Healthcare Utilization of Oral and Oropharyngeal Cancer Patients in Emergency Department and Outpatient Settings: An 8-year Population-Based Study

INTRODUCTION

This study aimed to determine trends in the healthcare utilization by Oral Cavity and Oropharyngeal cancer patients across emergency department (ED) and outpatient settings in Alberta and examine the predictors of ED visits.

METHODS

This is a retrospective, population-based, cohort study using administrative data collected by all healthcare facilities between 2010 and 2019 in Alberta, Canada. Trend of visits to different facilities, patients' primary diagnosis, and predictors of ED visits were analyzed.

RESULTS

In total, 34% of patients had at least one cancer-related ED visit. With a rise of 31% in cancer incidence, there was a notable upswing in visits to outpatient clinics and community offices, while ED visits decreased. Cancer stage, rural residence, high material deprivation score, and treatments were found as predictors of ED visits.

CONCLUSION

Improved symptom management and better care access for disadvantaged and rural oral cancer patients may decrease avoidable ED visits.

Xanthoma of the Jaw Bones: Cases Series and Review of Literature

BACKGROUND

Intraosseous xanthomas are rare benign lesions sometimes associated with excess lipid production. Xanthoma of the jaw bones (XJB) was first reported in 1964, and fewer than 50 cases have been reported in the English literature to date. The etiopathogenesis of XJB is highly suggestive of a reactive process or a metabolic condition.

METHOD

Seven cases of XJBs were retrieved from the archives of 4 oral and maxillofacial pathology services. Clinical, radiographic and histopathologic features of all these cases were retrospectively analyzed. Immunohistochemical (IHC) stains for S100 and CD68 were performed.

RESULTS

All seven cases involved the mandible. Patients' age ranged between 13 and 69 years with an evenly distributed female to male ratio. One patient had a medical history of hyperlipidemia, but the medical and dental histories of the others were unremarkable. For most cases, XJB was an incidental finding discovered during routine radiographic examination. Swelling and cortical expansion were noted in a few cases. Radiographically, cases typically presented as either well-defined multilocular or unilocular lesions, which were either radiolucent or mixed radiolucent/radiopaque. All the lesions were treated with surgical curettage and no recurrence was observed during subsequent follow-ups. Each of the seven cases exhibited sheets of foamy macrophages. The diagnosis is established by exclusion of entities with overlapping microscopic features and involved correlation with the clinical, histological, radiographic and IHC profiles. Immunohistochemically, all the cases expressed diffuse positivity for CD68 and were negative for S100.

CONCLUSION

XJB is a rare lesion of unknown etiology, which may mimic other benign or reactive jaw lesions. Due to its rarity and the potential diagnostic challenges it presents, clinicians must remain vigilant and consider CXJ in their differential when assessing radiolucent jaw anomalies.

Dental students' perceptions of instructor storytelling for clinical learning: A qualitative description study

OBJECTIVE

Storytelling has been infrequently used in dental education to link clinical knowledge and practice. Our study aimed to explore dental students' views of instructor storytelling with an emphasis on clinical reasoning within a case-based oral pathology seminar.

METHODS

Qualitative description guided the study design. Participants were third- and fourth-year undergraduate dental students who participated in the seminar. Data were collected through semi-structured, one-on-one interviews. Data analysis was approached using inductive, manifest thematic analysis. Verification strategies were employed to ensure methodological rigor throughout the analysis.

RESULTS

In total, 21 students participated in the study ranging in age from 22 to 29 years. Three interrelated themes were identified, which were related to storytelling authenticity, benefits, and recommendations for improvement. Specifically, students reported that instructor stories effectively conveyed genuine cases and clinical reasoning; were beneficial in terms of engagement, awareness, knowledge acquisition, and skill development; and needed to be educationally and clinically relevant to bridge the knowledge-practice gap.

CONCLUSIONS

Instructor storytelling was regarded by dental students as both positive and beneficial. Research is needed to further demonstrate the effectiveness of instructor storytelling in fostering clinical learning and reasoning using indirect and direct outcome measures.

Multiple cases in case-based learning: A qualitative description study

INTRODUCTION

Case-based learning is widely used in health professions education to improve clinical learning, but little is known about how best to approach multiple cases in this active learning strategy. Our study explored dental student views of multiple case-based learning in oral pathology.

MATERIALS AND METHODS

Qualitative description informed the study design. Data were collected through semi-structured, individual interviews with twenty-one third- and fourth-year dental students who participated in multiple case-based learning seminars. Data were analysed using inductive, manifest thematic analysis.

