Assessment of Clinical and Patient-Centered Outcomes in Nonsurgical Periodontal Therapy

Aim  The study was conducted to assess the clinical and patient-centered outcomes among the patients who had undergone nonsurgical periodontal therapy (NSPT). Methodology The participants for this study were 40 individuals with generalized chronic periodontitis. Numerous clinical parameters including clinical attachment level (CAL), probing pocket depth (PPD), plaque index (PI), and gingival index (GI) were evaluated along with the administration of a customized questionnaire before and after three months of therapy to evaluate patient-centered outcomes. Results Clinical parameters showed significant (p < 0.05) improvement post-NSPT. There was 100% satisfaction in few patient-centered outcomes such as bleeding gums, bad breath, food entrapment, and mobility. Conclusion A significant improvement in the clinical parameters does not guarantee improvement in patient-centered outcomes. Achieving the improvement in patient-centered outcomes can improve the overall quality of life (QOL), marking this a holistic treatment.

Immediately loaded full arch implant rehabilitation and oral health-related quality of life: A retrospective cohort study from primary dental care

AIMS

This study evaluates patient-centered outcomes in patients undergoing full-arch rehabilitation, with immediate loading of implants. Using the Oral Health Impact Profile questionnaire pre-and post-treatment, it assesses the hypothesis that immediate full arch loading significantly improves quality of life.

METHODOLOGY

A dataset was defined as: 20 consecutive patients from a research database who had undergone IFAL surgery (maxilla, mandible, or both) and definitive restoration by a single clinician, and completed the OHIP-14 questionnaire prior to treatment and after restoration.

RESULTS

Pre (T0 ) and post (T1 ) treatment questionnaires were analyzed from 20 consecutive patients in whom a total of 160 implants were placed. The mean T0 score was 26.7, and mean T1 score 4.6. Differences were statistically significant (p = 0.00008). Greatest improvements were seen in psychological discomfort and disability, and pain. Worsening quality of life was shown by questions relating to speech in six patients and taste in three patients.

CONCLUSION

This study demonstrates that overall IFAL significantly improves tooth-related quality of life. It suggests reasons for patients to seek treatment while providing evidence to manage expectations, such as possible implications on speech, thus supporting informed consent of future patients in a primary care setting.

Group 2 ITI Consensus Report: Technological developments in implant prosthetics

OBJECTIVES

Group-2 reviewed the scientific evidence in the field of «Technology». Focused research questions were: (1) additive versus subtractive manufacturing of implant restorations; (2) survival, complications, and esthetics comparing prefabricated versus customized abutments; and (3) survival of posterior implant-supported multi-unit fixed dental prostheses.

MATERIALS AND METHODS

Literature was systematically screened, and 67 publications could be critically reviewed following PRISMA guidelines, resulting in three systematic reviews. Consensus statements were presented to the plenary where after modification, those were accepted.

RESULTS

Additively fabricated implant restorations of zirconia and polymers were investigated for marginal/internal adaptation and mechanical properties without clear results in favor of one technology or material. Titanium base abutments for screw-retained implant single crowns compared to customized abutments did not show significant differences concerning 1-year survival. PFM, veneered and monolithic zirconia implant-supported multi-unit posterior fixed dental prostheses demonstrated similar high 3-year survival rates, whereas veneered restorations exhibited the highest annual ceramic fracture and chipping rates.

CONCLUSIONS

For interim tooth-colored implant single crowns both additive and subtractive manufacturing are viable techniques. The clinical performance of additively produced restorations remains to be investigated. Implant single crowns on titanium base abutments show similar clinical performance compared to other type of abutments; however, long-term clinical data from RCTs are needed. The abutment selection should be considered already during the planning phase. Digital planning facilitates 3D visualization of the prosthetic design including abutment selection. In the posterior area, monolithic zirconia is recommended as the material of choice for multi-unit implant restorations to reduce technical complications.

