Clinical Impact on Dental Implant Survival in Patients Taking Antiresorptive Medications: A Systematic Review and Meta-Analysis

Dental implants are a predictable option to replace missing teeth. Patients on antiresorptive medications used to treat disorders associated with bone resorption may need dental implants to replace missing teeth. The data on implant failure in patients on antiresorptive medication requiring dental implants, is conflicting and limited. This systematic review aims to investigate if antiresorptive medications have any clinical impact on dental implant survival. Electronic databases were searched until May 2020. The focus question (PICOS): Participants: humans, Interventions: implant placement surgery in patients on antiresorptive medication, Comparisons: patients on antiresorptive medication vs control (patients not on antiresorptive medication), Outcomes: implant survival, and Study design: clinical studies. The protocol of this systematic review was registered in PROSPERO (CRD42020209083). Fourteen nonrandomized studies were selected for data extraction and risk of bias assessment using the ROBINS-1 tool. Only studies with a control were included for the meta-analysis, 8 articles were included in the meta-analysis using implant-level data, and 5 articles were included in the meta-analysis using patient-level data. There was no statistical significance between the 2 groups at the patient level based on 265 patients. However, there was a statistically significant difference at the implant level based on 2697 implants. Therefore, antiresorptive medications, mainly bisphosphonates (BPs), may significantly contribute to implant failure. Antiresorptive medications, especially BPs may reduce implant survival and impair the osseointegration of dental implants. Failed implants in patients on BPs may not lead to osteonecrosis and may be replaced with success.

Liver Injury Following Isoniazid Preventive Therapy in HIV Patients Attending Halibet National Referral Hospital, Eritrea: A Prospective Cohort Study

INTRODUCTION

A 6-month course of isoniazid, 300 mg daily, was programmatically introduced in Eritrea in 2014 as tuberculosis preventive therapy in people living with human immunodeficiency virus (PLHIV). The rollout of isoniazid preventive therapy (IPT) in PLHIV was successful in the first 2-3 years. After 2016, rumours based on rare but real incidents of liver injuries following use of IPT spread widely across the country and created concerns amongst healthcare professionals and consumers, that ultimately caused dramatic decline in the rollout of the intervention. Decision makers have been demanding better evidence as previously conducted local studies had inherent methodological limitations. This real-world observational study was conducted to evaluate the risk of liver injury associated with IPT among PLHIV attending Halibet national referral hospital, Asmara, Eritrea.

METHODS

A prospective cohort study, that consecutively enrolled PLHIV attending Halibet hospital, was conducted between 1 March and 30 October 2021. Those exposed to anti-retroviral therapy (ART) plus IPT were considered as exposed and those taking only ART were considered as unexposed. Both groups were prospectively followed up for 4-5 months with monthly liver function tests (LFTs). A Cox proportional hazard model was used to explore whether there was increased risk of drug-induced liver injury (DILI) associated with IPT. Probability of survival without DILI was also estimated using Kaplan-Meier curves.

RESULTS

A total of 552 patients, 284 exposed and 268 unexposed, completed the study, with a mean follow-up time of 3.97 (SD 0.675) months for the exposed and 4.06 (SD 0.675) months for the unexposed. Twelve patients developed drug-induced liver injury (DILI), with a median time-to-onset of 35 days (interquartile range: 26.8, 60 days). All cases were from the exposed group and all except two cases were asymptomatic. The incidence rate of DILI in the exposed group was 10.6 cases per 1000 person-months and zero for the unexposed group (p = 0.002).

CONCLUSION

DILI in PLHIV taking IPT was common; therefore, liver function should be closely monitored to safely administer the product. Despite high levels of deranged liver enzymes, the majority had no symptoms of DILI, emphasising the importance of close laboratory monitoring, especially during the first 3 months of treatment.