RESULTS

Themes were identified at approach and case levels. Approach-level themes included preparing students for clinical practice and board exams and maximising exposure (e.g., to lesions/conditions), knowledge application, and engagement within the time allotted for the learning session. Case-level themes included using challenging but manageable cases, linking cases to lecture content, providing the necessary clinical information to solve the cases, and ensuring that cases were authentic and common with non-typical presentations. Aspects of themes encompassed definitions of case characteristics, benefits, conditions of implementation, and recommendations for improvement.

CONCLUSION

Cases should be considered individually, collectively, purposefully, and contextually in multiple case-based learning. Evaluations of learning and behavioural outcome are needed to further establish the effectiveness of approaches and case characteristics in multiple case-based learning.

Active learning in undergraduate classroom dental education- a scoping review

INTRODUCTION

Previous reviews on active learning in dental education have not comprehensibly summarized the research activity on this topic as they have largely focused on specific active learning strategies. This scoping review aimed to map the breadth and depth of the research activity on active learning strategies in undergraduate classroom dental education.

METHODS

The review was guided by Arksey & O'Malley's multi-step framework and followed the PRISMA Extension Scoping Reviews guidelines. MEDLINE, ERIC, EMBASE, and Scopus databases were searched from January 2005 to October 2022. Peer-reviewed, primary research articles published in English were selected. Reference lists of relevant studies were verified to improve the search. Two trained researchers independently screened titles, abstracts, and full-texts articles for eligibility and extracted the relevant data.

RESULTS

In total, 93 studies were included in the review. All studies performed outcome evaluations, including reaction evaluation alone (n = 32; 34.4%), learning evaluation alone (n = 19; 20.4%), and reaction and learning evaluations combined (n = 42; 45.1%). Most studies used quantitative approaches (n = 85; 91.3%), performed post-intervention evaluations (n = 70; 75.3%), and measured student satisfaction (n = 73; 78.5%) and knowledge acquisition (n = 61; 65.6%) using direct and indirect (self-report) measures. Only 4 studies (4.3%) reported faculty data in addition to student data. Flipped learning, group discussion, problem-based learning, and team-based learning were the active learning strategies most frequently evaluated (≥6 studies). Overall, most studies found that active learning improved satisfaction and knowledge acquisition and was superior to traditional lectures based on direct and indirect outcome measures.

CONCLUSION

Active learning has the potential to enhance student learning in undergraduate classroom dental education; however, robust process and outcome evaluation designs are needed to demonstrate its effectiveness in this educational context. Further research is warranted to evaluate the impact of active learning strategies on skill development and behavioral change in order to support the competency-based approach in dental education.

Demographic and Clinicopathologic Distribution of Oral Cavity and Oropharyngeal Cancer in Alberta, Canada: A Comparative Analysis

OBJECTIVES

The aims of this study were to determine demographic profiles, tumour characteristics and treatment factors related to oral cavity and oropharyngeal cancer (OCC and OPC) and comparatively analyze these cancers in the adult population of Alberta, Canada, over 12 years.

METHODS

Demographic, tumour characteristics and treatment data regarding OCC and OPC incidence in Alberta residents ≥18 years in 2005-2017 were extracted from the Alberta Cancer Registry database. Age-standardized incidence and mortality rates (ASIR and ASMR) were computed.

RESULTS

Among 3448 OCC and OPC cases, mean (standard deviation) age at diagnosis was 63.9 (14.4) and 60.1 (10.2) years, respectively. There was a male predilection for both OCC (58.2%) and OPC (81.7%). With some fluctuations, ASIR remained the same for OCC but increased for OPC. ASMR increased for both. The most common site for OCC was tongue and for OPC tonsil. Squamous cell carcinoma was the most common diagnosis for OCC and OPC. Involvement of at least 1 lymph node was observed in 38.5% of OCC and 85.8% of OPC cases. For 45.2% of OCC and 82.3% of OPC cases, diagnosis occurred at stage IV. The most common initial treatments for OCC were surgery, alone or combined with radiation, whereas radiation with chemotherapy was the main treatment modality for OPC.

CONCLUSION

The incidence of OPC in younger males was higher than that of OCC. Although incidence of OPC per 100 000 population increased over the 12-year study period, it remained largely unchanged for OCC. For both cancers, initial diagnoses were made at advanced stages, with almost twice as many stage IV OPC cases than OCC cases.