Patient experiences of a care transition intervention for Veterans to reduce emergency department visits

OBJECTIVES

Care transition interventions (CTIs) are used to improve outcomes after an emergency department (ED) visit. A recent randomized controlled trial of a Veterans Health Administration (VHA) CTI titled Discharge Information and Support for Patients receiving Outpatient care in the ED (DISPO ED) demonstrated no difference in repeat ED visits. However, changes in health care utilization are not the only measures of a CTI worth evaluation, and there is interest in using patient-centered outcomes to assess CTIs as well. To inform future CTI design and outcome measure selection, the study aims were to understand how patients experienced the CTI and what elements they valued.

METHODS

This was a qualitative study of participants randomized to the intervention arm of the DISPO ED trial using semistructured interviews. The interview guide included questions about clinical health and other issues addressed by the study nurse, the most and least helpful aspects of the intervention, and impacts of the intervention on their perceptions of self-management. Interviews were analyzed using directed content analysis.

RESULTS

Our sample comprised 24 participants, with average age of 61 years, 58% male, and 50% Black or African American. We identified six major themes related to (1) experiences during the intervention and (2) elements they valued. Patients reported clinical health coaching recommendations covering a wide range of topics as well as care coordination actions such as appointment scheduling. Valuable elements of the intervention highlighted personal characteristics of the study nurse that promoted a sense of interpersonal connection and empathy in their interactions.

CONCLUSIONS

Intervention users described assistance with care coordination as well as clinical concerns. We identified aspects that were highly valued by the participants, such as interpersonal support and empathy from the interventionist. These findings suggest the need for more comprehensive nonutilization outcome measures for CTIs to capture the patient's perspective.

Low patient engagement is associated with reduced health-related quality of life in adults with cyclic vomiting syndrome

INTRODUCTION

Patient engagement, adaptation and self-management play a critical role in improving Health Related Quality of Life (HRQOL) and reducing health care utilization in chronic disorders. There is no data on the level of patient engagement in patients with cyclic vomiting syndrome (CVS); we thus sought to determine their level of engagement and its association with clinical covariates.

METHODS

The Patient Activation Measure (PAM-13), a validated tool that measures the degree of patient engagement in their health was administered prospectively to patients with CVS. Data on demographics, health care utilization, and HRQOL (using the NIH PROMIS 10) were obtained. Patients were stratified into low engagement (PAM 1 & 2) and high engagement (PAM 3 & 4). The Fisher's exact test and Wilcoxon rank-sum tests were used to identifying significant differences between the groups.

RESULTS

Of 96 patients, 45% of patients had low levels of patient engagement. On multivariate analysis, low patient engagement was significantly associated with an increased number of CVS hospitalizations in the past year (aOR 1.26 [1.07, 1.54] p = .010), lower mental HRQOL scores (aOR 0.88 [0.78, 0.97] p = .022), current tobacco use (aOR 4.85 [1.24, 22.74] p = .031), and patients who were newly established in a specialized CVS clinic (aOR 44.40 [5.38, 70.02] p = .002).

CONCLUSION

Almost half of CVS patients demonstrate poor patient engagement, which is associated with poor outcomes. Identifying these patients and treatment in a specialized CVS center can potentially improve HRQOL, reduce health care utilization and improve overall healthcare outcomes.

The Impact of Adverse Events on Functional Capacity and Quality of Life After HeartWare Ventricular Assist Device Implantation

Left ventricular assist devices (LVADs) improve quality of life (QoL) and functional capacity (FC) for patients with advanced heart failure. The association between adverse events (AEs) and changes in QoL and FC are unknown. Patients treated with the HeartWare ventricular assist device (HVAD) with paired 6-minute walk distance (6MWD, n = 263) and Kansas City Cardiomyopathy Questionnaires (KCCQ, n = 272) at baseline and 24 months in the ENDURANCE and ENDURANCE Supplemental Trial databases were included. Patients were stratified based upon occurrence of clinically significant AEs during the first 24 months of support and analyzed for the mean change in 6MWD and KCCQ. The impact of AE frequency on change in 6MWD and KCCQ from baseline to 24 months was evaluated. Of the AEs examined, only sepsis was associated with an improvement in 6MWD (109 m vs. 16 m, p = 0.002). Patients without improvement in 6MWD test from baseline to 24 months had significantly more AEs than those with FC improvement (p = 0.0002). Adverse events did not affect the KCCQ overall summary score. In this analysis, patients with fewer AEs had greater improvement in FC during the 24-month follow up. The frequency of AEs did not have a significant impact on QoL after LVAD implantation.

