Placement Procedure Research Articles

Annals for Hospitalists - April 2023

Annals for Hospitalists - April 2023

770 Gastrostomy Sequence With Ventriculoperitoneal Shunting—Does it Matter?

INTRODUCTION: Patients who suffer neurologic injury that require ventriculoperitoneal shunt(VPS) placement often also require gastrostomy procedures for feeding access and nutritional support. The timing of these procedures in relation to each other has been debated in the literature, largely steaming from a proposed risk of infection and displacement resulting in a need for revision related to the presence of a gastrostomy. METHODS: In an all-payor database, patients undergoing index gastrostomy procedures and VPS placement between 1/2010-10/2020 were identified. Patients were stratified as undergoing gastrostomy placement before, on the same day as, and following the placement of a shunt. The primary outcome of the study was rates of revision All outcomes were evaluated within 30-months following index-shunting. Patients were matched based upon logistic-regression models that evaluated the independent effects of patient and procedural factors on the primary-outcome. RESULTS: A total of 4,290-patients were identified as undergoing VPS and gastrostomy procedures. Following a 1:1:1-match procedure, 852-patient records were analyzed. Patients undergoing gastrostomy and VPS on the same day or gastrostomy procedures before VPS (Odds Ratio [OR] 0.55, 95% Confidence Interval [CI] 0.33-0.91 vs. OR 0.60, 95% CI 0.36-0.97, respectively) were observed to have significantly lower rates of revision at 30-months following index shunting when compared to those patients who underwent gastrostomy placement after VPS. No significant differences were noted in rates of infection, mechanical complications, g-tube infections, or shunt displacement between the three approaches. CONCLUSIONS: Patients undergoing shunting and gastrostomy tube placement procedures may benefit from undergoing the procedures at the same time as patients undergoing these procedures at the same time are at a decreased risk of repeat requirement for anesthesia reduced rates of VPS revision following observed in comparison to patients undergoing gastrostomy placement after VPS.

New Diffusion Abnormalities Following Endovascular Treatment for Intracranial Atherosclerosis.

Background There are limited data on new ischemic brain lesions after endovascular treatment for symptomatic intracranial atherosclerotic stenosis (ICAS). Purpose To investigate the (a) characteristics of new ischemic brain lesions at diffusion-weighted MRI (new diffusion abnormalities) after endovascular treatment, (b) characteristics between those treated with balloon angioplasty and stent placement procedures, and (c) predictors of new ischemic brain lesions. Materials and Methods Patients with symptomatic ICAS in whom maximum medical therapy failed were prospectively enrolled between April 2020 and July 2021 from a national stroke center and underwent endovascular treatment. All study participants underwent thin-section diffusion-weighted MRI (voxel size, 1.4 × 1.4 × 2 mm3 with no section gap) before and after treatment. The characteristics of new ischemic brain lesions were recorded. Multivariable logistic regression analysis was performed to determine potential predictors of new ischemic brain lesions. Results A total of 119 study participants (mean age, 59 years ± 11 [SD]; 81 men; 70 treated with balloon angioplasty and 49 with stent placement) were enrolled. Of the 119 participants, 77 (65%) had new ischemic brain lesions. Five of the 119 participants (4%) had symptomatic ischemic stroke. New ischemic brain lesions were located in (61%, 72 of 119) and/or beyond (35%, 41 of 119) the territory of the treated artery. Of the 77 participants with new ischemic brain lesions, 58 (75%) had lesions located in peripheral brain areas. There was no evidence of a difference in the frequency of new ischemic brain lesions between the balloon angioplasty and stent groups (60% vs 71%, P = .20). In adjusted models, cigarette smoking (odds ratio [OR], 3.6; 95% CI: 1.3, 9.7) and more than one operative attempt (OR, 2.9; 95% CI: 1.2, 7.0) were independent predictors of new ischemic brain lesions. Conclusion New ischemic brain lesions on diffusion-weighted MRI scans were common after endovascular treatment for symptomatic intracranial atherosclerotic stenosis, and occurrence may be associated with cigarette smoking and the number of operative attempts. Clinical trial registration no. ChiCTR2100052925 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Russell in this issue.