Retrospective study of factors associated with late detection of oral cancer in alberta: A qualitative study

Oral cancer continues to be diagnosed in advanced stages, giving patients lower chances of survival. The objective of this study was to explore reasons for delayed diagnosis of oral cancer in Alberta. A retrospective qualitative design was implemented through seven steps suggested for conducting a narrative clinical document. Data was retrieved from the Alberta Cancer Registry database between 2005 and 2017. A sample of initial consultation notes (ICN) of oral and oropharyngeal cancer patients were identified through a purposeful sampling method and added to the study until saturation was achieved. A deductive analysis approach inspired by the model pathways to treatment health care provider (HCP) was employed. From the 34 ICN included in our analysis, five main categories were identified: appraisal interval, help-seeking interval, diagnosis interval, pre-treatment interval, and other contributing factors such as health-related behaviours, system delay, and tumor characteristics. These factors negatively contributed to early detection of oral and oropharyngeal cancers and affect treatment wait time with patients, providers, and the healthcare system. Patient's lack of awareness, provider's oversight and prolonged access to care were the main reasons of delay in cancer diagnosis and management in our study. A sustainable plan for public awareness interventions and implementation of a solid curriculum for medical and dental students is needed to enhance their related knowledge, competence in clinical judgement, and treatment managements.

Dental students' perceptions of the wildcard as a novel teaching technique in case-based learning

OBJECTIVE

Cases used in case-based learning should be realistic, relatively difficult, engaging, and educational to maximize clinical knowledge and skills. Data are needed to support the effectiveness of existing and new techniques to ensure these case attributes. The purpose of this study was to explore dental students' perceptions of the wildcard technique in case-based learning. This novel technique aims to ensure key case attributes by adding new information to the analysis of a case that challenges the initial diagnosis and/or treatment plan.

METHODS

Constructivism (paradigm) and interpretative description (approach) informed the study design. Participants were 21 third- and fourth-year dental students who took part in an oral pathology seminar in which the wildcard was employed. Data were collected through individual, semi-structured interviews that were digitally recorded and transcribed verbatim. Inductive, manifest thematic analysis was used to analyze the data. Several verification strategies were implemented to ensure rigor throughout data analysis.

RESULTS

Identified themes suggest that students perceived the wildcard as a new scenario that simulated clinical practice regarding settings, situations, conditions, and required skills. They also enjoyed the wildcard and found it effective in terms of knowledge acquisition, skills development, and engagement. Students valued and recommended wildcards that were challenging, authentic, and educational.

CONCLUSIONS

Students positively valued the wildcard, which seems to ensure several case attributes. Learning and behavioral outcome evaluations are needed to further establish the effectiveness of the wildcard in case-based learning.

Factors Associated with Oral Cancerous and Precancerous Lesions in an Underserved Community: A Cross-Sectional Study

Street-involved people with limited access to regular healthcare have an increased risk of developing oral cancer and a lower survival rate. The objective of this study was to measure the prevalence of oral cancerous/precancerous lesions and determine their associated risk factors in a high-risk, underserved population. In this cross-sectional study, English-speaking adults aged 18 years and older living in a marginalized community in Edmonton were recruited from four non-profit charitable organizations. Data were collected through visual oral examinations and a questionnaire. Descriptive statistics, chi-squared tests, and logistic regressions were applied. In total, 322 participants with a mean (SD) age of 49.3 (13.5) years completed the study. Among them, 71.1% were male, 48.1% were aboriginal, and 88.2% were single. The prevalence of oral cancerous lesions was 2.4%, which was higher than the recorded prevalence in Canada (0.014–1.42: 10,000) and in Alberta (0.011–1.13: 10,000). The clinical examinations indicated that 176 (54.7%) participants had clinical inflammatory changes in their oral mucosa. There was a significant association between clinical inflammatory oral lesions and oral cancerous/precancerous lesions (p < 0.001). Simple logistic regression showed that the risk of the presence of oral cancerous/precancerous lesions was two times higher in participants living in a shelter or on the street than in those living alone (OR = 2.06; 95% CI: 1.15–3.82; p-value: 0.021). In the multiple logistic regression analysis, the risk of oral cancerous/precancerous lesions was 1.68 times higher in participants living in a shelter or on the street vs. living alone after accounting for multiple predictors (OR = 1.67; 95% CI: 1.19–2.37; p-value: 0.022). The results demonstrated a high prevalence of cancerous/precancerous lesions among the study participants, which was significantly associated with clinical inflammatory oral lesions. The evidence supports the need for developing oral cancer screening and oral health promotion strategies in underserved communities.