Low Urinary Iodine Concentration Is Associated with Increased Risk for Elevated Plasma Glucose in Females: An Analysis of NHANES 2011-12

Iodine intake in the US has declined in recent years. Iodine insufficiency increases the risk for inadequate thyroid hormone production and there is growing evidence that sub-clinical hypothyroidism may be disruptive to metabolic health, including insulin resistance (IR). We investigated the association between urinary iodine concentrations (UIC), a measurement of iodine status, and IR in adults. Data from 1286 US adults (≥20 years) in the NHANES 2011-2012 were analyzed. Two subgroups (low = UIC < 100 µg/L and normal = UIC ≥ 100 µg/L) were compared for markers of IR, including fasting plasma glucose (FPG) and insulin, homeostatic model assessment of insulin resistance (HOMA-IR), and glycated hemoglobin (HbA1C). Chi-square test, both linear and logistic regression models were used. In males, there were no significant associations between UIC and markers of IR; however, females with normal UIC had greater risks for elevated HOMA-IR (AOR = 0.56, 95% CI= 0.32-0.99) and HbA1C (AOR = 0.56, 95% CI = 0.34-0.90), while females with low UIC had a greater risk for FPG ≥ 5.6 mmol/L (AOR = 1.73, 95% CI = 1.09-2.72). Results only partially support our hypothesis that UIC is associated with the odds of IR in adults. The finding of an increased risk for elevated FPG, a marker of prediabetes, in female adults with low iodine status requires further investigation.

Sociodemographic diversity in cancer clinical trials: New findings on the effect of race and ethnicity

BACKGROUND

Cancer clinical trials (CCT) offer significant potential benefit, not only for future patients but also for enrolled participants, yet a very small minority of cancer patients participate, resulting in low levels of enrollment that have stalled clinical trials dramatically. Though many have endeavored to study this phenomenon, relatively little research has explored the demographic factors which may affect CCT enrollment. Understanding patient demographics is critical to optimizing enrollment, evaluating generalizability, and ensuring equity of CCT.

METHODS

To better understand the effect of social determinants of health on CCT enrollment, the authors constructed a multivariable logistic regression model to analyze data collected in the last ten years in the CDC Behavioral Risk Factor Surveillance System (BRFSS) Survey, an annual national survey conducted among the non-institutionalized adult population of the U.S.

RESULTS

In multivariable regression analysis, enrollment varied significantly with sociodemographic factors. Individuals of higher income, Hispanic ethnicity, and younger age were most likely to participate in CCTs. Enrollment did not vary significantly by educational attainment.

CONCLUSION

Our multivariable analysis indicated people of color are more likely to participate in CCT, perhaps demonstrating that structural barriers shape participation more than race alone. Efforts to improve CCT enrollment may benefit from a shift in focus towards access to care by alleviating structural and financial barriers to enrollment.

Defining an intermediate category of tuberculin skin test: A mixture model analysis of two high-risk populations from Kampala, Uganda

One principle of tuberculosis control is to prevent the development of tuberculosis disease by treating individuals with latent tuberculosis infection. The diagnosis of latent infection using the tuberculin skin test is not straightforward because of concerns about immunologic cross reactivity with the Bacille Calmette-Guerin (BCG) vaccine and environmental mycobacteria. To parse the effects of BCG vaccine and environmental mycobacteria on the tuberculin skin test, we estimated the frequency distribution of skin test results in two divisions of Kampala, Uganda, ten years apart. We then used mixture models to estimate parameters for underlying distributions and defined clinically meaningful criteria for latent infection, including an indeterminate category. Using percentiles of two underlying normal distributions, we defined two skin test readings to demarcate three ranges. Values of 10 mm or greater contained 90% of individuals with latent infection; values less than 7.2 mm contained 80% of individuals without infection. Contacts with values between 7.2 and 10 mm fell into an indeterminate zone where it was not possible to assign infection. We conclude that systematic tuberculin skin test surveys within populations at risk, combined with mixture model analysis, may be a reproducible, evidence-based approach to define meaningful criteria for latent tuberculosis infection.