Success of staged revision reverse total shoulder arthroplasty in eradication of periprosthetic joint infection.

Management of periprosthetic joint infection (PJI) in shoulder arthroplasty remains a challenge, with no established gold standard treatment. This study presents the unique experience of a high-volume single-surgeon, single-institution approach on staged revision reverse total shoulder arthroplasty (RTSA) for infection. The authors theorize that staged revision RTSA is an effective treatment for PJI. Between 2013 and 2018, 38 patients underwent a staged RTSA for treatment of PJI. Patient histories were collected and classified using Cierny-Mader classification. Infection workup for all patients included radiographs, laboratory indices, and computed tomographic aspiration arthrogram. PJI was identified based on high clinical and radiographic suspicion, elevated serologic markers, and/or aspirate culture results per 2018 International Consensus Meeting Shoulder guidelines on Orthopedic Infections. All patients underwent first stage with implant removal, irrigation and débridement, and antibiotic spacer placement. Next, intravenous antibiotics were administered by infectious disease consultants for a minimum of 6 weeks. Infection workup was then repeated and, if normalized, final-stage revision commenced with antibiotic spacer removal and revision to RTSA. If indices were persistently abnormal, an additional stage of débridement and spacer placement procedure was performed. Treatment failure was defined as recurrent periprosthetic infection after final prosthesis implantation or persistently elevated indices despite adequate débridement and spacer placement. Mean age of the cohort was 68(standard deviation [SD] 8.9) years and mean follow-up was 33(SD 14) months with 34 Cierny-Mader C hosts and 4 B hosts. Patients underwent a mean of 2(SD 1.1) previous surgeries. The staged revision protocol was successful in 34 (89.5%) patients for management of PJI. Four patients (10.5%) were considered failures with recurrent infections at a mean of 13 months (range 2-26 months) after the final RTSA implantation and underwent repeat staged revisions. Of the 34 patients who had successful infection eradication, 31 had 2-stage treatment and 3 had to undergo 3 stages. There were no treatment-associated mortalities and 10 major complications (26%), including permanent neuropathy, instability, and periprosthetic fractures. The most common cultured microorganism was Cutibacterium acnes (18%), with no polymicrobial infections detected. Although there are multiple treatment options for PJI management, staged revision remains an effective means of treatment. Although there were several patients who required an additional stage of treatment, and a significant complication rate, staged revision RTSA proved successful in the ultimate eradication of the PJI.

Primary placement of low-profile or ‘button’ versus traditional balloon-retention radiologically inserted gastrostomy catheters in adults: a retrospective review

ObjectiveDe novo percutaneous placement of radiologically inserted low-profile or ‘button-type’ gastrostomy catheters (LPG) is infrequently reported in adults. This study compares the safety and clinical outcomes of primary percutaneous placement...

Combination of ketamine and fentanyl (KetaFent) for safe insertion of ultrasound-guided central venous catheters in infants.

Centrally inserted central catheters (CICCs) are placed by ultrasound guided puncture of the internal jugular or brachio-cephalic vein. It is crucial to achieve a good level of sedation and analgesia in order to keep the babies still thus reducing the risk of procedural failure. The aim of this study is to evaluate the efficacy of the combination of ketamine and fentanyl during the CICC placement procedure. We retrospectively collected data from 72 infants who underwent CICC insertion after sedation with KetaFent protocol. The primary outcome was to assess the success of the procedure defined as CICC placement. Secondary outcome was intubation during the procedure in non-ventilated infants (noninvasive ventilation or spontaneous respiration), need for repeat doses of study medications to complete the procedure, time to complete the procedure, the level of analgesia assessed using vital parameters. The procedure was completed in 100% of cases. There were no cases of hypotension during and at the end of the procedure. No intubation was performed on non-ventilated infants. The combination of ketamine and fentanyl for sedation and analgesia in infants requiring insertion of a CICC is 100% successful. It is associated with a low risk of side effect like apnea and intubation. Insertion of a central venous catheter is a painful procedure for infants. Adequate sedation is mandatory to keep the baby still thus reducing the risk of procedural failure.

