Rugby players' satisfaction with custom-fitted mouthguards made with different materials

OBJECTIVES

This study compared the comfort of two bimaxillary custom-fitted mouthguards. One type was made with silicone rubber and the other with methyl-methacrylate (acrylic).

METHODS

The study was a within-subject crossover clinical trial with 52 high-school rugby players who were randomly allocated to one of two groups. The first group wore a silicone mouthguard for 4 months and an acrylic one for the following 4-month period. The second group wore an acrylic mouthguard followed by a silicone one for similar periods. Comfort, bulkiness, stability, hardness, ability to talk and to breathe, oral dryness, nausea and inclination to chew were evaluated for each period using a Visual Analogue Scale questionnaire.

RESULTS

There was no significant difference concerning comfort, bulkiness, ability to talk and to breathe, oral dryness and nausea between silicone and acrylic mouthguards by group and time of examination (Three-way ANOVA P>0.05). Acrylic mouthguards were more stable and harder than silicone ones (Wilcoxon's test P<0.01). Tendency to chew was greater for silicone appliances (P<0.01). For stability, hardness and inclination to chew, there was no significant difference in the response of the players based on the sequence of use of the two types of mouthguard during the survey (Mann-Whitney test P>0.05). At the end of the study, 56% of the players preferred to keep the acrylic mouthguard and 44% chose the silicone one. This choice did not vary between the groups (chi2, P>0.05).

CONCLUSION

Silicone rubber mouthguards were well accepted by the players but technical improvements in silicone materials are needed to improve hardness and stability of silicone mouthguards for sport.

Parental reactions to children with congenital heart disease

Informal discussions with 260 families of children with congenital heart disease are reported. Parents raised questions concerning etiology, timing of the diagnosis, pathophysiology and symptomatology, and need for restriction. Depending upon the stage and seriousness of the disease, common parental behavior was observed. A psychological process similar to mourning is required at the time of diagnosis and at the time of corrective surgery in order to promote the family's adaptation to the child with congenital heart disease. Management suggestions are included.

Ten 10-year trends for the future of healthcare: implications for academic health centers

The threat to the United States' Academic Health Centers (AHCs) has been reported for the past decade, signified most importantly by the decrease in the perceived value of patient care delivered and a significant reduction in direct payments to physicians in AHCs. These reductions have required AHCs to become more efficient and increased pressures to become more productive in both patient care and research. The U.S. healthcare system continues to evolve in response to these challenges and the additional pressures of increasing costs and the increasing numbers of uninsured. Ten trends for the next decade are evident: 1) more patients, 2) more technology, 3) more information, 4) the patient as the ultimate consumer, 5) development of a different delivery model, 6) innovation driven by competition, 7) increasing costs, 8) increasing numbers of uninsured, 9) less pay for providers, and 10) the continued need for a new healthcare system. In response to these trends, AHCs will have to continue to improve efficiency by increasing cooperation between researchers, clinicians, and educators while demonstrating how they are "different" and "better" than the competition.The AHC has the tools and the personnel not only to improve patient care processes but also to understand how to decrease costs while maintaining quality. AHCs also have the size and expertise to establish control over geographic market share with services not available elsewhere. Such programs must be able to evolve and respond to market pressures, and the AHC must be an engine of innovation, continuously regenerating new knowledge and programs with "Centers of Excellence" and appropriate industry partnerships. Such progress is driven by better communication and greater sharing of information and collaboration at all levels, including building better physician referral networks. These accomplishments, driven by technology, will allow AHCs to improve quality of care and increase efficiency even under the increasing burden of patients and uninsured. This will position AHCs as the most important advocates and lead players in the development of an improved national healthcare system.

Electrocardiography and 24-hour electrocardiographic ambulatory recording (Holter monitor) studies in children infected with human immunodeficiency virus type 1. The Pediatric Pulmonary and Cardiac Complications of Vertically Transmitted HIV-1 Infection Study Group

