Connecting the disconnected: Leveraging an in-home team member for video visits for older adults

BACKGROUND

Older adults are interested and able to complete video visits, but often require coaching and practice to succeed. Data show a widening digital divide between older and younger adults using video visits. We conducted a qualitative feasibility study to investigate these gaps via ethnographic methods, including a team member in older participants' homes.

METHODS

This ethnographic feasibility study included a virtual medication reconciliation visit with a clinical pharmacist for Veterans aged 65 and older taking 5 or more medications. An in-home study team member joined the participant and recorded observations in structured fieldnotes derived from the Updated Consolidated Framework for Implementation Research and Age-Friendly Health Systems. Fieldnotes included behind-the-scenes facilitators, barriers, and solutions to challenges before and during the visits. We conducted a thematic analysis of these observations and matched themes to implementation solutions from the Expert Recommendations for Implementing Change.

RESULTS

Twenty participants completed a video visit. Participants were 74 years old (range 68-80) taking 12 daily medications (range 7-24). Challenges occurred in half of the visits and took the in-home team member and/or pharmacist an average of 10 minutes to troubleshoot. Challenges included notable new findings, such as that half of the participants required technology assistance for challenges that would not have been able to be solved by the pharmacist virtually. Furthermore, although many participants had a device or had used video visits before, some did not have a single device with video, audio, Internet, and access to their email username and password.

CONCLUSIONS

Clinicians may apply these evidence-based implementation solutions to their approach to video visits with older adults, including having a team member join the visit before the clinician, involving tech-savvy family members, ensuring the device works with the visit platform ahead of time, and creating a troubleshooting guide from our common challenges.

Statins, Mortality, and Major Adverse Cardiovascular Events Among US Veterans With Chronic Kidney Disease

Importance

There are limited data for the utility of statins for primary prevention of atherosclerotic cardiovascular disease (ASCVD) and death in adults with chronic kidney disease (CKD).

Objective

To evaluate the association of statin use with all-cause mortality and major adverse cardiovascular events (MACE) among US veterans older than 65 years with CKD stages 3 to 4.

Design, Setting, and Participants

This cohort study used a target trial emulation design for statin initiation among veterans with moderate CKD (stages 3 or 4) using nested trials with a propensity weighting approach. Linked Veterans Affairs (VA) Healthcare System, Medicare, and Medicaid data were used. This study considered veterans newly diagnosed with moderate CKD between 2005 and 2015 in the VA, with follow-up through December 31, 2017. Veterans were older than 65 years, within 5 years of CKD diagnosis, had no prior ASCVD or statin use, and had at least 1 clinical visit in the year prior to trial baseline. Eligibility criteria were assessed for each nested trial, and Cox proportional hazards models with bootstrapping were run. Analysis was conducted from July 2021 to October 2023.

Exposure

Statin initiation vs none.

Main Outcomes and Measures

Primary outcome was all-cause mortality; secondary outcome was time to first MACE (myocardial infarction, transient ischemic attack, stroke, revascularization, or mortality).

Results

Included in the analysis were 14 828 veterans. Mean (SD) age at CKD diagnosis was 76.9 (8.2) years, 14 616 (99%) were men, 10 539 (72%) White, and 2568 (17%) Black. After expanding to person-trials and assessing eligibility at each baseline, there were 151 243 person-trials (14 685 individuals) of nonstatin initiators and 2924 person-trials (2924 individuals) of statin initiators included. Propensity score adjustment via overlap weighting with nonparametric bootstrapping resulted in covariate balance, with mean (SD) follow-up of 3.6 (2.7) years. The hazard ratio for all-cause mortality was 0.91 (95% CI, 0.85-0.97) comparing statin initiators to noninitiators. The hazard ratio for MACE was 0.96 (95% CI, 0.91-1.02). Results remained consistent in prespecified subgroup analyses.

Conclusions and Relevance

In this target trial emulation of statin initiation in US veterans older than 65 years with CKD stages 3 to 4 and no prior ASCVD, statin initiation was significantly associated with a lower risk of all-cause mortality but not MACE. Results should be confirmed in a randomized clinical trial.

Nurse-led supportive Coordinated Transitional Care (CTraC) program improves care for veterans with serious illness

BACKGROUND

The Coordinated Transitional Care (CTraC) program is a telephone-based, nurse-driven program shown to decrease readmissions. The aim of this project was to implement and evaluate an adapted version of CTraC, Supportive CTraC, to improve the quality of transitional and end-of-life care for veterans with serious illness.

METHODS

We used the Replicating Effective Programs framework to guide adaptation and implementation. An RN nurse case manager (NCM) with experience in geriatrics and palliative care worked closely with inpatient and outpatient care teams to coordinate care. Eligible patients had a life-limiting diagnosis with substantial functional impairment and were not enrolled in hospice. The NCM identified veterans at VA Boston Healthcare System during an acute admission and delivered a protocolized intervention to define care needs and preferences, align care with patient values, optimize discharge plans, and provide ongoing, intensive phone-based case management. To evaluate efficacy, we matched each Supportive CTraC enrollee 1:1 to a contemporary comparison subject by age, risk of death or hospitalization, and discharge diagnosis. We used Kaplan-Meier plots and Cox-Proportional Hazards models to evaluate outcomes. Outcomes included palliative and hospice care use, acute care use, Massachusetts Medical Orders for Life Sustaining Treatment documentation, and survival.

RESULTS

The NCM enrolled 104 veterans with high protocol fidelity. Over 1.5 years of follow-up, Supportive CTraC enrollees were 61% more likely to enroll in hospice than the comparison group (n = 57 vs. 39; HR = 1.61; 95% CI = 1.07-2.43). While overall acute care use was similar between groups, Supportive CTraC patients had fewer ICU admissions (n = 36 vs. 53; p = 0.005), were more likely to die in hospice (53 vs. 34; p = 0.008), and twice as likely to die at home with hospice (32.0 vs. 15.5; p = 0.02). There was no difference in survival between groups.

CONCLUSIONS

A nurse-driven transitional care program for veterans with serious illness is feasible and effective at improving end-of-life outcomes.

Caregiver Support Role in Occupational Therapy Video Telehealth: A Scoping Review

Caregiver involvement may facilitate patient participation in occupational therapy (OT) video telehealth. However, little is known about the extent to which caregivers participate and what they do. This scoping review aims to, 1) describe the caregiver role supporting patient participation in OT video telehealth, and, 2) identify barriers and facilitators to caregiver involvement. Findings reveal caregiver involvement in a range of OT evaluation and intervention processes, with details on what caregivers did overall lacking. Barriers and facilitators are also described. This study underscores the need for clear and robust descriptions of caregiver participation to increase best practices in video telehealth.

A Citation Review of 83 Dissemination and Implementation Theories, Models, or Frameworks Utilized in U.S.-Based Aging Research

BACKGROUND AND OBJECTIVES

Dissemination-implementation.org outlines 110 theories, models, and frameworks (TMFs): we conducted a citation analysis on 83 TMFs, searching Web of Science and PubMed databases.