In vitro and in vivo accuracy of full-arch digital implant impressions

OBJECTIVES

The main objective of the study was to compare the accuracy of full-arch digital implant impressions for fixed dental prosthesis under in vitro and in vivo conditions.

MATERIALS AND METHODS

Eight patients (five women and three men) with at least one edentulous arch and with 4-6 osseointegrated implants participated in this study. For each edentulous arch (n = 10), experimental screw-retained titanium bar with attached four scan bodies was fabricated. The bar containing four scan bodies was screw-retained intraorally on implants and scanned with Trios 3 intraoral scanner eight times (IOS group, in vivo). Then, the bar was attached to the master cast and scanned eight times again with the same intraoral scanner (MIOS group, in vitro). Finally, the bar with scan bodies was scanned 8 times with a laboratory scanner (reference). Precision and trueness were calculated for 3 distances and 3 angles between the scan bodies (1-2, 1-3, and 1-4) in IOS and MIOS groups.

RESULTS

Precision and trueness for the largest distance (1-4) were found to be 44 ± 18 µm and 32 ± 19 µm for the IOS group and 31 ± 16 µm and 30 ± 14 µm for MIOS group, respectively. Precision and trueness for the angle between the most distant scan bodies (1-4) were 0.22 ± 0.14° and 0.18 ± 0.10° for the IOS group and 0.16 ± 0.11° and 0.07 ± 0.05° for MIOS group, respectively.

CONCLUSIONS

Intraoral conditions moderately affected the precision and trueness of Trios 3 (3Shape) intraoral scanner. Results of in vitro accuracy studies cannot be directly transferred to the clinical field.

Comparing pre- and post-treatment patients' perceptions on dental implant therapy

BACKGROUND

Appropriate patients' perceptions as one of Patient Reported Outcome Measures (PROMs), are shown to be critical for the sustainable success of implant therapy, little is known however of how they prospectively evolve throughout the treatment process.

OBJECTIVE

This study aimed to prospectively assess patients' perceptions before and after treatment with dental implants and to identify the impact of patients' characteristics on their perceptions.

MATERIALS AND METHODS

Patients' perceptions on implant therapy were prospectively assessed by means of purpose-made questionnaire, rating the extent of agreement/disagreement with a set of statements on a visual analog scale. The questionnaire was collected before initial consultation with the implant dentist and post-treatment at least 1 month after prosthetic loading of the implant. Changes in patients' perceptions were analyzed with the Wilcoxon signed-rank test.

RESULTS

Pretreatment questionnaire was collected from 359 patients. While 245 of them proceeded with implant therapy, 145 received final restoration within the timeframe of the study and completed the post-treatment questionnaires between 1 and 6 months after prosthesis delivery. The most common source of information was dental professions (72.4%). Although patients' perceptions were more realistic at post-treatment, few improper perceptions persisted as only 51% of patients agreed with the statement "There is a chance of dental implant failure," 28% agreed with the statement "Dental implants last longer than natural teeth," and higher percentage of patients agreed with "Dental implant therapy is appropriate for all patients."

CONCLUSIONS

Although patients appear to harbor more realistic perceptions of implant therapy, certain improper perceptions still persist at post-treatment. The design of appropriate patient educational program might be essential to correct misperceptions that might affect long term success of implant therapy. This study had been registered on Thai Clinical Trials Registry (TCTR) with the TCTR identification number: TCTR20181101001.