Limited data are available on the electrocardiogram and ambulatory electrocardiogram recording (Holter) in children infected with the human immunodeficiency virus type 1 (HIV-1). The purpose of this study was to estimate the prevalence and cumulative incidence of rhythm and conduction abnormalities in HIV-1-infected children. Electrocardiograms and Holter monitoring studies were performed annually on 205 HIV-1-infected children enrolled after 28 days of life (group I), 93 HIV-1-infected infants enrolled during pregnancy or during the first 28 days of life (group IIa), and 463 HIV-1-uninfected infants enrolled during pregnancy or during the first 28 days of life (group IIb). The 5-year cumulative incidence in the group I children of second-degree atrioventricular block or supraventricular or ventricular tachycardia was 13.4%, and the 5-year incidence was higher for the older infected group I children (16.8% for children > or =4 years old at first study and 11.4% for children <4 years, p = 0.04). The mean corrected QT interval was also longer for the older infected group I children (p = 0.002) and prolonged in the HIV-1-infected compared to the HIV-1-uninfected group II children (p = 0.02). None of the children had atrial fibrillation or flutter. Arrhythmias are uncommon in children infected with HIV-1 and in children of HIV-1-infected mothers and the arrhythmias identified tend to be benign. Therefore, routine Holter monitoring does not appear to be indicated in asymptomatic children.

Left thoracoscopic sympathectomy and stellate ganglionectomy for treatment of the long QT syndrome

The long QT syndrome (LQTS) is a rare inherited cardiac disorder that may induce fatal cardiac arrhythmias. Patients diagnosed with this disorder generally have several treatment options, including beta-blockade, cardiac pacing, an implantable automatic defibrillator, or a high thoracic left sympathectomy. We report the case of a 6-year-old girl with the LQTS treated by left thoracoscopic sympathectomy and stellate ganglionectomy. The procedure was performed after an initial thorascopic attempt at another institution failed due to inadequate resection of the sympathetic chain. Operative time was 85 min and blood loss was minimal. There were no intraoperative or postoperative complications. The girl's QT interval decreased and she was discharged on the 4th postoperative day. After 9 months of follow-up, she remains asymptomatic. We conclude that the LQTS patients who fail medical treatment can be treated successfully with left thoracoscopic cervicothoracic sympathectomy. We recommend that the extent of sympathectomy for treating the LQTS be T1-T4 and either the entire stellate ganglion or at least the inferior one-third.

The metrics process: Baylor's development of a "report card" for faculty and departments

In 1996, Baylor College of Medicine began the first year of its "metrics process," collecting, analyzing, and reporting data on the performance of each individual faculty member and each department in achieving the school's missions of education, patient care, research, service, and finance. This article is a report of the first two years of the process, with updates about the 1999 process, future plans, and lessons learned. The primary goal of the metrics process is to provide meaningful data to assess and improve the performance of faculty and departments across all missions. The authors (1) indicate the categories chosen, within each mission of the school, for measuring faculty time and effort (e.g., patient care, with or without learners) and state the measures chosen (e.g., percentage of time); (2) describe the development of questionnaires in 1996 and 1997 to acquire data from faculty, in the chosen categories and measures, about the time and effort they spent; and (3) report highlights of the resulting departmental data that were gathered in 1997. Among the key categories and units of measure chosen for measuring faculty (and departmental) time and effort are research grant dollars (total and per research full-time equivalent, or FTE); basic research grant dollars per square foot of laboratory space; percentage of faculty who spend at least 50% of their time in research who are National Institutes of Health principal investigators; numbers of inpatient and outpatient visits per evaluation and management FTE; total relative value units (RVUs) per patient-care FTE; patient-care income/RVU and expense/RVU for total faculty and support staff; percentage of faculty with at least one leadership position in a state or national organization; and income in excess of expense, by mission (e.g., patient care). Results of comparing data from the first two years of the metrics process demonstrate marked improvements in performance for most research measures (i.e., items of measurement agreed upon for the metrics process). The process is continually being redeveloped; the ultimate challenge is to place the objective measurements in a context where less objective qualities (e.g., innovation) also figure importantly in the evaluation and fostering of excellence. The metrics process is providing important management data, encouraging significant discussions among faculty and chairs about performance and accountability, and aiding greatly in departmental goal-setting and ultimately in determining the overall performance of the school.

Arrhythmias and sudden cardiac death in elite athletes. American College of Cardiology, 16th Bethesda Conference

