Emergency Medicine Clinician Experiences Addressing Uncertainty in First-Trimester Bleeding.

The purpose of this work is to understand Emergency Department (ED) clinicians' experiences in communicating uncertainty about first-trimester bleeding (FTB) and their need for training on this topic. This cross-sectional study surveyed a national sample of attending physicians and advanced practice providers (APPs). The survey included quantitative and qualitative questions about communicating with patients presenting with FTB. These questions assessed clinicians' frequency encountering challenges, comfort, training, prior experience, and interest in training on the topic. Of 402 respondents, 54% reported that they encountered challenges at least sometimes when discussing FTB with patients where the pregnancy outcome is uncertain. While the majority (84%) were at least somewhat prepared for these conversations from their training, which commonly addressed the diagnostic approach to this scenario, 39% strongly or moderately agreed that they could benefit from training on the topic. Because the majority of ED clinicians identified at least sometimes encountering challenges communicating with pregnant patients about FTB, our study indicates a need exists for more training in this skill.

Most Frequently Cited Accreditation Inspection Deficiencies for Clinical Molecular Oncology Testing Laboratories and Opportunities for Improvement.

CONTEXT.­: The College of American Pathologists (CAP), a laboratory accreditation organization with deemed status under the Clinical Laboratories Improvement Amendments of 1988 administers accreditation checklists. Checklists are used by laboratories to ensure regulatory compliance. Peer-level laboratory professionals audit laboratory records during inspections to assess compliance. OBJECTIVE.­: To identify the most frequently cited deficiencies for molecular oncology laboratories undergoing CAP accreditation inspections and describe laboratory improvement opportunities. DESIGN.­: The CAP Molecular Oncology Committee (MOC), which is involved in maintaining the Molecular Pathology checklist, reviewed data and inspector comments associated with the most frequently observed citations related to molecular oncology testing from laboratories inspected by the CAP during a 2-year period (2018-2020). RESULTS.­: Of 422 molecular oncology laboratories that underwent accreditation inspections, 159 (37.7%) were not cited for any molecular oncology-related deficiencies. For the All Common (COM) and Molecular Pathology checklists, there were 364 and 305 deficiencies, corresponding to compliance rates of 98.8% and 99.6%, respectively. The most frequently cited deficiencies are described. The COM checklist deficiencies were associated most often with the analytic testing phase; the MOL checklist deficiencies were more evenly distributed across the preanalytic, analytic, and postanalytic phases of testing. CONCLUSIONS.­: Molecular oncology laboratories demonstrated excellent compliance with practices that support high-quality results for patients and the health care providers who use those test results in patient management. This review includes a critical assessment of opportunities for laboratories to improve compliance and molecular oncology testing quality.

Emergency clinician participation and performance in the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System.

BACKGROUND: The Merit-based Incentive Payment System (MIPS) is the largest national pay-for-performance program and the first to afford emergency clinicians unique financial incentives for quality measurement and improvement. With little known regarding its impact on emergency clinicians, we sought to describe participation in the MIPS and examine differences in performance scores and payment adjustments based on reporting affiliation and reporting strategy. METHODS: We performed a cross-sectional analysis using the Centers for Medicare & Medicaid Services 2018 Quality Payment Program (QPP) Experience Report data set. We categorized emergency clinicians by their reporting affiliation (individual, group, MIPS alternative payment model [APM]), MIPS performance scores, and Medicare Part B payment adjustments. We calculated performance scores for common quality measures contributing to the quality category score if reported through qualified clinical data registries (QCDRs) or claims-based reporting strategies. RESULTS: In 2018, a total of 59,828 emergency clinicians participated in the MIPS-1,246 (2.1%) reported as individuals, 43,404 (72.5%) reported as groups, and 15,178 (25.4%) reported within MIPS APMs. Clinicians reporting as individuals earned lower overall MIPS scores (median [interquartile range {IQR}] = 30.8 [15.0-48.2] points) than those reporting within groups (median [IQR] = 88.4 [49.3-100.0]) and MIPS APMs (median [IQR] = 100.0 [100.0-100.0]; p < 0.001) and more frequently incurred penalties with a negative payment adjustment. Emergency clinicians had higher measure scores if reporting QCDR or QPP non-emergency medicine specialty set measures. CONCLUSIONS: Emergency clinician participation in national value-based programs is common, with one in four participating through MIPS APMs. Those employing specific strategies such as QCDR and group reporting received the highest MIPS scores and payment adjustments, emphasizing the role that reporting strategy and affiliation play in the quality of care.