Treatment concepts of horizontally deficient ridges-A retrospective study comparing narrow-diameter implants in pristine bone with standard-diameter implants in augmented bone

OBJECTIVES

To compare clinical and radiological outcomes of narrow-diameter implants (NDI) placed in pristine bone to standard-diameter implants placed in combination with horizontal bone augmentation procedures (SDI+A) for horizontally deficient alveolar ridges.

MATERIAL AND METHODS

For this retrospective study, the outcome of 597 NDI (∅ 3.3 mm, 272 patients), inserted in pristine bone, were compared with 180 SDI (∅ 4.1 mm, 83 patients), inserted in combination with horizontal augmentation procedures. Oral health-related quality of life was assessed in patients available for recall.

RESULTS

After a mean follow-up of 37.6 ± 40 months for the NDI and of 42.4 ± 49 months for the SDI+A, survival rates were 96.1% for NDI and 95.6% for SDI+A. Cumulative 5-year and 10-year implant survival rates were 94.3% and 92.2% for the NDI group and 97.0% and 88.3% for the SDI+A group, indicating no significant difference (p = .89). According to the criteria of Buser et al., an implant success rate of 84.3% was obtained for the NDI and an implant success rate of 81.3% for the SDI+A (p = .79). Regarding oral health-related quality of life, a similar and high patient satisfaction could be observed in both groups.

CONCLUSIONS

NDI without augmentation procedures showed a similar clinical outcome as SDI in combination with augmentation procedures after a follow-up of more than 3 years. Therefore, NDI might be a reasonable alternative in cases of horizontal bone atrophy (no clinical trial registration as patient inclusion started 2003).

Improvements in frailty contribute to substantial improvements in quality of life after lung transplantation in patients with cystic fibrosis

BACKGROUND

While lung transplantation (LTx) improves health-related quality of life (HRQL) in cystic fibrosis (CF), the determinants of this improvement are unknown. In other populations, frailty-a syndrome of vulnerability to physiologic stressors-is associated with disability and poor HRQL. We hypothesized that improvements in frailty would be associated with improved disability and HRQL in adults with CF undergoing LTx.

METHODS

In a single-center prospective cohort study from 2010 to 2017, assessments of frailty, disability, and HRQL were performed before and at 3- and 6-months after LTx. We assessed frailty by the short physical performance battery (SPPB). We assessed disability with the Lung Transplant Valued Life Activities scale (LT-VLA) and HRQL by the Medical Outcomes Study Short Form Physical and Mental Component Summary scales (SF12-PCS, -MCS), the Airway Questionnaire 20-Revised (AQ20R), and the Euroqol 5D (EQ5D). We tested the association of concurrent changes in frailty and lung function on disability and HRQL by linear mixed-effects models adjusted for sex and body mass index.

RESULTS

Among 23 participants with CF, improvements in frailty and lung function were independently associated with improved disability and some HRQL measures. For example, each 1-point improvement in SPPB or 200 mL improvement in FEV1 was associated with improved LT-VLA disability by 0.14 (95%CI: 0.08-0.20) and 0.07 (95%CI: 0.05-0.09) points and improved EQ5D by 0.05 (95%CI: 0.03 to 0.07) and 0.02 (95%CI: 0.01-0.03) points, respectively.

CONCLUSION

Improvement in frailty is a novel determinant of improved disability and HRQL in adults with CF undergoing LTx.

Physician-Centered Outcomes for Skin Cancer Treatment: A Single-Day Modified Delphi Process to Assess the Importance of Themes in Skin Cancer Management

BACKGROUND

Success in skin cancer treatment is determined through outcome measurement. Patients and physicians may prioritize different outcomes of care, and identification of such may enhance patient-centered care.

OBJECTIVE

To identify gaps between patient and physician attitudes toward skin cancer outcomes.

MATERIALS AND METHODS

A single-day, 21-patient, modified, in-person Delphi process to solicit and rate the importance of skin cancer-related outcomes was conducted. Twelve masked dermatologic surgeons rated patient-generated outcomes in a 2-round modified Delphi process. Each item was rated on a 1 to 9 scale (1, least important; 9, most important) using the Qualtrics web platform (Qualtrics, Provo, UT). Results of the physician ratings were compared with the patient ratings.