RESEARCH DESIGN AND METHODS

Search terms were broad and included "aging," "older," "elderly," and "geriatric." We extracted each TMF in identified articles from inception through January 28, 2022. Included articles must have used a TMF in research or quality improvement work directly linked to older adults within the United States.

RESULTS

We reviewed 2,681 articles of which 295 articles cited at least one of 56 TMFs. Five TMFs represented 50% of the citations: Reach, Effectiveness, Adoption, Implementation, and Maintenance 1.0, Consolidated Framework for Implementation Research, Greenhalgh Diffusion of Innovation in Service Organizations, Quality Enhancement Research Initiative, Community-Based Participatory Research, and Promoting Action on Research Implementation in Health Services. TMF application varied and there was a steady increase in TMF citations over time, with a 2- to 3-fold increase in citations in 2020-2021. We identified that only 41% of TMF use was meaningful.

DISCUSSION AND IMPLICATIONS

Our results suggest TMF utilization is increasing in aging research, but there is a need to more meaningful utilize TMFs. As the population of older adults continues to grow, there will be increasing demand for effective evidence-based practices and models of care to be quickly and effectively translated into routine care. Use of TMFs is critical to building such evidence and to identifying and evaluating methods to support this translation.

Association of Polypharmacy and Potentially Inappropriate Medications With Frailty Among Older Adults With Blood Cancers

BACKGROUND

Polypharmacy and potentially inappropriate medications (PIMs) are common among older adults with blood cancers, but their association with frailty and how to manage them optimally remain unclear.

PATIENTS AND METHODS

From 2015 to 2019, patients aged ≥75 years presenting for initial oncology consult underwent screening geriatric assessment. Patients were determined to be robust, prefrail, or frail via deficit accumulation and phenotypic approaches. We quantified each patient's total number of medications and PIMs using the Anticholinergic Risk Scale (ARS) and a scale we generated using the NCCN Medications of Concern called the Geriatric Oncology Potentially Inappropriate Medications (GO-PIM) scale. We assessed cross-sectional associations of PIMs with frailty in multivariable regression models adjusting for age, gender, and comorbidity.

RESULTS

Of 785 patients assessed, 603 (77%) were taking ≥5 medications and 421 (54%) were taking ≥8 medications; 201 (25%) were taking at least 1 PIM based on the ARS and 343 (44%) at least 1 PIM based on the GO-PIM scale. Among the 468 (60%) patients on active cancer treatment, taking ≥8 medications was associated with frailty (adjusted odds ratio [aOR], 2.82; 95% CI, 1.92-4.17). With each additional medication, the odds of being prefrail or frail increased 8% (aOR, 1.08; 95% CI, 1.04-1.12). With each 1-point increase on the ARS, the odds of being prefrail or frail increased 19% (aOR, 1.19; 95% CI, 1.03-1.39); with each additional PIM based on the GO-PIM scale, the odds increased 65% (aOR, 1.65; 95% CI, 1.34-2.04).

CONCLUSIONS

Polypharmacy and PIMs are prevalent among older patients with blood cancers; taking ≥8 medications is strongly associated with frailty. These data suggest careful medication reconciliation for this population may be helpful, and deprescribing when possible is high-yield, especially for PIMs on the GO-PIM scale.

Three Sides to the Story: Adherence Trajectories During the First Year of SGLT2 Inhibitor Therapy Among Medicare Beneficiaries

OBJECTIVE

We aimed to understand the factors associated with sodium-glucose cotransporter 2 inhibitor (SGLT2i) adherence and longitudinal adherence trajectories in older adults with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Using Medicare claims data (April 2013-December 2017), we identified 83,675 new SGLT2i users ≥66 years old with type 2 diabetes. We measured SGLT2i adherence as the proportion of days covered (PDC) during the first year of SGLT2i therapy. We used linear regression to assess the association between baseline covariates and PDC. Then we used group-based trajectory modeling to identify distinct longitudinal SGLT2i adherence groups and used a multivariable logistic regression model to examine the association between baseline covariates and membership in these adherence groups.

RESULTS

Unadjusted mean PDC was 63%. Previous adherence to statins had the strongest positive association with PDC (regression coefficient 6.00% [95% CI 5.50, 6.50]), whereas female sex (-5.51% [-6.02, -5.00]), and Black race/ethnicity (-5.06% [-6.03, -4.09]) had the strongest negative association. We identified three adherence trajectory groups: low (23% of patients, mean PDC 17%), moderate (32%, mean PDC 50%), and high (45%, mean PDC 96%) adherence. More patients in the high adherence group were previously adherent to statins (odds ratio 1.43 [95% CI 1.39, 1.48]), and more women (1.28 [1.23, 1.32]) and Black patients (1.31 [1.23, 1.40]) were in the low adherence group.

CONCLUSIONS

In a large population of older patients with type 2 diabetes, 45% were highly adherent during the first year of SGLT2i treatment. Female sex and Black race/ethnicity were most strongly associated with low adherence.

Medication Optimization for New Initiators of Empagliflozin for Diabetic Kidney Disease

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are recommended agents for the treatment of diabetic kidney disease (DKD). Additionally, SGLT2 inhibitors lower blood glucose, decrease blood pressure, and can be useful for volume management. For these reasons, we hypothesized that initiating SGLT2 inhibitor therapy may be associated with deprescribing of other medications in patients with DKD. We compared medication lists at SGLT2 inhibitor initiation and 6 months post-initiation in 21 patients with DKD who were followed in our interprofessional outpatient nephrology clinic to evaluate deprescribing patterns in diabetes, hypertension, and diuretic medications. Six months of SGLT2 inhibitor therapy in patients with DKD was associated with deprescribing of high-risk diabetes agents, antihypertensives, and loop diuretics with minimal changes in A1C and fewer adverse events.

Trajectories of Frailty in the 5 Years Prior to Death Among U.S. Veterans Born 1927-1934

BACKGROUND

Electronic frailty indices (eFIs) are increasingly used to identify patients at risk for morbidity and mortality. Whether eFIs capture the spectrum of frailty change, including decline, stability, and improvement, is unknown.

METHODS

In a nationwide retrospective birth cohort of U.S. Veterans, a validated eFI, including 31 health deficits, was calculated annually using medical record and insurance claims data (2002-2012). K-means clustering was used to assign patients into frailty trajectories measured 5 years prior to death.

RESULTS

There were 214 250 veterans born between 1927 and 1934 (mean [SD] age at death = 79.4 [2.8] years, 99.2% male, 90.3% White) with an annual eFI in the 5 years before death. Nine frailty trajectories were identified. Those starting at nonfrail or prefrail had 2 stable trajectories (nonfrail to prefrail, n = 29 786 and stable prefrail, n = 28 499) and 2 rapidly increasing trajectories (prefrail to moderately frail, n = 28 244 and prefrail to severely frail, n = 22 596). Those who were mildly frail at baseline included 1 gradually increasing trajectory (mildly to moderately frail, n = 33 806) and 1 rapidly increasing trajectory (mildly to severely frail, n = 15 253). Trajectories that started at moderately or severely frail included 2 gradually increasing trajectories (moderately to severely frail, n = 27 662 and progressing severely frail, n = 14 478) and 1 recovering trajectory (moderately frail to mildly frail, n = 13 926).