Perceived Effectiveness and Applicability of Think-Pair-Share Including Storytelling (TPS-S) to Enhance Clinical Learning

Problem: Think-pair-share (TPS) is a teaching strategy that promotes active and collaborative learning; however, the effectiveness and applicability of this strategy in its original or altered form remain to be established, especially in health professions education. As a first step in this direction, the objective of our study was to examine the perceived effectiveness and applicability of TPS including storytelling (TPS-S) in an oral pathology seminar from the perspectives of students, seminar instructors, and peer instructors (experienced instructors who observed the seminar). Intervention: Prompts for individual thinking (T), pair discussion (P), and class sharing (S) included clinical case-based questions related to diagnosis and management and wildcards with additional information about the cases. In addition to the traditional TPS phases, the experiences of the leading instructor in dealing with the cases discussed in the seminar were shared through storytelling to model good practices in clinical diagnosis and management. Context: Our study was conducted in the School of Dentistry at the University of Alberta. Participants in this mixed-method study included third (Y3) and fourth (Y4) year dental students (n = 55) in their clinical training, seminar instructors (n = 2), and peer instructors (n = 3). Data from students, seminar instructors, and peer instructors were obtained through the Student Evaluation of Educational Quality (SEEQ) questionnaire, journaling, and interview, respectively. Descriptive statistics were performed to analyze SEEQ dimensions and statements (factors). MANOVA was used to determine significant differences between Y3 and Y4 students for SEEQ dimensions and ANOVA to identify the factors that accounted for significant differences. Qualitative data were analyzed using inductive content analysis. Impact: Participants positively valued the TPS-S seminar. Students rated all SEEQ dimensions between good and very good and regarded the seminar as superior to traditional lectures. Perceived conditions that facilitated the implementation of TPS-S included the use of real-life clinical cases, instructor facilitation skills, and the scaffolded structure of the seminar. Perceived conditions that hindered the implementation of TPS-S included unequal participation of Y3 and Y4 students, time constraints, and issues related to student pairing. Lessons learned: TPS-S was perceived as effective to improve clinical learning and applicable to dental clinical education as long as its implementation matches the characteristics of the learning context. Further evidence is needed to empirically demonstrate the effectiveness and applicability of TPS-S.

Oral Cavity and Oropharyngeal Cancer Surveillance and Control in Alberta: A Scoping Review

OBJECTIVES

This scoping review provides a comprehensive overview of oral cavity cancer (OCC) and oropharyngeal cancer (OPC) in Alberta.

METHODS

A database search was conducted up to 2018 using Web of Science, Scopus, Medline, PubMed and Embase, along with a manual search of gray literature. Data from the Alberta Cancer Foundation's dedicated fund for research, Cancer Surveillance and Reporting and Alberta Cancer Registry were also collected.

RESULTS

Our review included 8 published papers and 14 other sources, including data on 3448 OCC and OPC patients from Surveillance and Reporting and Alberta Cancer Registry. Cancer registry data (2005-2017) showed that most OCC and OPC lesions were diagnosed at an advanced clinical stage, with a significantly large number of advanced OPC lesions in stage IV (OCC 45.2%, OPC 82.4%); 47.9% of these patients died. Survival rates were lowest in rural and First Nations areas. In Alberta, 35% of HPV-associated cancers were linked to OPCs, which were more prevalent in men and younger age groups. No routine public oral cancer screening program currently exists in Alberta. General practitioners and dentists refer patients to specialists, often with long waiting times.

CONCLUSION

OCC and OPC patients in Alberta continue to be diagnosed in stage IV and experience high mortality rates.

Efficacy and safety of catheter ablation for atrial fibrillation in patients with cancer

Background

Atrial fibrillation (AF) is the most common arrhythmia in patients with cancer. Management of AF in patients with cancer poses unique challenges. Long-term use of antiarrhythmic drug (AAD) therapy lacks evidence of efficacy in this population and poses risk of drug interactions. Catheter ablation is a well-established treatment modality for AAD resistant symptomatic AF and in patients with heart failure. Nevertheless, the effectiveness and safety of catheter ablation in patients with cancer is not well established.

Method

We retrospectively analyzed consecutive patients who underwent catheter ablation for AF, with either history of cancer (other than non-melanoma skin cancer) within 5-years prior or exposure to systemic anthracycline and/or thoracic radiation therapy at any time.