Maxillary sinus surgery with autologous or allogenic graft with platelet-rich plasma/fibrin for dental implants: a systematic review

Introduction: In the context of bone grafts and regenerative processes, the maxillary sinus acts in the equalization of barometric pressures in the nasal cavity, which is lined by a membrane called Schneider's membrane. When grafting procedures are needed, our focus is often on the type of biomaterial to be used, and the success and predictability of our results do not depend only on the biomaterial. Objective: It was to perform a systematic review of the main clinical approaches of maxillary sinus surgery with autologous and/or allogeneic graft, using platelet-rich plasma or fibrin. Methods: The systematic review rules of the PRISMA Platform were followed. The search was carried out from December 2022 to January 2023 in the Scopus, PubMed, Science Direct, Scielo, and Google Scholar databases, using articles from 2005 to 2022. The quality of the studies was based on the GRADE instrument and the risk of bias was analyzed according to the Cochrane instrument. Results and Conclusion: A total of 125 articles were found, 55 articles were evaluated in full and 27 were included and developed in this systematic review study. Considering the Cochrane tool for risk of bias, the overall assessment resulted in 25 studies with a high risk of bias and 20 studies that did not meet GRADE. It can be concluded from the present study that there is no statistical superiority observed between platelet-rich plasma, PerioGlas, or Bio-Oss in terms of their use as a grafting material along with the immediate implant placement procedure. Furthermore, the combination of autograft/xenograft and plasma rich in growth factors in the periosteal pocket flap technique is a simpler, cheaper, and faster technique than the guide bone regeneration technique to achieve moderate lateral bone augmentation in implant treatment. Tricalcium β-phosphate is a promising biomaterial for clinical situations that require bone augmentation. However, the addition of platelet-rich plasma results in decreased bone loss around dental implants.

Dental innovations which will influence the oral health care of baby boomers.

From the widespread use of smartphones and tablets to the multitude of applications available, older adults are showing an interest in utilizing technology to maintain their independence and to improve their quality of life. As technology continues to advance and be incorporated into many day-to-day activities, the baby boom generation will see these changes affecting the way they access and utilize dental services. Innovative toothbrushes and chemotherapeutics are continuing to be developed and utilized by many older adults. Within the dental office, older adults are seeing greater application of technology in every day dental procedures. These include the use of teledentistry, artificial intelligence (AI), innovative restorative materials, digitization of fixed and removable prosthodontics, cone beam computed tomography (CBCT) scans to guide dental implant placement and endodontic procedures. There is also new technology to aid in cancer detection and shielding during cancer treatment. Improved communication between the medical and dental fields has become increasingly necessary to facilitate effective patient care and a few innovative healthcare systems have begun to consolidate these services. Overall, the baby boom generation will continue to see dental innovations that will change the way they experience everyday life and dental services.

Imaging-Guided De Novo Retrograde Ureteral Access and Stent Placement without Cystoscopy in Women

PurposeTo evaluate the feasibility of a new technique for imaging-guided de novo retrograde ureteral double J (DJ) stent placement without cystoscopy in women. Materials and MethodsEighty-four women referred for ureteral stent placement between April 2019 and January 2022 were included. In all the patients, the initial attempt for stent placement was performed in a retrograde fashion. Successful ureteral catheterization and DJ stent placement were considered as technical success. The fluoroscopy time required to catheterize the ureter and that for the entire procedure were recorded. Factors affecting the technical success rate and fluoroscopy time were examined. ResultsA total of 108 ureteral stent placement procedures in 84 women, with a mean age of 57.5 years (range, 19–85 years), were performed. The most common underlying pathologies were cervical (n = 33, 31%) and ovarian (n = 32, 30%) carcinomas. The most commonly involved segments of the ureter were the lower half (n = 44, 40%) and trigone (n = 39, 36%). The technical success rate was 81.5%, and it reached 93% in the case of lower-half ureteral obstruction. Distorted trigonal anatomy caused by external compression of the bladder wall by a mass was associated with a higher rate of technical failure (90.6% vs 47.8%; P < .001). The use of ultrasound guidance to guide the sheath to the ureteral orifice allowed for a significant decrease in the fluoroscopy time for ureteral catheterization (4.6 minutes ± 3.91 vs 2.26 minutes ± 2.32; P = .003) and that for the entire procedure (9.42 minutes ± 4.95 vs 5.93 minutes ± 4.06; P = .001). ConclusionsImaging-guided de novo retrograde ureteral catheterization and stent placement can be successfully performed in a high percentage of patients within a reasonable fluoroscopy time without the need for cystoscopy in women.