CONCLUSIONS

Nine frailty trajectories, including 1 recovering trajectory, were identified in this cohort of older U.S. Veterans. Future work is needed to understand whether prevention and treatment strategies can improve frailty trajectories and contribute to compression of morbidity toward the end of life.

Association of Sodium-Glucose Cotransporter-2 Inhibitors With Fracture Risk in Older Adults With Type 2 Diabetes

IMPORTANCE

Whether sodium-glucose cotransporter-2 inhibitors (SGLT-2i) are associated with an increased risk of fractures in older adults with type 2 diabetes (T2D) outside of clinical trials remains unknown.

OBJECTIVE

To examine the association of incident fracture among older adults with T2D with initiating an SGLT-2i compared with initiating a dipeptidyl peptidase 4 inhibitor (DPP-4i) or a glucagon-like peptide 1 receptor agonist (GLP-1RA).

DESIGN, SETTING, AND PARTICIPANTS

This is a population-based, new-user cohort study including older adults (aged ≥65 years) with T2D enrolled in Medicare fee-for-service from April 2013 to December 2017. Data analysis was performed from October 2020 to April 2021.

EXPOSURES

New users of an SGLT-2i, DPP-4i, or GLP-1RA without a previous fracture were matched in a 1:1:1 ratio using 3-way propensity score matching.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite end point of nontraumatic pelvic fracture, hip fracture requiring surgery, or humerus, radius, or ulna fracture requiring intervention within 30 days. After 3-way 1:1:1 propensity score matching, multivariable Cox proportional hazards regression models were used to generate hazard ratios (HRs) for SGLT-2i compared with DPP-4i and GLP-1RA and Kaplan-Meier curves to visualize fracture risk over time across groups.

RESULTS

Of 466 933 new initiators of study drugs, 62 454 patients were new SGLT-2i users. After 3-way matching, 45 889 (73%) new SGLT-2i users were matched to new users of DPP-4i and GLP-1RA, yielding a cohort of 137 667 patients (mean [SD] age, 72 [5] years; 64 126 men [47%]) matched 1:1:1 for analyses. There was no difference in the risk of fracture in SGLT-2i users compared with DPP-4i users (HR, 0.90; 95% CI, 0.73-1.11) or GLP-1RA users (HR, 1.00; 95% CI, 0.80-1.25). Results were consistent across categories of sex, frailty (nonfrail, prefrail, and frail), age (<75 and ≥75 years), and insulin use (baseline users and nonusers).

CONCLUSIONS AND RELEVANCE

In this nationwide Medicare cohort, initiating an SGLT-2i was not associated with an increased risk of fracture in older adults with T2D compared with initiating a DPP-4i or GLP-1RA, with consistent results across categories of frailty, age, and insulin use. These findings add to the evidence base evaluating the potential risks associated with SGLT-2i use for older adults outside of randomized clinical trials.

Updating and Validating the U.S. Veterans Affairs Frailty Index: Transitioning From ICD-9 to ICD-10

BACKGROUND

The Veterans Affairs Frailty Index (VA-FI) is an electronic frailty index developed to measure frailty using administrative claims and electronic health records data in Veterans. An update to ICD-10 coding is needed to enable contemporary measurement of frailty.

METHOD

International Classification of Diseases, ninth revision (ICD-9) codes from the original VA-FI were mapped to ICD-10 first using the Centers for Medicaid and Medicare Services (CMS) General Equivalence Mappings. The resulting ICD-10 codes were reviewed by 2 geriatricians. Using a national cohort of Veterans aged 65 years and older, the prevalence of deficits contributing to the VA-FI and associations between the VA-FI and mortality over years 2012-2018 were examined.

RESULTS

The updated VA-FI-10 includes 6422 codes representing 31 health deficits. Annual cohorts defined on October 1 of each year included 2 266 191 to 2 428 115 Veterans, for which the mean age was 76 years, 97%-98% were male, 78%-79% were White, and the mean VA-FI was 0.20-0.22. The VA-FI-10 deficits showed stability before and after the transition to ICD-10 in 2015, and maintained strong associations with mortality. Patients classified as frail (VA-FI > 0.2) consistently had a hazard of death more than 2 times higher than nonfrail patients (VA-FI ≤ 0.1). Distributions of frailty and associations with mortality varied with and without linkage to CMS data and with different assessment periods for capturing deficits.

CONCLUSIONS

The updated VA-FI-10 maintains content validity, stability, and predictive validity for mortality in a contemporary cohort of Veterans aged 65 years and older, and may be applied to ICD-9 and ICD-10 claims data to measure frailty.

A blueprint for success: Using an implementation framework to create a medication history technician pilot program

BACKGROUND

Medication discrepancies at transitions of care may compromise patient safety. Trained pharmacy technicians can reduce harmful medication discrepancies at transitions of care by collecting medication histories.

OBJECTIVE

We describe how to create a program integrating medication history technicians (MHTs) into the hospital discharge process using implementation science.

PRACTICE DESCRIPTION

We created our MHT program at a Veterans Affairs (VA) hospital.

PRACTICE INNOVATION

We used an evidence-based framework and implementation science to tailor our MHT program to meet local stakeholder needs.

EVALUATION METHODS

We completed a literature review and review of current discharge practices. Then, we completed a workflow pilot, a needs assessment, and semistructured interviews with pharmacy technicians and pharmacists. We integrated these findings to identify barriers of MHT program implementation. Finally, we mapped these barriers to implementation strategies to create an MHT program implementation blueprint.

RESULTS

The literature review and review of current discharge practices revealed opportunities for our program to reduce medication discrepancies. We applied these findings to our proof-of-concept workflow pilot, which reduced medication discrepancy rates at discharge. When we explored barriers in the needs assessment, we learned that 4 of 6 pharmacy technicians had some training conducting medication histories, but 5 of 6 requested additional training for the new MHT role. We explored these and additional barriers in semistructured interviews. Four themes emerged: elements of pharmacy technician training, challenges to implementation, program logistics and workflow, and pharmacy technician self-efficacy. We mapped barriers to implementation strategies to create an MHT program implementation blueprint, including developing pharmacy technician training materials, modifying our workflow, creating program evaluation materials, and strategizing how to overcome anticipated and current implementation barriers.

CONCLUSIONS

We used implementation science to create a tailored MHT program. Others may adapt our implementation blueprint to fit local stakeholder needs.

There's no place like home-Integrating a pharmacist into the hospital-in-home model

BACKGROUND

Hospital-in-home (HIH) is an innovative model that provides hospital-level care in a patient's home. Pharmacists can enhance the HIH model through medication reconciliation and medication optimization.

OBJECTIVES

To integrate a clinical pharmacist into the HIH model and to conduct a formative evaluation of pharmacist contributions, including medication discrepancy resolution, cost savings, and cost avoidance.

PRACTICE DESCRIPTION

This is a prospective quality improvement study conducted at the Veterans Affairs Boston Healthcare System.

PRACTICE INNOVATION

We integrated a pharmacist into the HIH model. The pharmacist conducted a medication reconciliation at hospital discharge and after discharge through home video telehealth and provided longitudinal medication management.

