethroplasty performed by excision and primary anastomosis depends on vascular collateralization. Successful augmented urethroplasty depends on graft neovascularization. Older patients have more comorbid conditions including peripheral vascular disease associated with reduced penile blood flow.

METHODS

This is a retrospective review of urethroplasties from 11 institutions. Primary outcome was functional success at 1 year from surgery, defined as freedom from post-urethroplasty procedures. Secondary outcome was freedom from cystoscopic evidence of stricture recurrence at 3 months. Study outcomes were compared between 2 age cohorts (60 years old and ≥60 years old). Multivariable logistic regression analysis evaluated the influence of patient factors on our primary and secondary outcomes, using age as a continuous variable.

RESULTS

Of 322 urethroplasties, 258 were performed in patients 60 years and 64 in patients ≥60 years. Median follow-up was 1.8 years. The following were not significantly different between groups: stricture length or location, smoking status, number of previous urethrotomies or dilations, and urethroplasty type. The following were more common in patients ≥60 years: diabetes, hypertension, hyperlipidemia, coronary artery and peripheral vascular disease, chronic obstructive pulmonary disease, and cancer. There was no difference in need for repeat procedures or anatomic recurrence between age groups or with increasing age. Stricture length was the only statistically significant clinical factor.

CONCLUSION

Urethroplasty success may be affected by comorbidities but not age. Age alone should not be used as an absolute exclusion criterion for men needing urethral reconstruction.

INTRODUCTION

Emergency department visits and hospital admissions resulting from adult bicycle trauma have increased dramatically. Annual medical costs and work losses of these incidents last were estimated for 2005 and quality-of-life losses for 2000.

METHODS

We estimated costs associated with adult bicycle injuries in the USA using 1997-2013 non-fatal incidence data from the National Electronic Injury Surveillance System with cost estimates from the Consumer Product Safety Commission's Injury Cost Model, and 1999-2013 fatal incidence data from the National Vital Statistics System costed by similar methods.

RESULTS

Approximately 3.8 million non-fatal adult bicycle injuries were reported during the study period and 9839 deaths. In 2010 dollars, estimated adult bicycle injury costs totalled $24.4 billion in 2013. Estimated injury costs per mile bicycled fell from $2.85 in 2001 to $2.35 in 2009. From 1999 to 2013, total estimated costs were $209 billion due to non-fatal bicycle injuries and $28 billion due to fatal injuries. Inflation-free annual costs in the study period increased by 137% for non-fatal injuries and 23% for fatal injuries. The share of non-fatal costs associated with injuries to riders age 45 and older increased by 1.6% (95% CI 1.4% to 1.9%) annually. The proportion of costs due to incidents that occurred on a street or highway steadily increased by 0.8% (95% CI 0.4% to 1.3%) annually.

CONCLUSIONS

Inflation-free costs per case associated with non-fatal bicycle injuries are increasing. The growth in costs is especially associated with rising ridership, riders 45 and older, and street/highway crashes.

Promoting patient safety and increasing health care quality have dominated the health care landscape during the last 15 years. Health care regulators and payers are now tying patient safety outcomes and best practices to hospital reimbursement. Many health care leaders are searching for new technologies that not only make health care for patients safer but also reduce overall health care costs. New advances in ultrasonography have made this technology available to health care providers at the patient's bedside. Point-of-care ultrasound assistance now aids providers with real-time diagnosis and with visualization for procedural guidance. This is especially true for common deep needle procedures such as central venous catheter insertion, thoracentesis, and paracentesis.There is now mounting evidence that clinician-performed point-of-care ultrasound improves patient safety, enhances health care quality, and reduces health care cost for deep needle procedures. Furthermore, the miniaturization, ease of use, and the evolving affordability of ultrasound have now made this technology widely available. The adoption of point-of-care ultrasonography has reached a tipping point and should be seriously considered the safety standard for all hospital-based deep needle procedures.