With the recent high visibility deaths of Hank Gathers and Reggie Lewis, two nationally recognized elite basketball players due to cardiovascular disease and arrhythmias, our awareness of the most optimal ways to manage athletes with known arrhythmias has become heightened. In making medical decisions we physicians come to rely in large measure on data, in addition to clinical acumen and experience. Unfortunately, we are at a disadvantage with respect to athletes since previously published data on the natural history and outcome of such individuals with known arrhythmias are sparse. Furthermore, the tragedies of Lewis, Gathers, Pete Maravich and others are also poignant reminders that the denominator of this equation is not defined and that we do not really know precisely how many athletes experience important arrhythmias, nor their relation to sports activity. In the decade since the 16th Bethesda Conference, an American College of Cardiology sponsored consensus panel that developed standards and recommendations for the disqualification from competition of athletes with known cardiovascular disease, little new data have been developed to make objective decisions in these areas (including arrhythmias) much easier. Nevertheless, while such decision-making in athletes involves situations that are relatively rare, the consequences of misjudgement are substantial. Unfortunately, to complicate matters, even if the precise likelihood of sudden death for a given athlete with arrhythmias were known, many (if not most) professional and elite college athletes might still regard any risk as acceptable and withdrawal from formal competition as highly unacceptable from a financial and psychological standpoint. In this review, consideration will be given to the state of our medical knowledge in these areas. Many controversies persist with regard to arrhythmias, most notably for the athlete who has Wolff-Parkinson-White, mitral valve prolapse, myocarditis, or complex ventricular arrhythmias. Finally, consideration will be given to the broader issues of how, ad physicians and members of society, we may deal with these complex issues.

Management of the child with Wolff-Parkinson-White syndrome and supraventricular tachycardia: model for cost effectiveness

In the next decade, "better" management will be defined by cost effectiveness including morbidity, mortality, and cost. We used a cost-effectiveness model for children with Wolff-Parkinson-White syndrome (WPW) and supraventricular tachycardia (SVT) comparing medical, surgical, and catheter ablative treatment between age 5 years (estimated average age at first recurrence after infancy) and age 21. Charges were quantitated from actual hospital bills; mortality was estimated from the literature; morbidity was assessed by estimating the number of hours in SVT, hours in clinic, hours in routine hospital bed, and hours in hospital intensive care; and the hours were then multiplied by a severity factor, normalized to 1.0 for 1 hour of SVT (0.5 for 1 hour in clinic, 0.75 for routine hospital, and 2.0 for intensive care). Overall charges (5 to 21 years old) for catheter ablation ($17,236) were 39% of surgical management and 57% of medical management; estimated mortality for catheter ablation (5 to 21 years old including failures that reverted to medical management) was 0.15%, which was 10% of medical management and 28% of surgical management; morbidity for catheter ablation was 27.6 units, which was 32% of medical management and 36% of surgical management. Sensitivity analysis demonstrated that the catheter ablation strategy remained preferable throughout the range of plausible values of cost, mortality, and morbidity (including a repeat procedure for initial failures). Therefore, catheter ablation has lower cost, mortality, and morbidity than either medical management or surgery and is the treatment of choice for the child 5 years of age or older with WPW and SVT. This type of analysis can be used for other forms of chronic disease in children.

Cost-effectiveness analysis of stents, balloon angioplasty, and surgery for the treatment of branch pulmonary artery stenosis

Branch pulmonary artery stenosis is a common problem in pediatric cardiology. Treatment has included surgery, balloon angioplasty, and balloon expandable stent placement. It was the purpose of this investigation to demonstrate the cost-effectiveness of each of these modes of treatment. From 1983 to 1994 there were 30 patients admitted for treatment of branch pulmonary artery stenosis only. Data included age at procedure, sex, primary diagnosis, acute and intermediate term success, and complications. Acute success was defined by results at the end of the procedure where intermediate term (IT) success was defined by results at follow-up. Success of a procedure was defined by at least one of the following: an increase in vessel diameter by >/=50% of predilation diameter, a decrease in right ventricular to left ventricular or aortic systolic pressure ratio by >/=20%, or a decrease in peak to peak pressure gradient by >/=50%. The procedure was considered a failure if the previously mentioned criteria were not met or if the patient required a second procedure for the same stenosis. The expense of the procedure (estimated by using the patient charges) were collected from the time of the procedure until December 1994. Because of differing lengths of follow-up, the patients were analyzed separately for procedures and outpatient charges. The total charges were corrected to 1994 dollars using the Medical Consumer Price Index. Thirty patients had 46 separate procedures (12 patients had >1 procedure and 3 had >2 procedures). There were 13 surgeries, 13 balloon angioplasties, and 20 stents. Stents were the most successful (90% acute and 85% IT), but were not statistically superior to surgery (62% acute and IT). Balloon angioplasty was significantly less successful as compared with stents (31% acute and 23% IT), and was not statistically different from surgery over the acute and intermediate term. The charge data showed balloon angioplasty was the least expensive followed by stents and then by surgery. The average total charges per procedure, including outpatient charges, were: surgery $58,068 +/- $4372 (standard error), balloon $21,893 +/- $5019, stents $33,809 +/- $3533 (p < 0.001); excluding outpatient charges: surgery $52,989 +/- $3649, balloon $15,653 +/- $1691, and stents $29,531 +/- $2241 (p < 0.001). Average total charges per patient, including all procedure types and grouped by initial procedure, were: surgery $53,707 +/- $6388, balloon $50,040 +/- $8412, and stent $34,346 +/- $3488 (p = 0.047). Stents were at least as effective as surgery and were more effective than balloon angioplasty in both acute and intermediate term follow-up. Balloon angioplasty was least expensive per procedure but was also least effective. Therefore, intravascular balloon expandable stents are the most cost-effective means available in the treatment of branch pulmonary artery stenosis.