Emergency Providers' Familiarity with Firearms: A National Survey.

BACKGROUND: Emergency providers (EPs) are uniquely placed to advocate for firearm safety and have been shown to be at risk of exposure to firearms in the emergency department (ED). We sought to characterize EPs' knowledge of firearms, frequency of encountering firearms in the ED and level of confidence with safely removing firearms from patient care settings. METHODS: This was a survey study of EPs representing medical centers in 22 states. A 15-item questionnaire was e-mailed to all EPs at all included institutions. Questions pertained to EPs' knowledge of firearms, experience with handling firearms, and exposure to firearms while at work. We calculated response proportions with p-values and conducted association analyses among survey items. RESULTS: Of 2,192 survey recipients, 1,074 (49.0%) completed the survey. A total of 635 (59.1%) reported encountering firearms in the ED or its immediate environment at least once per year, and 582 (54.2%) were not confident in their ability to safely handle a firearm found in a patient's possession. Frequency of handling firearms was significantly higher in states in the top quartile for firearm ownership, with 21.5% of respondents reporting handling firearms daily or weekly, compared to 10.9% in bottom-quartile states. Level of firearms training also differed significantly: 42.1% of respondents in top-quartile states reported formal training compared to 33.0% in bottom-quartile states. Increased regional firearm ownership rates were associated with decreased rates of feeling unsafe at work. CONCLUSIONS: The majority of surveyed EPs reported little experience with handling firearms. Firearm experience was associated with comfort with managing firearms found in patients' possession. Regional differences were found regarding personal firearm experience and perceptions of workplace safety, both of which were associated with regional variations in firearm ownership. Despite this, no regional differences were found in encountering firearms in or around the ED. EPs may benefit from training on safely handling firearms.

What Did You Google? Describing Online Health Information Search Patterns of ED patients and Their Relationship with Final Diagnoses.

INTRODUCTION: Emergency department (ED) patients' Internet search terms prior to arrival have not been well characterized. The objective of this analysis was to characterize the Internet search terms patients used prior to ED arrival and their relationship to final diagnoses. METHODS: We collected data via survey; participants listed Internet search terms used. Terms were classified into categories: symptom, specific diagnosis, treatment options, anatomy questions, processes of care/physicians, or "other." We categorized each discharge diagnosis as either symptom-based or formal diagnosis. The relationship between the search term and final diagnosis was assigned to one of four categories of search/diagnosis combinations (symptom search/symptom diagnosis, symptom search/formal diagnosis, diagnosis search/symptom diagnosis, diagnosis search/formal diagnosis), representing different "trajectories." RESULTS: We approached 889 patients; 723 (81.3%) participated. Of these, 177 (24.5%) used the Internet prior to ED presentation; however, seven had incomplete data (N=170). Mean age was 47 years (standard deviation 18.2); 58.6% were female and 65.7% white. We found that 61.7% searched symptoms and 40.6% searched a specific diagnosis. Most patients received discharge diagnoses of equal specificity as their search terms (34% flat trajectory-symptoms and 34% flat trajectory-diagnosis). Ten percent searched for a diagnosis by name but received a symptom-based discharge diagnosis with less specificity. In contrast, 22% searched for a symptom and received a detailed diagnosis. Among those who searched for a diagnosis by name (n=69) only 29% received the diagnosis that they had searched. CONCLUSION: The majority of patients used symptoms as the basis of their pre-ED presentation Internet search. When patients did search for specific diagnoses, only a minority searched for the diagnosis they eventually received.

Use of Online Health Information by Geriatric and Adult Emergency Department Patients: Access, Understanding, and Trust.