Western influenced lifestyle and Kv2.1 association as predicted biomarkers for Tunisian colorectal cancer

BACKGROUND

Colorectal cancer (CRC) is the third most diagnosed malignancy worldwide. The global burden is expected to increase along with ongoing westernized behaviors and lifestyle. The etiology of CRC remains elusive and most likely combines environmental and genetic factors. The Kv2.1 potassium channel encoded by KCNB1 plays a collection of roles in malignancy of cancer and may be a key factor of CRC susceptibility. Our study provides baseline association between Tunisian CRC and interactions between KCNB1 variants and lifestyle factors.

METHODS

A case-control study involving 300 CRC patients, and 300 controls was conducted Patients were carefully phenotyped and followed till the end of study. KCNB1 genotyping was confirmed by Sanger sequencing. Bivariate and multivariable logistic regression analyses were used to assess the clinical status, lifestyle and study polymorphisms association with CRC.

RESULTS

We noted significant gender association with CRC occurrence. Moreover, CRC risk increases with high meat and fat consumption, alcohol use and physical activity (PA). Carriage of rs1051296 A/G and both rs11468831 ins/del and del/del genotypes (p < 0.001) were significantly associated with CRC risk. Analysis according to gender reveals correlation of rs1051295 A/G, rs11468831 non ins/ins (p = 0.01) with CRC susceptibility regardless of patients' gender while rs3331 T/C (p = 0.012) was associated with females. Stratification study according to malignancy site; Rectal Cancer (RC) and Colon Cancer (CC), reveals increasing RC risk by gender and high meat and fat consumption, alcohol use and PA. However, additional association with high brine consumption was noted for CC. The rs1051295 A/G (p = 0.01) was associated with RC risk. Increased CC risk was associated with carriage of rs1051295 A/G, rs11168831 (del/del) and (ins/del) genotypes.

CONCLUSION

The risk of CRC increases with modifiable factors by Western influences on Tunisian lifestyle such as alcohol use, high fat consumption and possibly inadequate intake of vegetables. In addition, KCNB1 polymorphisms also markedly influence CRC susceptibility. Our study establishes key elements of a baseline characterization of clinical state, Western influenced lifestyle and KCNB1 variants associated with Tunisian CRC.

Does a Pharmacist-Driven Protocol Increase Appropriate Prescribing of Rabies Postexposure Prophylaxis?

BACKGROUND

Human rabies can be prevented through postexposure prophylaxis (PEP). Although the case fatality rate is high, there are only one to three human cases per year in the United States. Despite the low incidence, the cost of rabies diagnostics, prevention, and control is significant. Recommendations exist regarding which patients should receive PEP, though several studies demonstrate a high frequency of unnecessary prescribing of PEP.

OBJECTIVE

The purpose of this study is to determine if an animal bite protocol improves compliance with state and national recommendations regarding treatment of patients presenting to the emergency department (ED). Potential cost savings will also be evaluated.

METHODS

An institutional review board-approved, single-center, retrospective chart review was conducted from January 1, 2017 to March 18, 2018 to evaluate patients presenting to the ED with an animal bite prior to and after implementation of a protocol. The primary outcome was defined as the percentage of PEP offered as indicated by the protocol. Secondary outcomes included the appropriateness of not offering PEP and estimated cost savings after protocol implementation.

RESULTS

PEP was indicated four times out of 29 offers pre-protocol and three times out of five offers post-protocol (p = 0.0476). There was no difference in the appropriateness of not offering PEP (pre-protocol 105/107 times vs. 29/29 times; p = 0.9998). Cost savings was associated with protocol implementation.

CONCLUSION

A pharmacist-driven protocol can beneficially influence prescribing habits after potential rabies exposure and is associated with cost savings.