Effect of repair strategy on hospital cost for infants with tetralogy of Fallot

OBJECTIVE

This study compares the total hospital cost (HC) for one-stage versus "two-stage" repair of tetralogy of Fallot (TOF) in infants younger than 1 year of age.

SUMMARY BACKGROUND DATA

Total (one-stage) correction of TOF is now being performed with excellent results in infancy. Alternatively, a two-stage approach, with palliation of infants in the first year of life, followed by complete repair at a later time can be used. In some institutions, the two-stage approach is standard practice for infants younger than 1 year of age or is used selectively in patients with an anomalous coronary artery across the right ventricular outflow tract (RVOT), "small pulmonary arteries," multiple congenital anomalies, critical illnesses (CI), which increase the risk of bypass (e.g., sepsis or DIC), or severe hypercyanotic spells (HS) at the time of presentation. The cost implications of these two approaches are unknown.

METHODS

The authors reviewed 22 patients younger than 1 year of age who underwent repair of TOF at their institution between 1993 and 1995. Eighteen patients had one-stage (1 degree) repair (mean age, 3.4 +/- 3.1 months; range, 3 days-9 months) and 4 patients were treated by a staged approach with initial palliation (1.6 +/- 0.4 month; range, 1.5-2 months) followed by later repair (14.75 +/- 1.5 months; range, 13-16 months). The reasons for palliation were severe HS at time of presentation (two patients), anomalous coronary artery (one patient) and CI (one patient). In the 18 patients undergoing 1 degree repair, 3 (16.6%) presented with HS, 6 (33.3%) had a transanular repair, and 6 (33.3%) were able to be repaired through an entirely transatrial approach (youngest patient, 1.5 months). The HC (1996 dollars) and hospital length of stay (LOS; days) were evaluated for all patients. The HCs were calculated using transition I, which is a cost accounting system used by our medical center since July 1992. Transition I provides complete data on all direct and indirect hospital-based, nonprofessional costs.

RESULTS

There was no mortality in either group. The group undergoing 1 degree repair had an average LOS of 14.5 +/- 11.2 days compared to an average LOS for palliation of 14 +/- 6.4 days. When the palliated group returned for complete repair, the average LOS was 28.8 +/- 25 days, yielding a total LOS for the two-stage strategy of 43 +/- 30.8 days (p = 0.003 compared to 1 degree repair). The HC for 1 degree repair was $32,541 +/- $15,968 compared to $25,737 +/- $1900 for palliation (p = not significant compared to 1 degree repair) and $54,058 +/- $39,395 for subsequent complete repair (p = not significant compared to 1 degree repair) (total two-stage repair HC = $79,795 +/- $40,625; p = 0.001 compared to 1 degree repair). The LOS and HC for the two-stage group combine a total of palliation plus later repair and, as such, reflect two separate hospitalizations and convalescent periods. To eliminate cost outliers, a best-case analysis was performed by eliminating 50% of patients from each group. Using this analysis, the two-stage approach resulted in an average (total) LOS of 16.5 +/- 2.1 days compared to 8.5 +/- 1.4 days for the 1 degree group. Total cost for the two-stage strategy in this best-case group was $44,660 +/- $3645 compared to $22,360 +/- $3331 for 1 degree repair (p = 0.00001).

CONCLUSIONS

The data from this review show that palliation alone generates HC similar to that from 1 degree infant repair of TOF, and total combined HC and LOS for palliation plus eventual repair of TOF (two-stage approach) are significantly higher than from 1 degree repair. Furthermore, these data do not include additional costs for care delivered between palliation and repair (e.g., outpatient visits, cardiac catheterization, serial echocardiography). Although there may be occasions when a strategy using initial palliation followed by later repair may seem prudent, the cost is clearly higher and use of health care resources greater.