EVALUATION METHODS

We adapted the PRECEDE-PROCEED model to guide program implementation. We conducted a formative evaluation using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, evaluating the reach, efficacy, adoption, and implementation of the pharmacist in the HIH team. We calculated cost savings associated with pharmacist-managed home intravenous (IV) therapy, cost avoidance from deprescribing, and cost avoidance from earlier hospital discharge.

RESULTS

The HIH program enrolled 102 patients from May 2019 to March 2020. The pharmacist completed 99 (97%) discharge and 95 (93%) postdischarge medication reconciliations, most of which 71 (75%) were conducted using home video telehealth. The pharmacist identified and resolved a total of 453 medication discrepancies: 181 (40%) at discharge and 272 (60%) during postdischarge medication reconciliation. A total of 84 (19%) discrepancies were considered high risk. The pharmacist managed 104 days of home IV therapy, resulting in a cost savings of approximately $17,000. The cost avoided by identifying and deprescribing 145 inappropriate medications was approximately $51,000. The cost avoided by earlier hospital discharge was $1.2 million.

CONCLUSION

Integrating a pharmacist into the HIH model enables the detection and resolution of medication discrepancies. Cost savings from medication deprescribing, cost avoided from pharmacist-managed home IV therapy, and cost avoided from early hospital discharge totaled $1268 million.

Pharmacologic Considerations for Opioid Use in Kidney Disease

Individuals with kidney disease have a high prevalence of chronic noncancer pain. Although opioids are not a recommended treatment option for chronic noncancer pain in the general population, a higher percentage of individuals with kidney disease receive opioid prescriptions for chronic pain. Individuals with kidney disease have an increased risk for opioid adverse events because of changes related to kidney disease progression, normative aging, and the pharmacology of opioid medications. Despite the frequent prescription of opioids for chronic noncancer pain among those with kidney disease, there are no guidelines for opioid management in this population. This article reviews the pharmacologic challenges of opioid use in relation to the physiologic changes occurring in kidney disease and normative aging. We highlight how understanding opioid pharmacology and human physiology can support safe practices of opioid management in patients with kidney disease who require opioids for chronic noncancer pain.

Differential Diagnoses and Clinical Implications of Medication Nonadherence in Older Patients with Chronic Kidney Disease: A Review

Older adults with chronic kidney disease (CKD) often have many comorbidities, which requires them to take multiple medications. As the number of daily medications prescribed increases, the risk for polypharmacy increases. Understanding and improving medication adherence in this patient population is vital to avoiding the drug-related adverse events of polypharmacy. The primary objective of this review is to summarize the existing literature and to understand the factors leading to medication nonadherence in older patients with CKD. In this review, we discuss the prevalence of polypharmacy, the current lack of consensus on the incidence of medication nonadherence, the heterogeneity of assessing medication adherence, and the most common differential diagnoses for medication nonadherence in this population. Specifically, the most common differential diagnoses for medication nonadherence in older adults with CKD are (1) medication complexity; (2) cognitive impairment; (3) low health literacy; and (4) systems-based barriers. We provide tailored strategies to address these differential diagnoses and subsequently improve medication adherence. The clinical implications include deprescribing to decrease medication complexity and polypharmacy, utilizing a team-based approach to identify and support patients with cognitive impairment, enriching communication between health providers and patients with low health literacy, and improving health care access to address systems-based barriers. Further research is needed to determine the effects of addressing these differential diagnoses and medication adherence in older adults with CKD.

Rapid Integration of Home Telehealth Visits Amidst COVID-19: What Do Older Adults Need to Succeed?

OBJECTIVE

Our objective was to identify and address patient-perceived barriers to integrating home telehealth visits.

DESIGN

We used an exploratory sequential mixed-methods design to conduct patient needs assessments, a home telehealth pilot, and formative evaluation of the pilot.

SETTING

Veterans Affairs geriatrics-renal clinic.

PARTICIPANTS

Patients with scheduled clinic visits from October 2019 to April 2020.

MEASUREMENTS

We conducted an in-person needs assessment and telephone postvisit interviews.

RESULTS

Through 50 needs assessments, we identified patient-perceived barriers in interest, access to care, access to technology, and confidence. A total of 34 (68%) patients were interested in completing a home telehealth visit, but fewer (32 (64%)) had access to the necessary technology or were confident (21 (42%)) that they could participate. We categorized patients into four phenotypes based on their interest and capability to complete a home telehealth visit: interested and capable, interested and incapable, uninterested and capable, and uninterested and incapable. These phenotypes allowed us to create trainings to overcome patient-perceived barriers. We completed 32 home telehealth visits and 12 postvisit interviews. Our formative evaluation showed that our pilot was successful in addressing many patient-perceived barriers. All interviewees reported that the home telehealth visits improved their well-being. Home telehealth visits saved participants an average of 166 minutes of commute time. Five participants borrowed a device from a family member, and five visits were finished via telephone. All participants successfully completed a home telehealth visit.

CONCLUSIONS

We identified patient-perceived barriers to home telehealth visits and classified patients into four phenotypes based on these barriers. Using principles of implementation science, our home telehealth pilot addressed these barriers, and all patients successfully completed a visit. Future study is needed to understand methods to deploy larger-scale efforts to integrate home telehealth visits into the care of older adults.

A Workshop for Interprofessional Trainees Using the Geriatrics 5Ms Framework

BACKGROUND/OBJECTIVES

Interprofessional trainees need geriatrics training to prepare them to care for our aging population. Team-based care will help them be ready to work in an Age-Friendly Health System. The Geriatrics 5Ms provides a framework to engage learners in five main domains of caring for older adults from an interprofessional perspective: Mobility, Mind, Medications, Multicomplexity, and what Matters Most.

DESIGN

We created a half-day workshop for interprofessional trainees using the Geriatric 5Ms framework to increase their preparedness in caring for older adults as part of an interprofessional team.

SETTING

The New England Geriatric Research Education and Clinical Center.

PARTICIPANTS

A total of 66 trainees from 10 professions.

INTERVENTION

After introductory sessions on careers in aging, participants engaged in an interactive session to learn about the professions represented. They then formed interprofessional groups to discuss a patient case using the Geriatrics 5Ms framework with a modified jigsaw format.

MEASUREMENTS

Trainees were surveyed before and after the workshop on their attitudes toward careers in aging, understanding of skills and training paths of other professions, and familiarity with the Geriatrics 5Ms framework.

RESULTS

Overall, 97% of the trainees rated the workshop highly. Trainee ratings significantly increased in the areas of understanding of other professions, and familiarity and applicability of the Geriatrics 5Ms, particularly for nonphysicians.

CONCLUSION

A workshop for interprofessional trainees using the Geriatrics 5Ms framework increased the readiness of trainees to care for older adults as part of an interprofessional team. This workshop offers a promising model for needed interprofessional geriatrics education. J Am Geriatr Soc 68:1857-1863, 2020.