Results

The study included 162 patients. The mean age was 65.5 (26–84 years) years and 50% were female. Overall 133 (82%) patients had freedom from AF at 12 months following ablation. Of these 74 (54%) required post-ablation AAD, 18 (13.5%) required another ablation within the first 12 months and 9 (6.7%) required both AAD and a second ablation to maintain sinus rhythm. There were 14 adverse events (8.6%); 5 access site and 4 non-access site bleeding, 2 strokes, 2 cardiac tamponade and 1 pulmonary vein stenosis with ≈1% serious complications.

Conclusion

The success of catheter ablation for AF and the incidence of procedure related complications in patients with a history of recent cancer or prior exposure to cardiotoxic therapies are similar to that reported in patients without a history of cancer and hence if needed, it should be considered in select patients.

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Dr. S Ganatra is supported by Lahey Physician Research Stipend Program.

Cardiovascular effects of chimeric antigen receptor t-cell therapy for refractory or relapsed non-hodgkin lymphoma

Purpose

Cardiovascular complications of chimeric antigen receptor T-cell (CAR T-cell) therapy are poorly understood. We examined the incidence, predictors and impact of new or worsening cardiomyopathy in patients undergoing CAR T-cell therapy.

Methods

All patients with refractory or relapsed non-Hodgkin's lymphoma, undergoing CAR T-cell therapy at collaborative institutes underwent serial echocardiograms at baseline and within 7 days after developing high-grade cytokine release syndrome (CRS), and were followed for all-cause mortality. New or worsening cardiomyopathy was defined as a reduction in left ventricular ejection fraction (LVEF) &gt;10% from baseline to &lt;50% during the index hospitalization.

Results

Among 187 consecutive CAR T-cell therapy patients, 116 (50 Grade ≤1 CRS, 66 Grade ≥2 CRS) had &gt;1 echocardiogram performed and were included in this analysis. The median age was 63 (range 19–80) years, 42% were women, 91% were Caucasian. A total of 12 (10.3%) patients developed new or worsening cardiomyopathy with a decline in LVEF from 58±6% to 36±7% within a median of 12.5 (range 2–24) days of CAR T-cell infusion. In multivariable analyses, older age, prior stem cell transplantation, baseline angiotensin-converting enzyme inhibitor use and CRS grade ≥2 were associated with the development of cardiomyopathy. Patients who developed cardiomyopathy were more likely to require vasopressor support (p=0.004) and mechanical ventilation (p=0.014). LVEF improved in 9/12 (75%) patients. CAR T-cell associated cardiomyopathy did not impact overall mortality or cancer response to CAR-T cell therapy.

Conclusions

Patients undergoing CAR T-cell therapy are at risk of developing cardiomyopathy and hemodynamic instability. Pre-CAR T-cell therapy cardiovascular risk stratification and echocardiogram surveillance during therapy should be considered for prompt identification and mitigation of cardiac complications.

Predictors of Cardiomyopathy Development

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Anju Nohria, MD is supported by the Gelb Master Clinician Award at Brigham and Women's Hospital.

Management of cardiac disease in cancer patients throughout oncological treatment: ESMO consensus recommendations

Cancer and cardiovascular (CV) disease are the most prevalent diseases in the developed world. Evidence increasingly shows that these conditions are interlinked through common risk factors, coincident in an ageing population, and are connected biologically through some deleterious effects of anticancer treatment on CV health. Anticancer therapies can cause a wide spectrum of short- and long-term cardiotoxic effects. An explosion of novel cancer therapies has revolutionised this field and dramatically altered cancer prognosis. Nevertheless, these new therapies have introduced unexpected CV complications beyond heart failure. Common CV toxicities related to cancer therapy are defined, along with suggested strategies for prevention, detection and treatment. This ESMO consensus article proposes to define CV toxicities related to cancer or its therapies and provide guidance regarding prevention, screening, monitoring and treatment of CV toxicity. The majority of anticancer therapies are associated with some CV toxicity, ranging from asymptomatic and transient to more clinically significant and long-lasting cardiac events. It is critical however, that concerns about potential CV damage resulting from anticancer therapies should be weighed against the potential benefits of cancer therapy, including benefits in overall survival. CV disease in patients with cancer is complex and treatment needs to be individualised. The scope of cardio-oncology is wide and includes prevention, detection, monitoring and treatment of CV toxicity related to cancer therapy, and also ensuring the safe development of future novel cancer treatments that minimise the impact on CV health. It is anticipated that the management strategies discussed herein will be suitable for the majority of patients. Nonetheless, the clinical judgment of physicians remains extremely important; hence, when using these best clinical practices to inform treatment options and decisions, practitioners should also consider the individual circumstances of their patients on a case-by-case basis.