OBJECTIVE: The objective was to characterize geriatric patients' use of online health information (OHI) relative to younger adults and assess their comfort ith OHI compared to health information (HI) from their physician. METHODS: This was a prospective cross-sectional survey study of adult emergency department (ED) patients. The survey assessed patients' self-reported use of OHI in the past year and immediately prior to ED visit and analyzed differences across four age groups: 18-39, 40-64, 65-74, and 75+. Patients' ability to access, understand, and trust OHI was assessed using a 7-point Likert scale and compared to parallel questions regarding HI obtained from their doctor. Patient use of OHI was compared across age groups. Comfort with OHI and HI obtained from a doctor was compared across age groups using the Kruskal-Wallis test. Comparisons between sources of HI were made within age groups using the Wilcoxon signed-rank test. RESULTS: Of 889 patients who were approached for study inclusion, 723 patients (81.3%) completed the survey. The majority of patients had used OHI in the past year in all age groups, but older patients were less likely to have used OHI: age 18-39, 90.3%; 40-64, 85.3%; 65-74, 76.4%; and 75+, 50.7% (p < 0.001). The youngest patients were most likely to have used OHI prior to coming to the ED, 47.1%, 28.3%, 17.1%, and 8.0% (p < 0.001). Older patients were more likely to have an established doctor-18-39, 79.4%; 40-64, 91.1%; 65-74, 97.5%; and 75+ 97.4% (p < 0.001)-and were more likely to have contacted their doctor prior to their ED visit: 36.7, 40.2, 46.7, and 53.5% (p = 0.02). The oldest patients were most likely to find HI more accessible from their doctor than the Internet, while the youngest patients found HI more accessible on the Internet than from their doctor. Regardless of age, patients noted that information from their physician was both easier to understand and more trustworthy than information found on the Internet. CONCLUSION: Although many older patients used OHI, they were less likely than younger adults to use the Internet immediately prior to an ED visit. Despite often using OHI, patients of all age groups found healthcare information from their doctor easier to understand and more trustworthy than information from the Internet. As health systems work to efficiently provide information to patients, addressing these perceived deficiencies may be necessary to build effective OHI programs.

Decrowding of lower anterior segment with and without photobiomodulation: a single center, randomized clinical trial.

The aim of this study was to evaluate the effect of low-level light therapy using light-emitting diodes (LEDs) on the speed of tooth movements that were required for the leveling and aligning of the lower anterior segment during non-extraction orthodontic treatment. The sample was comprised of patients (n = 40) with lower anterior crowding who were treated with self-ligating orthodontic brackets and a standardized wire sequence. A test group of patients (n = 20) who were treated with extraoral infrared light therapy for 20 min daily with at least 80 % compliance was compared to a control group (n = 20). The date of the first arch wire placement was recorded as T1, and the date of the completion of the lower anterior segment decrowding was recorded as T2. A final impression was also taken at T2. The time between T1 and T2 was significantly reduced by 22 % in the test group compared to the control group (68.3 vs. 87.8 days, respectively, p < 0.043). The use of photobiomodulation for 20 min daily at a wavelength of 850 nm might reduce the time required to resolve lower anterior crowding. This trial and its protocol were not registered on a publicly accessible registry.

A Novel Tool for Assessment of Emergency Medicine Resident Skill in Determining Diagnosis and Management for Emergent Electrocardiograms: A Multicenter Study.

BACKGROUND: Reading emergent electrocardiograms (ECGs) is one of the emergency physician's most crucial tasks, yet no well-validated tool exists to measure resident competence in this skill. OBJECTIVES: To assess validity of a novel tool measuring emergency medicine resident competency for interpreting, and responding to, critical ECGs. In addition, we aim to observe trends in this skill for resident physicians at different levels of training. METHODS: This is a multi-center, prospective study of postgraduate year (PGY) 1-4 residents at five emergency medicine (EM) residency programs in the United States. An assessment tool was created that asks the physician to identify either the ECG diagnosis or the best immediate management. RESULTS: One hundred thirteen EM residents from five EM residency programs submitted completed assessment surveys, including 43 PGY-1s, 33 PGY-2s, and 37 PGY-3/4s. PGY-3/4s averaged 74.6% correct (95% confidence interval [CI] 70.9-78.4) and performed significantly better than PGY-1s, who averaged 63.2% correct (95% CI 58.0-68.3). PGY-2s averaged 69.0% (95% CI 62.2-73.7). Year-to-year differences were more pronounced in management than in diagnosis. CONCLUSIONS: Residency training in EM seems to be associated with improved ability to interpret "critical" ECGs as measured by our assessment tool. This lends validity evidence for the tool by correlating with a previously observed association between residency training and improved ECG interpretation. Resident skill in ECG interpretation remains less than ideal. Creation of this sort of tool may allow programs to assess resident performance as well as evaluate interventions designed to improve competency.