RESULTS

A list of 53 skin cancer treatment-related themes and outcomes was generated. Eight items were ranked by physicians as "very high" (>80% importance), 5 as "high" (>70% importance), 19 as intermediate, and 21 as low. The physician and patient panels' ratings were concordant for 56% of items, whereas 7 outcome items showed a 2-category discordance.

CONCLUSION

Physicians and patients were concordant regarding skin cancer treatment on multiple spheres. Areas of discordance include patient fear of unknown future risk, recurrence, or empowering patients to make treatment choices, and may be areas of continued improvement for delivery of patient-centered care.

Comparison of postoperative intraoral scan versus cone beam computerised tomography to measure accuracy of guided implant placement-A prospective clinical study

OBJECTIVE

To evaluate the accuracy of implant placement with a digitally planned guided implant procedure. Two methods for identifying the actual postoperative positioning of the implants were compared: CBCT and IO scanning.

MATERIAL AND METHODS

Twenty-eight implants with a sandblasted and acid-etched surface were placed in thirteen patients using tooth-supported surgical guides following a digital planning procedure. The implants were submerged for 12-15 weeks. New CBCT images were taken for identification of the implant position. After second stage surgery, scan bodies were mounted on the implants and scanned with an IO digital scanner. The recordings from the CBCT images and the IO scans were compared with respect to the identified positions of the implants.

RESULTS

The study did not resolve any significant differences of the identified positioning of the implants as measured by CBCT or IO, except for the apical deviations at the coronal and apical points. The angular difference between CBCT and IO scanning at the coronal point was -0.011 (±0.6) degrees, whereas the 3D deviation was 0.03(±0.17) mm. The distal deviation between CBCT and IO scanning was 0.01(± 0.16) mm, and the vestibular deviation 0.033(± 0.16) mm and the apical deviation difference was 0.09(± 0.16) mm. The 3D deviation at the apical point was 0.04(± 0.22) mm. The distal deviation between CBCT and IO scanning was 0.06(± 0.19) mm, and the vestibular deviation 0.032(± 0.23) mm and the apical deviation difference was 0.09(± 0. 16) mm.

CONCLUSION

The study demonstrated that accuracy measurements using IO scanning yields comparable results to those obtained by CBCT.

Dental Implant Quality Register-A possible tool to further improve implant treatment and outcome

The Board of EAO (European Association for Osseointegration) has discussed an initiative to explore the conditions to establish a Dental Implant Register. It was suggested to bring this issue to the EAO Consensus Conference 2018 for a discussion and to possibly propose relevant and manageable parameters. This article presents some select examples from quality registers in the medical field. Based on the experience of established registers, essentially in the medical field, factors considered to be of importance, if and when establishing a Dental Implant Register are introduced and discussed.

Dental implant register: Summary and consensus statements of group 2. The 5th EAO Consensus Conference 2018

OBJECTIVES

This publication reports the EAO Workshop group-2 and consensus plenary discussions and statements on a narrative review providing the background and possible facilities and importance of a dental implant register, to allow for a systematic follow-up of the clinical outcome of dental implant treatment in various clinical settings. It should be observed that the format of the review and the subsequent consensus report consciously departs from conventional consensus publications and reports.

MATERIAL AND METHODS

The publication was a narrative review on the presence and significance of quality registers regarding select medical conditions and procedures. The group discussed and evaluated the publication and made corrections and recommendations to the authors and agreed on the statements and recommendations described in this consensus report.

RESULTS

Possible registrations to be included in an implant register were discussed and agreed as a preliminary basis for further development, meaning that additional parameters be included or some be deleted.

CONCLUSIONS

It was agreed to bring the idea of an implant quality register, including the presented results of discussions and proposals by the group- and plenary sessions, to the EAO Board for further discussion and decision.