Barriers to receipt of novel oral oncolytics: A single-institution quality improvement investigation

INTRODUCTION

Novel oral oncolytic agents have become the standard of care and first-line therapies for many malignancies. However, issues impacting access to these drugs are not well explored. As part of a quality improvement project in a large tertiary academic institution, we aim to identify potential barriers that delay treatment for patients who are prescribed novel oral oncolytics.

METHODS

This was a retrospective review of adults who were newly prescribed a novel oral oncolytic for Food and Drug Administration-approved indications at a single tertiary care center. Patients were identified via electronic prescription data (e-Scribe). Demographics, insurance information, and prescription dates were extracted from the electronic medical record and pharmacy claims data. Statistical analyses were performed to determine whether time-to-receipt was associated with insurance category, pharmacy transfers, cost assistance, and drug prescribed.

RESULTS

Of the 270 successfully filled prescriptions, the mean time-to-receipt was 7.3 ± 10.3 days (range: 0-109 days). Patients with Medicare experienced longer time-to-receipt (9.1 ± 13.1 days) compared to patients with commercial insurance (4.4 ± 3.3). Uninsured patients experienced the longest time-to-receipt (15.7 ± 7.8 days) overall. Pharmacy transfers and cost assistance programs were also significantly associated with longer time-to-receipt. Ten prescriptions remained unfilled 90 days after the study period and were considered abandoned.

CONCLUSION

Insurance has a significant effect on the time-to-receipt of newly prescribed novel oral oncolytics. Pharmacy transfers and applying for cost assistance are also associated with longer wait times for patients. Our retrospective analysis identifies areas of improvement for future interventions to reduce wait times for patients receiving novel oral oncolytics.

Evidence on radiation dose reduction using rectangular collimation: a systematic review

BACKGROUND

The goal of an intraoral radiograph is to be a valuable diagnostic tool while keeping the radiation exposure dose as low as reasonably achievable. The International Commission on Radiological Protection (ICRP) has strong recommendations for patient dose-reduction strategies.

OBJECTIVE

To answer the following research question: 'In either patient or in phantoms, does rectangular collimation compared with other forms of collimation reduce the radiation absorbed dose during intraoral imaging?'

METHODS

The search strategy was developed specifically for each electronic database. Information was collected from MEDLINE, all EBM Reviews including the Cochrane Library, EMBASE, LILACS, PubMed and Web of Science, and from a search of the grey literature via Google Scholar. Studies were included if they reported the radiation dose in intraoral imaging using rectangular collimation compared with any other type of collimation or the absence of it. Studies that did not involve comparison/control groups were excluded. A qualitative appraisal of the included studies was performed. The Methodological Index for NOn-Randomised Studies (MINORS) tool assessed the potential risk of bias among the studies, while the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach determined the level of available evidence.

RESULTS

Thirteen studies using different types of receptors, including D-speed film, E-speed film, phosphor storage plates (PSP) and direct digital sensors, were included. Different methods to access absorbed and effective dose by exploring distinct technical parameters, such as distance object-receptor, long- and short-cone, kVp and mA, exposure time and beam filtering, were used. High heterogeneity between the studies was found. The level of evidence was classified as moderate. The radiation dose reduction ranged from 40% to 92% compared with circular collimation. The limitations of the cross-sectional design and in vivo studies were discussed. As this systematic review applied validated tools and guidelines designed for population-based studies, the application for studies based on computer simulations and dosimetry measurements was challenging.

CONCLUSION

There is moderate evidence suggesting that rectangular collimation significantly reduces radiation dose when compared with round collimation, justifying its implementation in clinical settings/private practices while taking intraoral radiographs.

Digital Intraoral Imaging Re-Exposure Rates of Dental Students

A guiding principle of radiation safety is ensuring that radiation dosage is as low as possible while yielding the necessary diagnostic information. Intraoral images taken with conventional dental film have a higher re-exposure rate when taken by dental students compared to experienced staff. The aim of this study was to examine the prevalence of and reasons for re-exposure of digital intraoral images taken by third- and fourth-year dental students in a dental school clinic. At one dental school in Canada, the total number of intraoral images taken by third- and fourth-year dental students, re-exposures, and error descriptions were extracted from patient clinical records for an eight-month period (September 2015 to April 2016). The data were categorized to distinguish between digital images taken with solid-state sensors or photostimulable phosphor plates (PSP). The results showed that 9,397 intraoral images were made, and 1,064 required re-exposure. The most common error requiring re-exposure for bitewing images was an error in placement of the receptor too far mesially or distally (29% for sensors and 18% for PSP). The most common error requiring re-exposure for periapical images was inadequate capture of the periapical area (37% for sensors and 6% for PSP). A retake rate of 11% was calculated, and the common technique errors causing image deficiencies were identified. Educational intervention can now be specifically designed to reduce the retake rate and radiation dose for future patients.