Effect of ICD implantation on cardiovascular outcomes in patients with cardiac amyloidosis: A systematic review and meta-anaylsis

INTRODUCTION

Cardiac amyloidosis is associated with a high rate of sudden cardiac death (SCD). Whether implantable cardioverter-defibrillator (ICD) use in such patients prevents SCD is uncertain. This study assesses outcomes of ICD use in patients with cardiac amyloidosis.

METHODS

A systematic review and meta-analysis of data were performed after searching multiple databases and scientific sites pertaining to ICD use and cardiac amyloidosis. Of 8260 citations identified, six studies comprising 194 patients met inclusion criteria.

RESULTS

Mean values and frequencies of patient characteristics were as follows: mean NT-proBNP: 6867.9 pg/mL, mean left ventricular ejection fraction: 48.1%, heart failure: 67%, nonsustained ventricular tachycardia: 51%, syncope: 21%, and secondary prevention: 33%. During the mean follow-up period of 18.21 months, 18% of patients received appropriate ICD treatment and 5% received inappropriate ICD treatment. The mortality rate was 31%. Two studies assessed the difference between patients with appropriate ICD treatment and patients with absence of appropriate ICD treatment. There was no difference between the two groups when stratified on multiple selected third variables except for two subgroups. Male gender was associated with a higher rate of appropriate ICD treatment, whereas New York Heart Association class III or IV heart failure patients was associated with a lower rate of appropriate ICD treatment.

CONCLUSION

The frequency of appropriate ICD treatment in cardiac amyloidosis is low and is not predicted by nonsustained ventricular tachycardia. Male gender is associated with appropriate ICD treatment. New York Heart Association class III or IV heart failure is associated with lower rate of appropriate ICD treatment.

Outcome of implantable cardioverter defibrillator in cardiac sarcoidosis: a systematic review and meta-analysis

PURPOSE

Cardiac sarcoidosis is a multisystem inflammatory disorder characterized by ventricular arrhythmias. Implantable cardioverter defibrillator (ICD) is used to prevent sudden cardiac death.

METHODS

We performed literature search for studies that addressed the outcome and complications of ICD in Cardiac Sarcoidosis (CS). Multiple search sites were reviewed from January 1, 2000 until December 1, 2018. We then performed a meta-analysis using a random effects model. Two investigators independently extracted the data and assessed studies' quality.

RESULTS

Ten studies with 585 patients qualified for the analysis. In the pooled analysis, 57% were male with mean left ventricular ejection fraction (LVEF) of 38.4%. Appropriate and inappropriate ICD treatments (AT and IAT) were reported in 39% and 15% of patients respectively over mean follow-up period of 25 months and mortality rate of 8%. A sub-analysis of four studies indicated that patients with appropriate therapy did not differ from the rest of CS population in LVEF% (mean difference (MD) = - 7.37%, 95% confidence interval (CI) - 16.89 to 2.15, p = 0.12), age (MD = - 3.87 years, 95% CI - 10.19 to 2.46, p = 0.23), primary prevention (range difference (RD) = - 0.11, 95% CI - 0.31 to 0.10, p = 0.31) or secondary prevention indication (RD = 0.09, 95% CI - 0.12 to 0.3, p = 0.37). High degree AV block was more common in patients with AT (RD = 0.07, 95% CI 0.00 to 0.14 p = 0.05).

CONCLUSIONS

ICD placement in CS is associated with high incidence of both appropriate and inappropriate therapy. High degree AV block appears to be predictive of appropriate ICD therapy.

Does Surveillance-Detected Disease Progression Yield Superior Patient Outcomes in High-Grade Glioma?

BACKGROUND

Standard follow-up care for patients with high-grade glioma (HGG) involves routine surveillance imaging to detect disease progression, assess treatment response, and monitor clinical symptoms. Although logical in nature, evidence supporting this practice is limited. We hypothesize patients with tumor recurrence detected on routine surveillance imaging will experience superior outcomes relative to symptomatic detection, using measures of survival and postrecurrence neurologic function.