Comparative effectiveness of prostate cancer treatments for patient-centered outcomes: A systematic review and meta-analysis (PRISMA Compliant)

BACKGROUND

In the context of prostate cancer (PCa) characterized by the multiple alternative treatment strategies, comparative effectiveness analysis is essential for informed decision-making. We analyzed the comparative effectiveness of PCa treatments through systematic review and meta-analysis with a focus on outcomes that matter most to newly diagnosed localized PCa patients.

METHODS

We performed a systematic review of literature published in English from 1995 to October 2016. A search strategy was employed using terms "prostate cancer," "localized," "outcomes," "mortality," "health related quality of life," and "complications" to identify relevant randomized controlled trials (RCTs), prospective, and retrospective studies. For observational studies, only those adjusting for selection bias using propensity-score or instrumental-variables approaches were included. Multivariable adjusted hazard ratio was used to assess all-cause and disease-specific mortality. Funnel plots were used to assess the level of bias.

RESULTS

Our search strategy yielded 58 articles, of which 29 were RCTs, 6 were prospective studies, and 23 were retrospective studies. The studies provided moderate data for the patient-centered outcome of mortality. Radical prostatectomy demonstrated mortality benefit compared to watchful waiting (all-cause HR = 0.63 CI = 0.45, 0.87; disease-specific HR = 0.48 CI = 0.40, 0.58), and radiation therapy (all-cause HR = 0.65 CI = 0.57, 0.74; disease-specific HR = 0.51 CI = 0.40, 0.65). However, we had minimal comparative information about tradeoffs between and within treatment for other patient-centered outcomes in the short and long-term.

CONCLUSION

Lack of patient-centered outcomes in comparative effectiveness research in localized PCa is a major hurdle to informed and shared decision-making. More rigorous studies that can integrate patient-centered and intermediate outcomes in addition to mortality are needed.

Redefining Health: The Evolution of Health Ideas from Antiquity to the Era of Value-Based Care

The current healthcare system in the United States (US) is characterized by high costs and poor patient outcomes. A value-based healthcare system, centered on providing the highest quality of care for the lowest cost, is the country's chosen solution for its healthcare crisis. As the US transitions to a value-based model, a new definition of health is necessary to clearly define what constitutes a healthy state. However, such a definition is impossible to develop without a proper understanding of what "health" actually means. To truly understand its meaning, one must have a thorough historical understanding of the changes in the concept of health and how it has evolved to reflect the beliefs and scientific understanding of each time period. Thus, this review summarizes the changes in the definition of health over time in order to provide a context for the definition needed today. We then propose a new definition of health that is specifically tailored to providers working in the era of value-based care.

The influence of professional competence on the inter- and intra-individual esthetic evaluation of implant-supported crowns in the anterior maxilla

OBJECTIVES

Evaluation of the influence of professional competence on esthetic predictability of implant-supported crowns in the anterior maxilla and identification of objective factors allowing predictable planning for esthetic results.

MATERIALS AND METHODS

Sixty patients with 82 implants in the esthetic zone were included in this study. Width of keratinized mucosa, biotype, recessions, and papilla index according to Jemt as well as radiological bone loss were assessed. Study casts and photographs were obtained. Each patient as well as people with different level of expertise (laypersons, students and dentists) rated the esthetic satisfaction after final restoration on a scale (1-10). Correlations between esthetic assessments and previously documented clinical parameters were tested.

RESULTS

The study failed to show a significant relationship between the raters' level of dental expertise and their subjective esthetic evaluation. However, patients rated themselves much more favorable than the three evaluator groups did. A comparison of the clinical parameters with the esthetic evaluation revealed significantly more favorable ratings by the lay group in the presence of a wide attached gingiva (P = 0.021) than by the other groups and by the laypersons (P = 0.002), the dentists (P = 0.003), and students (P = 0.009) in the absence of recessions. The ratio of the implant crown length to the length of the contralateral crown had a negative effect on ratings for all three groups ([laypersons P < 0.001], [students P < 0.001] and [dentists P = 0.001]). The papilla index of the mesial papilla correlated significantly with laypersons' ratings (P = 0.036).