Faculty Prediction of In-Training Examination Scores of Emergency Medicine Residents: A Multicenter Study.

BACKGROUND: The Emergency Medicine In-Training Examination (EMITE) is one of the few validated instruments for medical knowledge assessment of emergency medicine (EM) residents. The EMITE is administered only once annually, with results available just 2 months before the end of the academic year. An earlier predictor of EMITE scores would be helpful for educators to institute timely remediation plans. A previous single-site study found that only 69% of faculty predictions of EMITE scores were accurate. OBJECTIVE: The goal of this article was to measure the accuracy with which EM faculty at five residency programs could predict EMITE scores for resident physicians. METHODS: We asked EM faculty at five different residency programs to predict the 2014 EMITE scores for all their respective resident physicians. The primary outcome was prediction accuracy, defined as the proportion of predictions within 6% of the actual scores. The secondary outcome was prediction precision, defined as the mean deviation of predictions from the actual scores. We assessed faculty background variables for correlation with the two outcomes. RESULTS: One hundred and eleven faculty participated in the study (response rate 68.9%). Mean prediction accuracy for all faculty was 60.0%. Mean prediction precision was 6.3%. Participants were slightly more accurate at predicting scores of noninterns compared to interns. No faculty background variable correlated with the primary or secondary outcomes. Eight participants predicted scores with high accuracy (>80%). CONCLUSIONS: In this multicenter study, EM faculty possessed only moderate accuracy at predicting resident EMITE scores. A very small subset of faculty members is highly accurate.

Scoring of MYC protein expression in diffuse large B-cell lymphomas: concordance rate among hematopathologists.

Recent studies have shown that immunohistochemical evaluation of MYC protein expression in diffuse large B-cell lymphoma is a useful prognostic tool with high concordance rate among pathologists. Concordance in these studies was assessed among few pathologists from one institution by scoring tissue microarrays. In daily practice, MYC evaluation is performed on entire tumor sections by a diverse group of pathologists. In our study, nine hematopathologists from two institutions scored whole-tissue sections of two sets of cases. The training set included 13 cases of diffuse large B-cell lymphoma and 4 cases of Burkitt lymphoma. The validation set included 18 cases of diffuse large B-cell lymphoma and 1 case of Burkitt lymphoma. MYC positivity was defined as ≥40% of tumor cells demonstrating nuclear staining similar to prior studies. The mean score for each case was used to determine MYC status with discrepant cases defined as having any score causing a different MYC status designation. Discrepant cases from the training set were characterized by staining heterogeneity, extensive necrosis or crush artifact and had mean scores within 15 percentage points of 40%. Cases from the validation set that demonstrated any of these features were scored twice on two different days. Overall concordance was moderate (Kappa score: 0.68, P-value<0.001) with no significant change between the two sets (Kappa scores: 0.69 vs 0.67). Thirty-nine percent of cases were discrepant. The findings indicate that a significant number of diffuse large B-cell lymphomas are inherently difficult to score due to staining heterogeneity. The effect of heterogeneity can be under-represented when concordance is measured among few pathologists scoring tissue microarrays. Careful scoring strategy in our study failed to improve concordance. In the absence of specific instructions on how to deal with heterogeneity, caution is advised when evaluating MYC expression in diffuse large B-cell lymphoma.

Geriatric emergency department innovations: preliminary data for the geriatric nurse liaison model.