Decision Algorithm for Prescribing SGLT2 Inhibitors and GLP-1 Receptor Agonists for Diabetic Kidney Disease

Diabetic kidney disease and its comorbid conditions, including atherosclerotic cardiovascular disease, heart failure, diabetes, and obesity, are interconnected conditions that compound the risk of kidney failure and cardiovascular mortality, and exponentiate health care costs. Sodium glucose cotransporter 2 inhibitor (SGLT2i) and glucagon-like peptide 1 receptor agonist (GLP-1 RA) are novel diabetes medications that prevent cardiovascular events and kidney failure. Clinical trials exploring the cardiovascular and kidney outcomes of SGLT2i and GLP-1 RA have fundamentally shifted the treatment paradigm of diabetes. Clinical guidelines for diabetes management recommend a more holistic approach beyond glycemic control and emphasize heart and kidney protection of SGLT2i and GLP-1 RA. However, the adoption of prescribing SGLT2i and GLP-1 RA for patients with diabetes and high cardiovascular and kidney risk has been slow. In this review, we provide a decision-making tool to help clinicians determine when to consider SGLT2i and GLP-1 RA for heart and kidney protection. First, we discuss a comprehensive risk assessment for patients with diabetic kidney disease. We compare the effectiveness of SGLT2i and GLP-1 RA for different risk categories. Then, we present a decision algorithm using cardiovascular and kidney failure risk stratification and the strength of current evidence for the use of SGLT2i and GLP-1 RA. Lastly, we review the adverse effects of SGLT2i and GLP-1 RA and propose mitigation strategies.

Opioid Management in Older Adults with Chronic Kidney Disease: A Review

Chronic pain, a common comorbidity of chronic kidney disease, is consistently under-recognized and difficult to treat in older adults with nondialysis chronic kidney disease. Given the decreased kidney function associated with aging and chronic kidney disease, these patients are at increased risk for drug accumulation and adverse events. Emerging research has demonstrated the efficacy of opioids in chronic kidney disease patients, but research specifically focusing on older, nondialysis chronic kidney disease patients is scarce. The primary objective of this review is to determine which oral and transdermal opioids are the safest for older, nondialysis chronic kidney disease patients. We discuss the limited existing evidence on opioid prescription in older, nondialysis chronic kidney disease patients and provide recommendations for the management of oral and transdermal opioids in this patient population. Specifically, transdermal buprenorphine, transdermal fentanyl, and oral hydromorphone are the most tolerable opioids in these patients; hydrocodone, oxycodone, and methadone are useful but require careful monitoring; and tramadol, codeine, morphine, and meperidine should be avoided due to risk of accumulation and adverse events. Because older adults with nondialysis chronic kidney disease are at increased risk for adverse events, vigilant monitoring of opioid prescription is critical. Lastly, collaboration among an interprofessional clinical team can ensure safe prescription of opioids in older adults with nondialysis chronic kidney disease.

Statins for Primary Prevention in Those Aged 70 Years and Older: A Critical Review of Recent Cholesterol Guidelines

The risk of atherosclerotic cardiovascular disease rises with age and remains the leading cause of death in older adults. Evidence for the use of statins for primary prevention in older adults is limited, despite the possibility that this population may derive significant clinical benefit given its increased cardiovascular risk. Until publication of the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the Management of Blood Cholesterol, and the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease, guidelines for statin prescription in older adults remained unchanged despite new evidence of possible benefit in older adults. In this review, we present key updates in the 2018 and 2019 guidelines and the evidence informing these updates. We compare the discordant recommendations of the seven major North American and European guidelines on cholesterol management released in the past 5 years and highlight gaps in the literature regarding primary prevention of cardiovascular disease in older adults. As most cardiovascular events in older adults are nonfatal, we ask how clinicians should weigh the risks and benefits of continuing a statin for primary prevention in older adults. We also reframe the concept of deprescribing of statins in the older population, using the Geriatrics 5Ms framework: Mind, Mobility, Medications, Multi-complexity, and what Matters Most to older adults. A recent call from the National Institute on Aging for a statin trial focusing on older adults extends from similar concerns.

Brown Bag Simulation to Improve Medication Management in Older Adults

INTRODUCTION

Medical students must care for aging patients with growing medication lists and need training to address negative patient outcomes associated with polypharmacy. The literature shows that many trainees and practitioners are not confident in their abilities to care for this older population with complex medical conditions. We created an innovative simulation activity to teach safe, effective, and simplified medication management to second-year medical students.

METHODS

We developed the brown bag medication reconciliation simulation to improve self-efficacy and knowledge for trainees working with older adults. The case example was an older patient who presented with his brown bag of medications and prefilled pillbox for a medication reconciliation with his provider. Teams of medical students identified his medication-management errors and determined strategies for resolution. We assessed learner self-efficacy, knowledge, and satisfaction.

RESULTS

A class of 137 second-year medical students completed the simulation. The average number of learners confident about medication management in older adults increased overall by 41%, with a significant increase across all four self-efficacy domains (p < .001). The average percentage of correctly answered knowledge questions significantly increased from 85% on the presurvey to 92% on the delayed postsurvey (p = .009). Learner open-ended feedback indicated high satisfaction with the simulation.

DISCUSSION

The brown bag medication reconciliation simulation increased medical student self-efficacy and knowledge related to medication reconciliation and management for older adults. Interactive simulations like this one may be considered for inclusion in health science curricula to improve skills in medication reconciliation and management.

Finding the Sweet Spot: An Interactive Workshop on Diabetes Management in Older Adults

INTRODUCTION

Intensive glucose lowering in older adults with diabetes leads to increased risks with minimal benefits. Surveys indicate that clinician confidence for individualizing glycemic goals and regimens remains low. We created an interactive workshop and clinical tool kit to improve clinician knowledge of safe diabetes management in older adults.

METHODS

Finding the Sweet Spot was a 1-hour workshop taught by pharmacists to medical and pharmacy learners that introduced a five-step framework for diabetes management in older adults. The interactive presentation included cases and a clinical tool kit based on current recommendations from the American Diabetes Association and American Geriatrics Society. Pilot workshops were held for 6 months, allowing for real-time revisions based on feedback; final implementation occurred for 6 months thereafter. We evaluated learner self-efficacy (via a 5-point Likert scale) and knowledge (via multiple-choice questions) of diabetes management in older adults before and after the workshop.

RESULTS

Thirty learners participated in Finding the Sweet Spot (70% medicine, 30% pharmacy). The percentage of confident learners increased from 55% to 97% (p < .05) after the workshop. All learners demonstrated improvements in knowledge, with the mean score on the knowledge assessment increasing from 61% to 80% (p < .05). Via open-ended feedback, learners expressed satisfaction and found the clinical tool kit especially helpful.

DISCUSSION

Our Finding the Sweet Spot workshop demonstrated statistically significant changes in self-efficacy and knowledge among learners, indicating that this interactive workshop improves medical and pharmacy provider confidence and skills in caring for older adults with diabetes.

A Pilot Study Embedding Clinical Pharmacists Within an Interprofessional Nephrology Clinic for the Initiation and Monitoring of Empagliflozin in Diabetic Kidney Disease

BACKGROUND

The American Diabetes Association (ADA) recommends sodium-glucose cotransporter-2 (SGLT2) inhibitors as the second medication to be started, after metformin, for patients with chronic kidney disease (CKD). Sodium-glucose cotransporter-2 inhibitors may cause volume, blood pressure, and electrolyte disturbances; consequently, frequent monitoring and adjustments to other diabetes, blood pressure, and/or diuretic medications may be necessary.

