Faculty Bibliography

OBJECTIVE:An intra-oral remineralization study was conducted to compare the ability of a dentifrice containing 8% arginine and calcium carbonate (Pro-Argin Technology), and 1450 ppm fluoride as sodium monofluorophosphate (MFP) to remineralize acid-softened bovine enamel specimens compared to a silica-based dentifrice with 1450 ppm fluoride as MFP. METHODS:The intra-oral clinical study employed a double blind, two-treatment, crossover design, and used an upper palatal retainer to expose the enamel specimens to the oral environment during product use and periods of remineralization. The retainer was designed to house three partially demineralized bovine enamel samples. The study population was comprised of 30 adults, ages 18 to 70 years. The study consisted of two treatment phases with a washout period lasting seven (+/- three) days preceding each treatment phase. A silica-based dentifrice without fluoride was used during the washout period. The Test Dentifrice used in this study contained 8% arginine, calcium carbonate, and 1450 ppm fluoride as sodium monofluorophosphate (MFP). The Control Dentifrice was silica-based and contained 1450 ppm fluoride as MFP. The treatment period consisted of a three-day lead-in period with the assigned product. The panelists brushed two times per day during the three-day lead-in period with the assigned product. On the fourth day, the panelists began brushing with the assigned product with the retainer in their mouth. The panelists brushed for one minute, followed by a one-minute swish with the slurry and a rinse with 15 ml of water in the morning, in the afternoon, and night with the retainer in the mouth. The panelists brushed only their teeth and not the specimens directly. Changes in mineral content before and after treatment were measured using a Knoop microhardness tester. RESULTS:The results of the study showed that percent remineralization values for the Test Dentifrice and Control Dentifrice were 14.99% and 8.66%, respectively. A statistical analysis showed that the Test Dentifrice was statistically significantly more effective at remineralizing acid-softened enamel in comparison to the Control Dentifrice (p < 0.05). CONCLUSION/CONCLUSIONS:This study demonstrated that the Test Dentifrice with 8% arginine, calcium carbonate, and 1450 ppm fluoride as MFP is highly effective treatment for promoting remineralization of enamel that has been softened by an erosive challenge.

OBJECTIVES/OBJECTIVE:The objectives were to examine how emergency medicine (EM) residents learn to care for patients in the emergency department (ED) who are homeless and how providing care for patients who are homeless influences residents' education and professional development as emergency physicians. METHODS:We conducted in-depth, one-on-one interviews with EM residents from two programs. A random sample of residents stratified by training year was selected from each site. Interviews were digitally recorded and professionally transcribed. A team of researchers with diverse content-relevant expertise reviewed transcripts independently and applied codes to text segments using a grounded theory approach. The team met regularly to reconcile differences in code interpretations. Data collection and analysis occurred iteratively, and interviews continued until theoretical saturation was achieved. RESULTS:Three recurring themes emerged from 23 resident interviews. First, residents learn unique aspects of EM by caring for patients who are homeless. This learning encompasses both specific knowledge and skills (e.g., disease processes infrequently seen in other populations) and professional development as an emergency physician (e.g., the core value of service in EM). Second, residents learn how to care for patients who are homeless through experience and informal teaching rather than through a formal curriculum. Residents noted little formal curricular time dedicated to homelessness and instead learned during clinical shifts through personal experience and by observing more senior physicians. One unique method of learning was through stories of "misses," in which patients who were homeless had bad outcomes. Third, caring for patients who are homeless affects residents emotionally in complex, multifaceted ways. Emotions were dominated by feelings of frustration. This frustration was often related to feelings of futility in truly helping homeless patients, particularly for patients who were frequent visitors to the ED and who had concomitant alcohol dependence. CONCLUSIONS:Caring for ED patients who are homeless is an important part of EM residency training. Our findings suggest the need for increased formal curricular time dedicated to the unique medical and social challenges inherent in treating patients who are homeless, as well as enhanced support and resources to improve the ability of residents to care for this vulnerable population. Future research is needed to determine if such interventions improve EM resident education and, ultimately, result in improved care for ED patients who are homeless.

Among the countries in the Organization for Economic Cooperation and Development, the United States ranks first in health care spending but 25th in spending on social services. High spending on health care may result from low spending on social services. Safe housing, healthful food, and opportunities for education and employment have critical impacts on health. Lack of investment in social determinants of health probably contributes to the high spending on medical care in the United States, which is well behind other countries on basic indicators of population health. This is especially true for homelessness and housing. If homeless people can be provided supportive housing, that is, affordable housing coupled with supportive services, such as on-site case management and referrals to community-based services, health can be improved, hospital use can be reduced, and health care costs can be lowered. New York State is testing an innovation that provides investment in supportive housing for high-risk homeless and unstably housed Medicaid recipients. These recipients include people living on the streets or in shelters and thousands residing in nursing facilities because they have no homes in the community to which they can return. Supportive housing is part of a larger Medicaid Redesign effort initiated in 2011. A working group of representatives from more than 20 organizations discussed barriers to implementing supportive housing and identified solutions. The group's final recommendations included providing integrated funds for capital, operating expenses, rent subsidies, and services in new supportive housing units, targeting high-need, high-cost Medicaid recipients. The 2013-2014 Medicaid budget includes $86 million for supportive housing. Current federal Medicaid rules do not allow capital funding for supportive housing, and to date, New York has been unable to advance a request that the Centers for Medicare and Medicaid Services allow capital funding for supportive housing, so this funding has come entirely from the state budget. The costs of supportive housing are largely offset by savings in services used, mostly within the health care system. The degree of cost offsets or savings depends on how effective programs are targeting patients with high and modifiable costs. Such targeting is challenging because of the transient nature of homeless people, who often are not high-cost health care users. Targeting interventions to patients identified by predictive modeling as high risk or long-term homeless patients or those in institutional settings with consistent patterns of high use is more likely to create savings. This New York innovation will become even more relevant in 2014, when nearly all homeless people will become Medicaid eligible in states that expand eligibility. Many of these people will become part of the 5% of Medicaid recipients who account for 50% of Medicaid costs. The hope is that the New York effort will be a model for other states seeking to provide better, more cost-efficient care for Medicaid recipients who are homeless, unstably housed, or institutionalized.

Varicocele is the most common correctible cause of male infertility and is present in 15% to 20% of the male population. Despite its prevalence, the pathophysiology of varicocele remains under investigation. One of the largest obstacles in studying varicocele is that it is almost exclusively found in humans. This has necessitated the creation of an animal model of varicocele. The most commonly used animal model involves the creation of a varicocele in a rodent by partially occluding the left renal vein. This model has provided a significant amount of data on varicocele, and a modification of this model utilizing microsurgery appears even more promising. Animal models have proven critical to investigating the pathophysiology of varicocele.

Brain imaging and genetic studies over the past two decades suggest that substance use disorders are best considered chronic illnesses. The passing of the Affordable Care Act in the United States has set the occasion for integrating treatment of substance use disorders into mainstream healthcare; and for using the proactive, team-oriented Chronic Care Model (CCM). This paper systematically examines and compares whether and how well the CCM could be applied to the treatment of substance use disorders, using type 2 diabetes as a comparator. The chronic illness management approach is still new in the field of addiction and research is limited. However comparative findings suggest that most proactive, team treatment-oriented clinical management practices now used in diabetes management are applicable to the substance use disorders; capable of being implemented by primary care teams; and should offer comparable potential benefits in the treatment of substance use disorders. Such care should also improve the quality of care for many illnesses now negatively affected by unaddressed substance abuse.