Older adults account for a large and growing segment of the emergency department (ED) population. They are often admitted to the hospital for nonurgent conditions such as dementia, impaired functional status, and gait instability. The aims of this geriatric ED innovations (GEDI) project were to develop GEDI nurse liaisons by training ED nurses in geriatric assessment and care coordination skills, describe characteristics of patients that these GEDI nurse liaisons see, and measure the admission rate of these patients. Four ED nurses participated in the GEDI training program, which consisted of 82 hours of clinical rotations in geriatrics and palliative medicine, 82 hours of didactics, and a pilot phase for refinement of the GEDI consultation process. Individuals were eligible for GEDI consultation if they had an Identification of Seniors At Risk (ISAR) score greater than 2 or at ED clinician request. GEDI consultation was available Monday through Friday from 9:00 a.m. to 8:00 p.m. An extensive database was set up to collect clinical outcomes data for all older adults in the ED before and after GEDI implementation. The liaisons underwent training from January through March 2013. From April through August 2013, 408 GEDI consultations were performed in 7,213 total older adults in the ED (5.7%, 95% confidence interval (CI) = 5.2-6.2%), 2,124 of whom were eligible for GEDI consultation (19.2%, 95% CI = 17.6-20.9%); 34.6% (95% CI = 30.1-39.3%) received social work consultation, 43.9% (95% CI = 39.1-48.7) received pharmacy consultation, and more than 90% received telephone follow-up. The admission rate for GEDI patients was 44.9% (95% CI = 40.1-49.7), compared with 60.0% (95% CI = 58.8-61.2) non-GEDI. ED nurses undergoing a 3-month training program can develop geriatric-specific assessment skills. Implementation of these skills in the ED may be associated with fewer admissions of older adults.

Faculty prediction of in-training examination scores of emergency medicine residents.

BACKGROUND: The Emergency Medicine In-Training Examination (EMITE) is one of the only valid tools for medical knowledge assessment in current use by emergency medicine (EM) residencies. However, EMITE results return late in the academic year, providing little time to institute potential remediation. OBJECTIVE: The goal of this study was to determine the ability of EM faculty to accurately predict resident EMITE scores prior to results return. METHODS: We asked EM faculty at the study site to predict the 2012 EMITE scores of the 50 EM residents 2 weeks prior to results being available. The primary outcome was prediction accuracy, defined as the proportion of predictions within 6% of the actual score. The secondary outcome was prediction precision, defined as the mean deviation of predictions from the actual scores. We assessed several faculty background variables, including years of experience, educational leadership status, and clinical hours worked, for correlation with the two outcomes. RESULTS: Thirty-two of the 38 faculty (84.2%, 95% confidence interval [CI] 69.6-92.6) participated in the study, rendering a total of 1600 predictions for 50 residents. Mean resident EMITE score was 81.1% (95% CI 79.5-82.8%). Mean prediction accuracy for all faculty participants was 69% (95% CI 65.9-72.1%). Mean prediction precision was 5.2% (95% CI 4.9-5.5%). Education leadership status was the only background variable correlated with the primary and secondary outcomes (Spearman's ρ = 0.51 and -0.53, respectively). CONCLUSION: Faculty possess only moderate accuracy at predicting resident EMITE scores. We recommend a multicenter study to evaluate the generalizability of the present results.

Video self-instruction for police officers in cardiopulmonary resuscitation and automated external defibrillators.

INTRODUCTION: Police officers often serve as first responders during out-of-hospital cardiac arrests (OHCA). Current knowledge and attitudes about resuscitation techniques among police officers are unknown. Hypothesis/problem This study evaluated knowledge and attitudes about cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs) among urban police officers and quantified the effect of video self-instruction (VSI) on these outcomes. METHODS: Urban police officers were enrolled in this online, prospective, educational study conducted over one month. Demographics, prior CPR-AED experience, and baseline attitudes were queried. Subjects were randomized into two groups. Each group received a slightly different multiple-choice test of knowledge and crossed to the alternate test after the intervention, a 10-minute VSI on CPR and AEDs. Knowledge and attitudes were assessed immediately before and after the intervention. The primary attitude outcome was entering "very likely" (5-point Likert) to do chest compressions (CC) and use an AED on a stranger. The primary knowledge outcomes were identification of the correct rate of CC, depth of CC, and action in an OHCA scenario. RESULTS: A total of 1616 subjects responded with complete data (63.6% of all electronic entries). Randomization produced 819 participants in group 1, and 797 in group 2. Groups 1 and 2 did not differ significantly in any background variable. After the intervention, subjects "very likely" to do CC on a stranger increased by 17.2% (95% CI, 12.5%-21.8%) in group 1 and 21.2% (95% CI, 16.4%-25.9%) in group 2. Subjects "very likely" to use an AED on a stranger increased by 20.0% (95% CI, 15.3%-24.7%) in group 1 and 25.0% (95% CI, 20.2%-29.6%) in group 2. Knowledge of correct CC rate increased by 59.0% (95% CI, 55.0%-62.8%) in group 1 and 64.8% (95% CI, 60.8%-68.3%) in group 2. Knowledge of correct CC depth increased by 44.8% (95% CI, 40.5%-48.8%) in group 1 and 54.4% (95% CI, 50.3%-58.3%) in group 2. Knowledge of correct action in an OHCA scenario increased by 27.4% (95% CI, 23.4%-31.4%) in group 1 and 27.2% (95% CI, 23.3%-31.1%) in group 2. CONCLUSION: Video self-instruction can significantly improve attitudes toward and knowledge of CPR and AEDs among police officers. Future studies can assess the impact of VSI on actual rates of CPR and AED use during real out-of-hospital cardiac arrests.