CONCLUSION

Earlier investigations are confirmed. Width of keratinized mucosa is a risk factor for esthetic predictability of implant-supported crowns in the anterior maxilla in laypersons' ratings. Furthermore, there is an association between the discrepancy of lengths of implant-supported single crowns to their contralateral natural teeth and esthetic satisfaction for all expertise levels.

Initial report of the osteogenesis imperfecta adult natural history initiative

BACKGROUND

A better understanding of the natural history of osteogenesis imperfecta (OI) in adulthood should improve health care for patients with this rare condition.

METHODS

The Osteogenesis Imperfecta Foundation established the Adult Natural History Initiative (ANHI) in 2010 to give voice to the health concerns of the adult OI community and to begin to address existing knowledge gaps for this condition. Using a web-based platform, 959 adults with self-reported OI, representing a wide range of self-reported disease severity, reported symptoms and health conditions, estimated the impact of these concerns on present and future health-related quality of life (QoL) and completed a Patient-Reported Outcomes Measurement Information System (PROMIS®) survey of health issues.

RESULTS

Adults with OI report lower general physical health status (p < .0001), exhibit a higher prevalence of auditory (58% of sample versus 2-16% of normalized population) and musculoskeletal (64% of sample versus 1-3% of normalized population) concerns than the general population, but report generally similar mental health status. Musculoskeletal, auditory, pulmonary, endocrine, and gastrointestinal issues are particular future health-related QoL concerns for these adults. Numerous other statistically significant differences exist among adults with OI as well as between adults with OI and the referent PROMIS® population, but the clinical significance of these differences is uncertain.

CONCLUSIONS

Adults with OI report lower general health status but are otherwise more similar to the general population than might have been expected. While reassuring, further analysis of the extensive OI-ANHI databank should help identify areas of unique clinical concern and for future research. The OI-ANHI survey experience supports an internet-based strategy for successful patient-centered outcomes research in rare disease populations.

Defining novel health-related quality of life domains in lung transplantation: a qualitative analysis

PURPOSE

Health-related quality of life (HRQL) domains vary across disease conditions and are determined by standards, values, and priorities internal to patients. Although the clinical goals of lung transplantation are to improve patient survival and HRQL, what defines HRQL in lung transplantation is unknown. Employing a qualitative approach, we aimed to identify HRQL domains important in lung transplantation.

METHODS

We conducted semi-structured interviews in purposefully sampled lung transplant recipients (n = 8) representing a spectrum of ages, gender, indications for transplantation, and time since transplantation as well as healthcare practitioners representing a spectrum of practitioner types (n = 9). Grounded theory was used to identify HRQL domains important in lung transplantation, building on but going beyond domains already defined in the SF-36, the most commonly used instrument in this population.

RESULTS

In addition to confirming the relevance of the eight SF-36 domains, we identified 11 novel HRQL domains. Palliation of respiratory symptoms was identified as important. After transplant surgery, new HRQL domains emerged including: distressing symptoms spanning multiple organ systems, worry about infection and acute rejection, treatment burden, and depression. Further, patients identified challenges to intimacy, changes in social relationships, and problems with cognitive functioning. Saliently, worry about limited life expectancy was pervasive and impaired life planning.

CONCLUSIONS

We found that HRQL in lung transplantation is defined by both generic and transplant-specific domains. Delineating and refining these domains can inform efforts to improve clinical outcomes and HRQL measurement in lung transplantation.