OBJECTIVE

To evaluate the safety and efficacy of an interprofessional clinic model partnering nephrologists and pharmacists for the initiation and monitoring of SGLT2 inhibitors.

METHODS

A clinical pharmacist was embedded within the nephrology clinic to provide patient education, telephone follow-up, and to work collaboratively with the nephrologists. Diabetes, hypertension, and diuretic regimens were adjusted as needed after empagliflozin initiation. Diabetes regimens were adjusted to adhere to the 2019 ADA guidelines that promote agents with CKD and atherosclerotic cardiovascular disease benefit.

RESULTS

Fourteen patients were initiated on empagliflozin during the study period. Urine albumin-to-creatinine ratio (UACR) improved (mean % change -12% ± 61%); the mean percentage change was greater in patients with a higher baseline UACR. The mean change in hemoglobin A_1c was 0.3% ± 0.6%. Common adverse reactions were observed and improved over time; no serious adverse drug reactions occurred. Finally, empagliflozin initiation necessitated adjustments to diabetes, hypertension, and diuretic regimens in almost all patients (n = 13, 93%).

CONCLUSION

The implementation of an innovative, interprofessional care model within a nephrology clinic for the initiation and monitoring of empagliflozin in patients with DKD demonstrated clinical benefit with minimal safety concerns.

The missing piece: Clinical pharmacists enhancing the interprofessional nephrology clinic model

OBJECTIVES

To embed pharmacy residents in an interprofessional nephrology clinic to conduct medication reconciliation in targeted high-risk patients with nondialysis kidney disease.

SETTING

This pilot was a prospective quality improvement initiative conducted in an interprofessional outpatient nephrology clinic.

PRACTICE DESCRIPTION

The nephrology clinic team includes nephrology providers, a social worker, and a geriatrician. The team is responsible for the management of conditions such as nondialysis kidney disease, resistant hypertension, acute kidney injury, proteinuria, and nephropathy.

EVALUATION

Primary outcomes included the number and type of medication discrepancies and drug therapy problems identified. Secondary outcomes included the changes in care process directly resulting from the pharmacy residents' recommendations. The perceived value of the pharmacy residents to the interprofessional team was assessed through postintervention anonymous surveys and semistructured interviews.

RESULTS

The pharmacy residents conducted 118 visits for 87 unique patients (mean age 73 years, 97% male) with nondialysis kidney disease (89% stages III-V), polypharmacy (87% of patients taking > 10 medications), and a heavy comorbidity burden (85% hypertension, 80% dyslipidemia, 59% diabetes mellitus type II) from January to October 2017. Pharmacists identified 344 medication discrepancies and 301 drug therapy problems, resulting in 398 changes in care process. The most frequently identified discrepancies and drug therapy problems were the omission of an active medication from the medication list (86 of 344 discrepancies, 25%) and potentially inappropriate medications (106 of 301 drug therapy problems, 35%). Pharmacists recommended 228 medication changes, provided 76 adherence devices, facilitated 24 consults or referrals, and communicated with the primary care team on 70 occasions. The interprofessional team members all strongly agreed that patients and the team benefited from the pharmacists' involvement.

CONCLUSION

Pharmacy resident-led medication reconciliation resulted in the identification and resolution of medication discrepancies and drug therapy problems, leading to changes in the care process.

Sodium-glucose cotransporter 2 inhibitors for diabetic kidney disease: a primer for deprescribing

Chronic kidney disease (CKD) is a critical global public health problem associated with high morbidity and mortality, poorer quality of life and increased health care expenditures. CKD and its associated comorbidities are one of the most complex clinical constellations to manage. Treatments for CKD and its comorbidities lead to polypharmacy, which exponentiates the morbidity and mortality. Sodium-glucose cotransporter 2 inhibitors (SGLT2is) have shown remarkable benefits in cardiovascular and renal protection in patients with type 2 diabetes mellitus (T2DM). The pleiotropic effects of SGLT2is beyond glycosuria suggest a promising role in reducing polypharmacy in diabetic CKD, but the potential adverse effects of SGLT2is should also be considered. In this review, we present a typical case of a patient with multiple comorbidities seen in a CKD clinic, highlighting the polypharmacy and complexity in the management of proteinuria, hyperkalemia, volume overload, hyperuricemia, hypoglycemia and obesity. We review the cardiovascular and renal protection effects of SGLT2is in the context of clinical trials and current guidelines. We then discuss the roles of SGLT2is in the management of associated comorbidities and review the adverse effects and controversies of SGLT2is. We conclude with a proposal for deprescribing principles when initiating SGLT2is in patients with diabetic CKD.

Coordinated-Transitional Care for Veterans with Heart Failure and Chronic Lung Disease

OBJECTIVES

Patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) account for most 30-day hospital readmissions nationwide. The Coordinated-Transitional Care (C-TraC) program is a telephone-based, nurse-driven intervention shown to decrease readmissions in Veterans Affairs (VA) and non-VA hospitals. The goal of this project was to assess the feasibility and efficacy of adapting C-TraC to meet the needs of complex patients with CHF and COPD in a large urban tertiary care VA medical center.

DESIGN

We used the Replicating Effective Programs model to guide the implementation. The C-TraC nurse received intensive training in cardiology and pulmonology and worked closely with both inpatient and outpatient providers to coordinate care. Eligible patients were admitted with CHF or COPD and had at least one additional risk for readmission.

SETTING

The nurse met patients in the hospital, participated in their discharge planning, and then provided intensive case management for up to 4 weeks.

PARTICIPANTS

Over its initial 14 months, the program successfully enrolled 299 veterans with good fidelity to the protocol.

MEASUREMENTS

A total of 43 (15.8%) C-TraC participants were rehospitalized within 30 days compared with 172 (21.0%) of historical controls matched 3:1 on age, risk of 90-day hospital admission, and discharge diagnosis.

RESULTS

Participants were 54% less likely to be rehospitalized (odds ratio = .46; 95% CI = .24-.89).

CONCLUSION

The program was financially sustainable. The total cost of care in the 30-day postdischarge period was $1842.52 less per C-TraC patient than per controls, leading the medical center to sustain and expand the program.

Geriatrics 5Ms for Primary Care Workshop

INTRODUCTION

The Geriatrics 5Ms provide a novel framework for caring for older adults that directly maps to the current Accreditation Council for Graduate Medical Education (ACGME) core competencies in geriatrics for internal and family medicine residents. Using the 5Ms framework of Mobility, Medications, Mind, Multicomplexity, and Matters Most, we conducted a workshop for residents in a primary care clinic to improve care of older adults.

METHODS

Through Kern's six-step approach to curriculum development, we used our needs assessment and stakeholder interviews to guide development of a half-day Geriatrics 5Ms workshop for residents in primary care. The workshop was piloted with 33 internal medicine residents and included interactive modules and point-of-care tools for each of the Geriatrics 5Ms centered on a longitudinal primary care patient case.