Assessment of knowledge and attitudes regarding automated external defibrillators and cardiopulmonary resuscitation among American University students.

AIM: We sought to quantify knowledge and attitudes regarding automated external defibrillators (AEDs) and cardiopulmonary resuscitation (CPR) among university students. We also aimed to determine awareness of the location of an actual AED on campus. METHODS: We performed an online survey of undergraduate and graduate students at a mid-sized, private university that has 37 AEDs located throughout its two campuses. RESULTS: 267 students responded to the survey. Almost all respondents could identify CPR (98.5%) and an AED (88.4%) from images, but only 46.1% and 18.4%, respectively, could indicate the basic mechanism of CPR and AEDs. About a quarter (28.1%) of respondents were comfortable using an AED without assistance, compared with 65.5% when offered assistance. Of those who did not feel comfortable, 87.7% indicated that they were 'afraid of doing something wrong.' One out of 6 (17.6%) respondents knew that a student centre had an AED, and only 2% could recall its precise location within the building. Most (66.3%) respondents indicated they would look for an AED near fire extinguishers, followed by the entrance of a building (19.6%). CONCLUSIONS: This study found that most students at an American university can identify CPR and AEDs, but do not understand their basic mechanisms of action or are willing to perform CPR or use AEDs unassisted. Recent CPR/AED training and 9-1-1 assistance increases comfort. The most common fear reported was incorrect CPR or AED use. Almost all students could not recall where an AED was located in a student centre.

A novel online didactic curriculum helps improve knowledge acquisition among non-emergency medicine rotating residents.

OBJECTIVES: Rotating residents represent a significant proportion of housestaff in academic emergency departments (EDs), yet they rarely receive targeted didactic education during their emergency medicine (EM) rotations. The goals of this study were: 1) to determine the effectiveness of an online didactic curriculum in improving EM knowledge among rotating residents and 2) to assess rotating resident satisfaction with this curriculum. METHODS: The authors created an online lecture series of six EM subject areas targeted to rotating residents called the Northwestern University Rotating Resident Curriculum (NURRC). All rotating residents at the study site were eligible, written consent was obtained, and the study was approved by the institutional review board. Consenting participants were pretested with a 42-question multiple-choice examination and then randomized to two groups: one with access to the NURRC during the first 2 weeks of the rotation (experimental) and one without (control). Halfway through the rotation, all participants were post-tested with a different multiple-choice examination, and the controls were then granted NURRC access. The primary outcome was the difference between pretest and posttest scores (score delta). The t-test was used to compare mean scores, and a linear regression model was used to determine the association of NURRC access on score delta after adjustment for pretest type and resident type. A postintervention survey was administered at the end of the rotation to assess satisfaction with the NURRC and collect suggestions for improvement. RESULTS: Fifty-four rotating residents were enrolled: 29 in the experimental group and 25 in the control group. There was no significant difference in pretest scores between the two groups. Mean score delta was 17.3% in the experimental group and 1.6% in the control group, an absolute difference of 15.7% (95% confidence interval [CI]=10% to 22%). After adjustment for resident type and pretest type, the only variable positively associated with the primary outcome was NURRC access. Third-year and preliminary-year internal medicine (IM) residents demonstrated the greatest absolute improvement in score delta when granted NURRC access. Eighty percent of the participants responded to the satisfaction survey. Over 80% of the survey respondents approved of each component lecture and of the NURRC overall. CONCLUSIONS: After exposure to an online didactic curriculum, rotating residents demonstrated a significant increase in EM knowledge and reported a high level of satisfaction with the didactic program.