Atrial arrhythmias during chronic follow-up of surgery for complex congenital heart disease

After surgery for complex congenital heart disease, clinically important atrial tachyarrhythmias have a higher than normal incidence if sufficiently large regions of conduction block occur within the atria, especially in the presence of hemodynamic alterations. Sinus bradycardia may result from direct damage to sinus node and its blood supply. Historical data have identified patients who have undergone the Mustard or Senning operations for dextrotransposition of the great vessels and the Fontan operation in cases of functional single ventricle as being at great risk for atrial tachyarrhythmias. These arrhythmias are especially poorly tolerated when there are co-existing hemodynamic alterations and are an important source of morbidity and mortality. Until recently, treatment strategies have been limited to antiarrhythmic drugs, bradycardia pacing, and--in suitable patients--antitachycardia pacing, often in combination. Amiodarone has been the most efficacious drug, but has only been of moderate value because of extracardiac side effects. Radiofrequency ablation of the atrial regions critical to reentrant circuits, which was discovered to be of value in patients with atrial flutter and a normal heart is being applied to this diverse group of patients. Early results are promising, but the Fontan operation patients are especially challenging because of early recurrences of apparently new reentrant circuits. Progress in this area will likely come from newer surgical techniques that prevent the milieu for atrial reentry and from multidimensional mapping systems for our current patients.

Difference in QT interval measurement on ambulatory ECG compared with standard ECG

Measurement of the QT interval on standard ECG has diagnostic importance in the congenital long QT syndrome, in pharmacological therapy of arrhythmias, as well as in ischemic heart disease. It has been suggested that QT prolongation on ambulatory ECG (Holter) may have similar importance. To assess agreement between methods, QT interval measurement on standard ECG was compared to that on Holter. Simultaneously obtained ECG and Holter tracings (25 mm/s) of the same complexes in leads V1 and V5 were studied in 14 patients (age range 4-36 years). ECG pairs (n = 100, 49 V1 and 51 V5) were compared over a range of QT interval from 300-620 ms, as determined with the use of calipers by two observers blinded to pairing relationship. Correlation between methods was high for both observers (observer 1:r[V1] = 0.872, r[V5] = 0.973; observer 2: r[V1] = 0.972, r[V5] = 0.988), and interobserver variability was small (> 85% of measurements within 20 ms). As compared to ECG, Holter underestimated QT interval in V1, mean difference (QT [Holter]-QT [ECG]) observer 1 (-23 ms, P < 0.001), observer 2 (-7 ms, P < 0.05), and overestimated QT in V5, mean difference observer 1 (+13 ms, P < 0.001), observer 2 (+ 13 ms, P < 0.001). However, individual variation between methods was wide, as expressed by the difference between individual measurements (95% confidence interval [V1]: observer 1 [-99 to +53 ms] observer 2 [-47 to +33 ms]; [V5]: observer 1 [-33 to +59 ms] observer 2 [-17 to +43 ms]). Furthermore, when using the QTA (interval from onset of Q wave to apex of T wave) similar variability was observed. In the assessment of QT interval, potential sources of error of this magnitude could limit the clinical utility of ambulatory monitoring in detecting prolongation of the QT interval for diagnostic purposes.

Fontan palliation versus heart transplantation: a comparison of charges

Surgical approaches to single-ventricle physiologic abnormalities have included Fontan palliation or transplantation. No cost expenditures have been published. This study compared expenditures between the Fontan procedure and heart transplantation. Between 1988 and 1992, records of 82 patients who underwent the Fontan procedure and 26 who underwent transplant were retrospectively reviewed. Charges for Fontan or transplant procedures were accrued from the date of surgical admission until discharge or patient death and included hospital, physician, and diagnostic laboratory charges. Additionally, the frequency and cost of postoperative hospital readmissions, outpatient evaluations, and diagnostic procedures were recorded for each patient. Estimated expenditures for each evaluated parameter were based on 1992 to 1993 dollar charges. The total expenditure (surgery plus yearly follow-up) for transplantation exceeded that for the Fontan procedure ($96,475 vs $29,730; p < 0.001). Although both groups had similar follow-up periods and mortality rates, the number of hospital readmissions and postoperative diagnostic tests was higher among transplant recipients. Within 1 postoperative year at least four high-risk patients who had undergone a Fontan procedure required listing for transplantation; the total costs of their combined procedures (approximately $80,000 + $3,000 to $5,000 annual outpatient charges) was markedly greater than the cost of the Fontan procedure alone. Although the expenditure for heart transplantation far exceeds that for the Fontan procedure, Fontan palliation in high-risk patients is ultimately more costly and increases postoperative morbidity. In this subgroup, we recommend heart transplantation as the initial definitive procedure because it may increase long-term survival rates and minimize health care expenditures.