RESULTS

Initial evaluation of the workshop showed high satisfaction and indicated residents appreciated learning about point-of-care tools for primary care, particularly for cognitive assessment, prognosticating, and deprescribing. Of the learners completing the workshop, 75% reported high self-efficacy ratings (score > 3.5) on the Geriatrics 5Ms domains, compared to only 40% of control learners and 20% of learners completing the preworkshop needs assessment.

DISCUSSION

A longitudinal, interactive, case-based workshop using the Geriatrics 5Ms framework improved primary care residents' self-efficacy and knowledge of tools in the care of older adults and geriatric competencies outlined by the ACGME. The workshop offers an innovative and efficient method to teach geriatrics to residents in primary care and prepare them to care for an aging population.

The Role of Deprescribing in Older Adults with Chronic Kidney Disease

Older adults with chronic kidney disease (CKD) often experience polypharmacy, a recognized predictor of prescribing problems including inappropriately dosed medications, drug-drug and drug-disease interactions, morbidity and mortality. Polypharmacy is also associated with nonadherence, which leads to recurrent hospitalizations and poorer hemodialysis outcomes in CKD patients. Further complicating medication management in this vulnerable population are the physiologic changes that occur with both age and CKD. This guide for pharmacists and prescribers offers considerations in medication evaluation and management among older adults with CKD. Careful prescribing with the aid of tools such as the American Geriatrics Society Beers Criteria can support safe medication use and appropriate prescribing. Polypharmacy may be systematically addressed through 'deprescribing,' an evidence-based process that enables identification and elimination of unnecessary or inappropriate medications. Detailed guidance for deprescribing in older adults with CKD has not been published previously. We highlight three specific targets for medication optimization and deprescribing in older adults with CKD: (1) proton pump inhibitors, (2) oral hypoglycemic agents, including newer classes of agents, and (3) statins. These medication classes have been chosen as they represent three of the most commonly prescribed classes of medications in the United States. For each area, we review considerations for medication use in older adults with CKD and provide strategies to avoid, modify, or discontinue these medications when clinically indicated. By utilizing deprescribing techniques, pharmacists are well positioned to help decrease the medication burden in older adults with CKD, thereby potentially reducing the risk of morbidity and mortality associated with polypharmacy.

A multi-center study comparing dual acid-etched and machined-surfaced implants in various bone qualities

BACKGROUND

A major reason for the success of modern dental implant systems has been the development of implant designs that enhance direct bone-implant interface. Surface roughness has been a factor in this success and different systems have utilized very different implant surface roughness. The major purpose of this study was to evaluate 2 similar implants with different surface roughness characteristics.

METHODS

Two similarly designed, screw-type, commercially pure titanium implants, one dual acid-etched (DAE) and the other machined-surfaced (MS), were compared in this prospective, randomized-controlled, multi-center study, in which a total of 97 patients were enrolled at a private dental practice or a university dental clinic. Both implant types were placed in each patient using a 2-stage approach with a conventional 4- to 6-month healing period. Implants supported fixed prostheses, hybrid prostheses, and overdentures as dictated by the individual patient's need. All of the cases were followed using clinical and radiographic examinations. Criteria of success were the absence of peri-implant radiolucency, mobility, and persistent signs or symptoms of pain or infection.

RESULTS

Of the 432 implants (247 dual acid-etched, 185 machined-surfaced), 36 implants (12 dual acid-etched and 24 machined-surfaced) have failed. The pre-loading integration success rate of the dual acid-etched implants (95.0%) was statistically higher (P < 0.01) than the success rate of the machined-surfaced implants (86.7%). At 36 months, the cumulative success rates (CSR) are 95.0% for the dual acid-etched implants and 86.7% for the machined-surfaced implants.

CONCLUSIONS

The difference in success rates is most likely attributed to the acid-etched surface characteristics. The greatest performance difference is observed in the conditions of poor quality or soft bone where the 3-year post-loading CSR are 96.8% (dual acid-etched) and 84.8% (machined-surfaced).

The effect of locally delivered controlled-release doxycycline or scaling and root planing on periodontal maintenance patients over 9 months

BACKGROUND

This research report evaluates clinical changes resulting from local delivery of doxycycline hyclate (DH) or traditional scaling and root planing (SRP) in a group of patients undergoing supportive periodontal therapy (SPT).

METHODS

In all, 141 patients received either DH (67) or SRP (74) treatment in sites > or =5 mm on one-half of their dentition at baseline and month 4.

RESULTS

Clinical results were determined at month 9. Baseline mean probing depth recordings were similar between the two groups (DH = 5.9 mm; SRP = 5.9 mm). Mean month 9 results showed similar clinical results for attachment level gain (DH 0.7 mm; SRP 0.8 mm) and probing depth reduction (DH 1.3 mm; SRP 1.1 mm). Percentage of sites showing > or =2 mm attachment level gain at month 9 was 24.7% in the DH group and 21.2% in the SRP group. Thirty-nine percent (39%) of DH sites and 38% of SRP sites showed > or =2 mm probing depth reduction. When treated sides of the dentition were compared to untreated sides, DH showed a difference in disease activity (> or =2 mm attachment loss) from 19.3% (untreated) to 7.2% (treated); and SRP from 14.3% (untreated) to 8.1% (treated).

CONCLUSIONS

Results show that both DH without concomitant mechanical instrumentation and SRP were equally effective as SPT in this patient group over the 9-month study period.

Two multi-center studies evaluating locally delivered doxycycline hyclate, placebo control, oral hygiene, and scaling and root planing in the treatment of periodontitis

BACKGROUND

The clinical efficacy and safety of doxycycline hyclate (8.5% w/w) delivered subgingivally in a biodegradable polymer (DH) was compared to placebo control (VC), oral hygiene (OH), and scaling and root planing (SRP) in 2 multi-center studies.

METHODS

Each study entered 411 patients who demonstrated moderate to severe periodontitis. Patients had 2 or more quadrants each with a minimum of 4 qualifying pockets > or =5 mm that bled on probing. At least 2 of the pockets were > or =7 mm. Treatment with DH, VC, OH, or SRP was provided at baseline and again at month 4. Clinical parameters were recorded monthly.

RESULTS

DH and SRP resulted in nearly identical clinical changes over time in both studies. Mean 9 month clinical attachment level gain (ALG) was 0.8 mm for the DH group and 0.7 mm for the SRP group in Study 1, and 0.8 mm (DH) and 0.9 mm (SRP) in Study 2. Mean probing depth (PD) reduction was 1.1 mm for the DH group and 0.9 mm for the SRP group in Study 1 and 1.3 mm for both groups in Study 2. Frequency distributions showed an ALG > or =2 mm in 29% of DH sites versus 27% of SRP sites in Study 1 and 31% of DH sites versus 34% of SRP sites in Study 2. PD reductions > or =2 mm were seen in 32% of DH sites versus 31% of SRP sites in Study 1 and 41% of DH sites versus 43% of SRP sites in Study 2. Comparisons between DH, VC, and OH treatment groups showed DH treatment to be statistically superior to VC and OH. Safety data demonstrated a benign safety profile with use of the DH product.