Building efficient comparative effectiveness trials through adaptive designs, utility functions, and accrual rate optimization: finding the sweet spot

The time is right for the use of Bayesian Adaptive Designs (BAD) in comparative effectiveness trials. For example, Patient Centered Outcomes Research Institute has joined the Food and Drug Administration and National Intitutes of Health in adopting policies/guidelines encouraging their use. There are multiple aspects to BAD that need to be considered when designing a comparative effectiveness design. First, the adaptation rules can determine the expected size of the trial. Second, a utility function can be used to combine extremely important co-endpoints (e.g., efficacy and tolerability) and is a valuable tool for incorporating clinical expertise and potentially patient preference. Third, accrual rate is also very, very important. Specifically, there is a juxtaposition related to accrual and BAD. If accrual rate is too fast we never gain efficient information for adapting. If accrual rate is too slow we never finish the clinical trial. We propose methodology for finding the 'sweet spot' for BAD that addresses these as design parameters. We demonstrate the methodology on a comparative effectiveness BAD of pharmaceutical agents in cryptogenic sensory polyneuropathy. The study has five arms with two endpoints that are combined with a utility function. The accrual rate is assumed to stem from multiple sites. We perform simulations from which the composite accrual rates across sites result in various piecewise Poisson distributions as parameter inputs. We balance both average number of patients needed and average length of time to finish the study.

Perioperative use of non-steroidal anti-inflammatory drugs might impair dental implant osseointegration

OBJECTIVE

To appraise whether adverse biological events following oral implant placement may be associated with perioperative use of non-steroidal anti-inflammatory drugs (NSAIDs).

METHODS

All patients treated in a university faculty postgraduate dental clinic between 1979 and 2012 that had experienced a failing and surgically removed dental implant (292 implants in 168 patients) were contacted to solicit additional information about their present dental and medical status and frequency of current and past use of NSAIDs. Potential associations between perioperative NSAIDs use and the occurrence of adverse biological events were explored by the use of 2 × 2 tables and two-tailed Fisher's exact tests.

RESULTS

One hundred and four patients with initially 468 implants had experienced 238 implant failures, of which 197 were due to failing osseointegration (42%). Sixty of the participants, initially with 273 implants, had used NSAIDs perioperatively and experienced 44% implant failures, versus 38% in the non-NSAID cohort. The NSAID cohort experienced 3.2 times more cases of radiographic bone loss greater than 30% of the vertical height of their remaining implants and 1.9 times more cases of cluster failures, defined as failure of 50% or more of the implant(s) placed.

CONCLUSIONS

Notwithstanding that a retrospective study design is open to potential bias, the current data indicate that dental implant osseointegration may be affected negatively by an inhibitory effect of NSAIDs on bone healing in vulnerable patients. Future and better clinical studies than the current should be designed to appraise more precisely the potential effects of NSAIDs on implant osseointegration in study populations that are not limited by stringent medical inclusion and exclusion criteria.

Single implant-supported crowns in the aesthetic zone: patient satisfaction with aesthetic appearance compared with appraisals by laypeople and dentists

OBJECTIVE

To appraise the patients' satisfaction with aesthetic outcomes following an implant restoration in the anterior maxilla as compared to appraisals made by dentists and laypeople.

MATERIAL AND METHODS

Randomly selected patients (n = 116) restored with an implant-retained crown in the anterior maxilla were invited to rate their satisfaction with aesthetic outcomes using a questionnaire containing seven criteria, each graded from excellent to poor. Projected images of the patient smiles were appraised by dentists (n = 8) and laypeople (n = 6) using the same assessment criteria in a room setting. In addition, the laypeople judged the same cases on printed 10 × 15 cm photographs in a separate setting. Jemt papilla scores, pink aesthetic score (PES) and white esthetic score (WES) were assigned by the dentists. Differences in the levels of satisfaction between the patient, and appraisals by the dentists and the laypeople were compared using non-parametric statistical tests.

RESULTS

Patients' opinions of their aesthetic appearance following the placement of a single implant-supported crown in the aesthetic zone were in general very favourable. The laypeople were more critical than the dentists when the aesthetic outcomes were appraised on magnified images projected onto a screen. Laypeople became less critical when evaluating the aesthetic outcomes on printed photographs compared to appraisals on a screen. Patient satisfaction with their aesthetic appearance differed from dentists' and laypeople's appraisals.

CONCLUSION

Factors other than the actual aesthetic outcome itself appear to influence patients' satisfaction with their end results. Laypeople's appraisal is influenced by the magnification and method used for appraising the aesthetic outcomes.