METHODS

Adult patients receiving treatment for HGG at our institution from 2004 to 2018 were identified, and data including tumor characteristics, imaging results, neurologic status, and survival were extracted from the medical records of patients meeting inclusion criteria. All participants were followed for a minimum of 12 months, or for survival duration. Survival and neurologic function differences were assessed using log rank and 2-sample t tests with 2-sided 0.05 alpha level of significance.

RESULTS

Of the 74 patients meeting inclusion criteria, 47 (63.5%) had recurrence detected via routine surveillance imaging, and 27 (36.5%) had symptomatic detection outside of the surveillance schedule. Neither median overall survival (14.8 months for surveillance and 15.7 months for symptomatic; P = 0.600) nor postrecurrence neurologic function (assessed by Karnofsky Performance Scale Index and Eastern Cooperative Oncology Group) differed between the surveillance and symptomatic detection groups (P = 0.699 and P = 0.908, respectively).

CONCLUSIONS

Recurrence detection occurring via routine surveillance imaging did not yield superior patient outcomes relative to symptomatic detection occurring outside of the standard surveillance schedule in patients with HGG. Further evaluation of surveillance imaging and alternative follow-up methods for this patient population may be warranted.

Recurrent laryngeal nerve transection in mice results in translational upper airway dysfunction

The recurrent laryngeal nerve (RLN) is responsible for normal vocal-fold (VF) movement, and is at risk for iatrogenic injury during anterior neck surgical procedures in human patients. Injury, resulting in VF paralysis, may contribute to subsequent swallowing, voice, and respiratory dysfunction. Unfortunately, treatment for RLN injury does little to restore physiologic function of the VFs. Thus, we sought to create a mouse model with translational functional outcomes to further investigate RLN regeneration and potential therapeutic interventions. To do so, we performed ventral neck surgery in 21 C57BL/6J male mice, divided into two groups: Unilateral RLN Transection (n = 11) and Sham Injury (n = 10). Mice underwent behavioral assays to determine upper airway function at multiple time points prior to and following surgery. Transoral endoscopy, videofluoroscopy, ultrasonic vocalizations, and whole-body plethysmography were used to assess VF motion, swallow function, vocal function, and respiratory function, respectively. Affected outcome metrics, such as VF motion correlation, intervocalization interval, and peak inspiratory flow were identified to increase the translational potential of this model. Additionally, immunohistochemistry was used to investigate neuronal cell death in the nucleus ambiguus. Results revealed that RLN transection created ipsilateral VF paralysis that did not recover by 13 weeks postsurgery. Furthermore, there was evidence of significant vocal and respiratory dysfunction in the RLN transection group, but not the sham injury group. No significant differences in swallow function or neuronal cell death were found between the two groups. In conclusion, our mouse model of RLN injury provides several novel functional outcome measures to increase the translational potential of findings in preclinical animal studies. We will use this model and behavioral assays to assess various treatment options in future studies.

Urban Disadvantage, Obesity, and Underweight in 31 Lower-Income Countries

Although some studies have shown that obesity and other non-communicable diseases are more common in more disadvantaged areas, no publications to date have examined the interaction of obesity with urban and rural disadvantage in lower-income countries. This study analyzed the rates of obesity and underweight in disadvantaged urban women and disadvantaged rural women in 31 lower-income countries, and calculated the age-adjusted odds ratios of urban vs. rural obesity and underweight. The odds of obesity were significantly (p<0.05) higher for urban populations in 16 of the 31 countries and in all aggregated regions; the evidence that underweight is also associated more with urban populations was mixed. Because obesity is a rapidly-growing threat to the public health and financial strength of lower-income countries, and urban disadvantage is associated with more obesity than rural disadvantage, policymakers should work to understand, predict, and prevent obesity in urban populations specifically.