CONCLUSIONS

Results of this trial demonstrate that treatment of periodontitis with subgingivally delivered doxycycline in a biodegradable polymer is equally effective as scaling and root planing and superior in effect to placebo control and oral hygiene in reducing the clinical signs of adult periodontitis over a 9-month period. This represents positive changes resulting from the use of subgingivally applied doxycycline as scaling and root planing was not limited regarding time of the procedure or use of local anesthesia.

Periodontal trauma and mobility. Diagnosis and treatment planning

With the dearth of well-controlled human clinical studies, it is still impossible to answer the question of whether occlusal trauma modifies the progression of attachment loss resulting from inflammatory periodontal disease and the companion questions related to the treatment of occlusal trauma and mobility. Teeth with stable mobility are apparently at no greater risk of attachment loss than nonmobile teeth. Increasing mobility is a concern that must be addressed by inflammatory control, occlusal adjustment, and perhaps some type of stabilization or splinting of the tooth in question. In addition, greater attachment gains have been noted when occlusal adjustment was included as part of surgical therapy. There is no question that aspects of occlusal therapy have an empiric base. It is incumbent on the clinician to examine for, diagnose, and treat trauma from occlusion to stabilize the dentition. Proper occlusal management assists in maintaining the patient's natural dentition in a state of health and comfortable function.

Serologic reactions of oral gram negative anaerobic bacilli

Serological reactions were performed using hyperimmune rabbit antisera and antigenic preparations of Leptotrichia buccalis, Fusobacterium fusiforme, and Fusobacterium polymorphum. All tests indicated that there was serologic cross reactivity between the two Fusobacterium species. No cross reactivity could be detected between the Fusobacterium species and L. buccalis. The findings suggest that F. fusiform and F. polymorphum are similar in their immunogenicity, and that the grouping of these two organisms as F. nucleatum may be justified.

Leptotrichia buccalis hemagglutination in cell binding and salivary inhibition studies

The characteristic hemagglutination (HA) of Leptotrichia buccalis was used for measuring its attachment to various human cells and for determining if saliva contained hemagglutination inhibition (HI) factors. The microbial strain utilized displayed the characteristic EM morphology of L. buccalis. Sonicated preparations of the organism were tested for HA activity before and after adsorption with human cells. Buccal epithelial cells, red blood cells (RBC), HeLa and embryonic kidney cells all bound the HA fragments of the organisms. The bacterial fragments on the cells could be observed by fluorescent antibody testing. The fragments were released from the cells used for adsorption with chelators and upon addition of CaCl2 the HA activity returned. Whole saliva displayed hemagglutination inhibition activity in a manner suggesting a binding site interaction. The similarity of the HA activity of F. nucleatum is discussed as are the relationships of cell binding to colonization of the organisms and immunopathology to host cells.

Anticomplementary activity of Fusobacterium polymorphum in normal and C4-deficient sources of guinea pig complement

Fusobacterium polymorphum has been isolated from the gingival crevice in humans and has been implicated in the immunopathology of periodontal diseases. The presence of alternative complement pathway factors in gingival crevice material suggests the contribution of this process in the manifestation of the local host response. A complement consumption assay was used to show that the anticomplementary activity of a cell-wall preparation from F. polymorphum in guinea pig complement progressed optimally at 37 degrees C and suboptimally at 0 degrees C. Similar levels of complement consumption were recorded at both temperatures, but a higher concentration of cell walls was required to demonstrate maximum activity in the cold. Augmentation experiments with additional normal and heat-treated complement showed the presence of heat-labile factors that controlled and limited the consumption of complement to a constant proportion of the total amount present. These same experiments indicated that there were no reactive antibodies in the complement used in the assay. Similar tests with C4-deficient guinea pig sera confirmed that F. polymorphum cell walls were capable of generating alternative complement pathway activity in guinea pig sera.

Hemagglutinating activity of Fusobacterium nucleatum

Gingival isolates of oral Fusobacterium nucleatum strains (gram-negative anaerobic fusiform bacilli) have shown the characteristic ability to hemagglutinate a variety of erythrocytes (RBC) of human and animal origin. Other members of the genus tested (F. necrophorus, F. varium, and F. mortiferum) displayed little if any ability to hemagglutinate RBC. The hemagglutination (HA) activity could be observed in the F. nucleatum strains with the whole cells and in most instances with sonicated preparations of the organisms. The HA activity was observed in cell wall preparations of the organism and appeared dependent upon a heat-labile protein component of the cell wall. In decreasing order, the RBC that would hemagglutinate with the smallest concentration of HA preparations were rabbit, monkey, human, sheep, horse, and ox. No differences in HA activity of the preparations with cells from the various human blood types were noted. Absorption of the HA preparation of one strain with human cells removed HA moiety was bound to the cells via a Ca2+ binding site interaction since ethylenediaminetetraacetic acid and ethylene glycol-bis-N,N'-tetraacetic acid inhibited binding, and HA could be reestablished by the addition of Ca2+ but not Mg2+. Rabbit antisera to the F. nucleatum strains inhibited HA activity when tested with the HA preparation in the standard test, whereas anti-Leptotrichia buccalis sera or normal rabbit sera had no effect. A tanned-cell passive HA test with rabbit anti-F. nucleatum sera displayed reactivity between the homologous strains but little reactivity with the other Fusobacterium species tested.

A histologic examination of a free osseous autograft. Case report

Twenty-eight months following free osseous autograft therapy, a block section was taken for histologic examination. (2) Microscopically, the periodontal structures were reconstructed with new alveolar bone, periodontal ligament, and cementum. (3) A 'separation artifact' was present between new and old cementum. This defect is probably an artifact of histologic processing.

An investigation of the clinical and histologic effects of selected dentifrices on human palatal mucosa

A study was undertaken in 24 human volunteer subjects to determine the possible effects of selected commercially available dentifrices on clinically normal masticatory mucosa. An acrylic stent was fabricated which was designed to hold four test dentifrices in close apposition to the palatal tissues for 1 hour. Evaluation approximately 8 hours later revealed pathologic responses which were evident clinically and histologically. 1. Clinically, palatal tissues exposed to Crest were not distinguishable from control areas, while Colgate (mfp), MacCleans, and Ultra Brite produced erythematous changes which were statistically significant when compared with adjacent control sites. 2. Histologically, epithelial changes were seen within the test sites which ranged from a parakeratin-like surface layer to necrosis and intraepithelial abcess formation. Control sites consisted of normal orthokeratinized palatal mucosa in all cases. 3. The more severe microscopic reactions were noted with MacCleans and Ultra Brite, while the milder reactions were associated with Colgate (MFP). Crest infrequently produced a parakeratin-like response. The response was not statistically significant when compared with controls. 4. The clinical and histologic reactions were generalized throughout the test population, suggesting that the responses were not due to individual hypersensitivity but due to irritation from one or more of the dentifrice components. Although the clinical significance of these findings could not be readily assessed, the potential for irritation of human palatal mucosa by selected dentifrices has been demonstrated. These findings support the suggestion by the World Workshop in Periodontics (1966)20 that efforts should be directed to the development of dentifrice materials less harsh to the oral tissues.