Barriers in time to initiation of therapy for newly prescribed novel oral oncolytics

e18005

Background: Novel oral oncolytics have been incorporated into standard of care for many malignancies. With increasing utility of these medications, accessibility issues have emerged. The purpose of this study is to examine the time-to-therapy initiation of novel oral oncolytics and to identify barriers that result in delays and access issues. Methods: A retrospective review of our electronic data warehouse was performed of adults newly prescribed a novel oral oncolytic for FDA approved indications from 04/01/16 to 12/31/16. Exclusion criteria: traditional chemotherapy or previous treatment with the same agent. Primary outcome: time from date prescribed to date filled. Record of pharmacy transfer, manufacturer assistance, and delays in treatment were also extracted. Kruskall-Wallis and Mann Whitney U tests of association were performed to identify whether pharmacy transfers or manufacturer assistance were associated with delays in time to treatment filled. Fisher’s Exact tests were performed to identify drug or insurance related associations with delays. Results: Of our interim analysis of 92 patients who met inclusion criteria, 9 (9.8%) were insured by Medicaid, 32 (34.8%) by Medicare, 51 (55.0%) by private insurance or other. The median time between date prescribed and date filled was 6 days (range 0-109 days). The most frequently prescribed drug was palbociclib (n = 22, 23.9%). 25 (27.2%) of patients had a pharmacy transfer prior to receiving their drug, 15 (16.3%) patients received manufacturer assistance, and 17 (19%) of patients’ records indicated a delay. Transfers, manufacturer assistance, and delays each had a statistically significant relation with time-to-fill (p < 0.05), though none were significantly associated with drug or insurance type. Time-to-fill was not significantly associated with a particular drug or insurance type. Conclusions: As the landscape of oncology changes, barriers to treatment will be discovered as new novel agents are approved. Our study shows that potential exists to prevent treatment delays and improve access to care. By studying the factors affecting time-to-treatment, quality improvement initiatives can be developed to better streamline the process.

Digital Imaging Capability for Caries Detection

The objective of this study was to identify the diagnostic capability of photostimulable phosphor plates (PSPs) and direct digital sensors (DDSs) in the detection of interproximal caries. Studies were identified that evaluated the diagnostic capability of PSPs and DDSs in detecting interproximal caries in human teeth, in both dentin and enamel. Histologic sections were the gold standard. This systematic review searched several electronic databases. In addition, Google Scholar and reference lists of the finally included studies were screened. QUADAS-2 was applied to evaluate the risk of bias among included studies. Six studies were finally included; 4 of which were considered homogeneous enough to conduct a meta-analysis. The meta-analysis evaluated 668 interproximal human tooth surfaces. All studies used extracted human teeth ranging from no caries present to caries into dentin. Each tooth was radiographed by both PSP and DDS technologies and then submitted for histologic analysis as the gold standard. Meta-analysis showed that intraoral digital imaging is of high specificity but low sensitivity in the detection of interproximal caries. The sensitivity and specificity for different studies with PSPs varied substantially from 15% to 54% and from 84% to 100%, respectively. Direct sensor analysis sensitivity and specificity ranged from 16% to 56% and from 90% to 100%, respectively. Newer PSP and DDS technologies had statistically significant higher sensitivities, yet the differences in diagnostic capabilities between the older and newer technologies were clinically insignificant. Both digital systems were excellent in identifying surfaces without caries (specificity) but were not sensitive enough to reliably identify interproximal surfaces with caries. Clinicians must therefore remain vigilant in performing a careful clinical examination and other diagnostic tests rather than relying solely on radiographic imaging to diagnose interproximal caries.

Knowledge Transfer Statement: This study will help clinicians make an evidence-based decision when deciding which digital radiography system to use when evaluating interproximal caries. Time, patient radiation safety, cost, and image quality are factors to be considered. The performance of the different available digital imaging systems was compared with the current gold standard—a histologic analysis—via meta-analysis.