Effect of selected accelerants on setting time and biocompatibility of mineral trioxide aggregate (MTA).

OBJECTIVE: Various additives have been suggested to be used with mineral trioxide aggregate (MTA) to improve its handling characteristics. The purpose of this study was to evaluate the effects of various additives on setting time and cell attachment on gray MTA (GMTA). STUDY DESIGN: Single-rooted caries-free teeth were split, and dentin disks with class I cavity were made and filled with test and control materials. Setting time was measured using Gilmore apparatus. Mouse MC3T3-E1 osteoblasts and L929 mouse fibroblasts were grown on dentin and GMTA disks. Cell attachment was examined under fluorescent microscope. RESULTS: Adding KY liquid, CaCl(2), and NaOCl to GMTA improved the handling properties and decreased setting time. Osteoblasts and fibroblasts attached and spread on GMTA mixed with additives in a manner similar to GMTA mixed with water. CONCLUSIONS: The various additives could be possible substitutes to water to decrease MTA setting time. MTA is biocompatible when mixed with the various additives.

Porphyromonas gingivalis lipids inhibit osteoblastic differentiation and function.

Porphyromonas gingivalis produces unusual sphingolipids that are known to promote inflammatory reactions in gingival fibroblasts and Toll-like receptor 2 (TLR2)-dependent secretion of interleukin-6 from dendritic cells. The aim of the present study was to examine whether P. gingivalis lipids inhibit osteoblastic function. Total lipids from P. gingivalis and two fractions, phosphoglycerol dihydroceramides and phosphoethanolamine dihydroceramides, were prepared free of lipid A. Primary calvarial osteoblast cultures derived from 5- to 7-day-old CD-1 mice were used to examine the effects of P. gingivalis lipids on mineralized nodule formation, cell viability, apoptosis, cell proliferation, and gene expression. P. gingivalis lipids inhibited osteoblast differentiation and fluorescence expression of pOBCol2.3GFP in a concentration-dependent manner. However, P. gingivalis lipids did not significantly alter osteoblast proliferation, viability, or apoptosis. When administered during specific intervals of osteoblast growth, P. gingivalis total lipids demonstrated inhibitory effects on osteoblast differentiation only after the proliferation stage of culture. Reverse transcription-PCR confirmed the downregulation of osteoblast marker genes, including Runx2, ALP, OC, BSP, OPG, and DMP-1, with concurrent upregulation of RANKL, tumor necrosis factor alpha, and MMP-3 genes. P. gingivalis total lipids and lipid fractions inhibited calvarial osteoblast gene expression and function in vivo, as determined by the loss of expression of another osteoblast differentiation reporter, pOBCol3.6GFPcyan, and reduced uptake of Alizarin complexone stain. Finally, lipid inhibition of mineral nodule formation in vitro was dependent on TLR2 expression. Our results indicate that inhibition of osteoblast function and gene expression by P. gingivalis lipids represents a novel mechanism for altering alveolar bone homeostasis at periodontal disease sites.

Cytotoxicity evaluation of endosequence root repair material.

OBJECTIVE: The purpose of this study was to evaluate the cytotoxicity of EndoSequence Root Repair Material (Brasseler USA, Savannah, GA) and compare it with gray and white MTA. STUDY DESIGN: Samples of 2 mg freshly mixed or set gray MTA (GMTA), white MTA (WMTA), EndoSequence Root Repair Material (ERRM), and AH26 were eluted with 300, 600, and 1,000 microL cell culture medium for 24 and 72 hours. L929 cells were seeded into 96-well plates at 3 x 10(4) cells/well and incubated with 100 microL elute from each elute group. Cells cultured only with culture medium served as negative control. AH26 was used as positive control. After 24 hours' incubation, cell cytotoxicity was evaluated by MTT assay. Cell viability was calculated as percentage of the control group. The results were analyzed with 1-way analysis of variance. RESULTS: For both set and fresh samples, there were no significant cell viability differences among GMTA, WMTA, and ERRM. Cell viability in the AH26 group was less than in all of the other 3 materials. CONCLUSION: This study suggests that ERRM may have cell viability similar to GMTA and WMTA in both set and fresh conditions.