Silver nitrate burn of the lower lip: a case report

Silver nitrate is used in medicine to treat a number of conditions because of its cauterizing properties. This case report describes management of a silver nitrate burn of the oral mucosa that resulted in a large mass of necrotic tissue and accompanying pain in a 41-year-old man. The patient bit his lip and received silver nitrate treatment from a physician. Significant swelling and pain occurred over a period of 3 weeks after application. Analysis of a biopsy specimen revealed necrotic tissue with chronically inflamed granulation tissue. The lesion persisted, and it was determined that debridement was necessary to enhance wound healing and prevent significant scar formation. The patient was reexamined 10 days and 1 month after debridement. The lesion had significantly decreased in size, and the patient reported notable reduction of pain. The final follow-up at 3 months showed a desirable result with minimal scar formation. Use of concentrated silver nitrate for cautery can result in significant damage to mucous membranes, including oral mucosa.

Histology near periodontitis osteoclasts

Histologic evaluation of periodontal tissues generally has included only areas adjacent to the gingival crevice, without knowledge or quantitation of alveolar crest osteoclastic (periodontitis) activity and infiltrate. The purpose of this study was to use human autopsy material to quantitate collagen and cell types adjacent to presumed periodontitis activity and quiescence, each in the same individual. Thirteen subjects contributed 4 sites each, 2 exhibiting alveolar crest periosteal osteoclasts in resorption lacunae/periodontitis activity (OC/PA) and 2 with no osteoclasts or resorption lacunae/ periodontal quiescence (NOC/PQ). Tissue and cell morphotypes were quantitated by 2 evaluators at 100 intersects in 0.06 mm2 fields progressing from the alveolar crest toward the gingival crevice. Cell morphotypes/tissue components were compared between groups and fields using a general linear model with repeated measures. OC/PA fields adjacent to the alveolar crest contained significantly more intersects with macrophage-like cells (10.7+/-1.1 versus 5.3+/-0.6%, P=0.0003), lymphocytes (4.6+/-1.1 versus 0.7+/-0.2%, P=0.0013), plasma cells (13.3+/-2.7 versus 2.1+/-0.6%, P=0.0004), and less with collagen (48.9+/-3.5 versus 75.0+/-2.0%, P=0.0001) than NOC/PQ fields. Numbers of lymphocytes and plasma cells increased (P=0.0006 and P=0.0002, respectively), and fibroblasts and collagen decreased (P=0.0024 and P=0.0001, respectively) in fields up to 1 mm closer to the gingival crevice. However, apparent osteoclastic activity in periodontitis subjects is associated with a significant inflammatory cell infiltrate, especially macrophages and plasma cells.

Studies on calcium absorption from milk using a double-label stable isotope technique

Calcium absorption was measured in ten male volunteers from skimmed milk, Ca-enriched skimmed milk or watercress (Nasturtium officinale) soup. The foods were labelled extrinsically with 30 mg 44Ca. Shortly after consuming the labelled meal, each subject was given an intravenous injection of 3 mg 42Ca. Fractional absorption from the oral dose was determined from plasma and urine samples collected 24-72 h later, using fast atom bombardment mass spectrometry to measure isotope ratios. The values for urine and plasma were in good agreement. Mean percentage absorption was 45.5 (SEM 1.9)% from the skimmed milk, 35.7 (SEM 4.7)% from the Ca-enriched milk and 27.4 (SEM 1.9)% from the watercress soup. The effect of consuming 568 ml (1 pint) Ca-enriched milk each day for 4 weeks on the efficiency of absorption of Ca was studied. Although there was no statistically significant difference between Ca absorption before and after the supplementation period, the results were considered to be somewhat inconclusive due to the small number of subjects and wide individual variation in Ca absorption.

Human fertilization by micro-injection of immotile spermatozoa

Microfertilization of human oocytes with spermatozoa from a man with immotile cilia syndrome is reported, confirming a preliminary investigation where a zona-free donor oocyte was fertilized with spermatozoa from the same patient. Oocytes from his spouse were obtained by laparoscopy after routine stimulation with clomiphene citrate, human menopausal and chorionic gonadotrophins, and were cultured for 4-6 h in Whittingham's T6 medium, supplemented with 10% of her serum. The spermatozoa were washed and processed in the same medium and capacitated for 6-8 h before micromanipulation. Three of five mature oocytes were fertilized by micro-injection of a single immotile spermatozoon into the perivitelline space. One oocyte produced a two-pronuclear ovum assessed 19 h after injection, while the other two produced 2-cell embryos with blastomeres of equal size, 22 h after injection. These embryos cleaved to 3-8-cell stages in culture before embryo replacement. No pregnancy resulted from embryo transfer. The results conclusively demonstrate that human oocytes can be fertilized successfully with immotile spermatozoa by micro-injection and the work has profound implications in the treatment of severe male infertility.