Improve the Completion Rate of ECMO Placement Assistance for Nurses in the NICU

The extracorporeal membrane oxygenation (ECMO) system can provide cardiopulmonary support to and reduce the mortality rate in severely ill newborns. According to our investigation, completion rate of the care process among staff nurses was only 63.5% in our ward. We assumed that the reasons for the above problems included: lack of care awareness, unfamiliarity with the ECMO operation process, inadequate instruments preparation, improper ECMO pipeline fixation, lack of designated space in the unit for placing ECMO supplies, lack of specialty care guidelines, lack of a regular inspection system, and lack of regular on-the-job education. Improve awareness related to assisting ECMO placement among nurses in the neonatal intensive care unit and the completeness of care. 1. Create a care process guidebook describing the procedures for ECMO system placement in newborns to help nurse accomplish proper placement. 2. Establish the ECMO system consumables checklist and install an ECMO system-specialized toolbox to reduce the preparation time and smooth the process. 3. Regularly organize comprehensive nurse training and develop performance indicators to enhance ECMO system placement awareness and skills. The cognitive accuracy rate for the assisted placement of ECMO among nurses in the neonatal intensive care unit increased from 51.9% before improvement to 89.9% afterward. Also, the complete care rate of ECMO placement increased from 63.5% before improvement to 100% afterward. This project effectively improved the accuracy rate of nurses involved in assisting with ECMO placement, made the ECMO system placement process easier to implement, improved the care process completion rate, and improved newborn care quality.

Impact of triglyceride-rich lipoproteins on early in-stent neoatherosclerosis formation in patients undergoing statin treatment

Neoatherosclerosis (NA), which refers to neointimal atherosclerosis within a stent, is considered one of the underlying causes of late-phase stent failure following a newer generation drug-eluting stent (DES) placement procedure. Even contemporary guideline-directed medical therapy may be insufficient to prevent NA. This study aimed to investigate how intricately lipid markers are associated with NA formation in the early phase of treatment with well-maintained low-density lipoprotein cholesterol (LDL-C) levels. We enrolled 114 consecutive patients undergoing statin treatment and percutaneous coronary intervention (PCI) with current-generation DES for coronary artery disease. At a median 12 months after PCI, optical coherence tomography (OCT) was performed. Various lipid markers, including LDL-C, triglyceride (TG), triglyceride-rich lipoprotein cholesterol (TRL-C), non-high-density lipoprotein cholesterol (non-HDL-C), malondialdehyde-modified LDL (MDA-LDL), and several apolipoproteins, were also evaluated. NA was observed in 17 (14.9%) patients. The LDL-C level was equivalent in patients with or without NA (77.2 vs. 69.8 mg/dL; p=0.15). However, the levels of TG, apolipoprotein C3 (apoC3), TRL-C, non-HDL-C, and apolipoprotein B (apoB), and MDA-LDL were significantly higher in the patients with NA. Furthermore, multivariate logistic regression adjusting for HbA1c and stent duration revealed apoC3, TRL-C, non-HDL-C, apoB, and MDA-LDL levels as risk factors for NA. However, when apoB was included as a covariate, other factors became nonsignificant. Abnormal triglyceride-rich lipoprotein metabolism and high atherogenic apoB-containing lipoprotein particle numbers are associated with the formation of NA in patients undergoing statin treatment at a median 12 months post-PCI.

Parents’ reactions to their child’s placement in special-education kindergartens: a grounded theory study in Israel

ABSTRACT The aim of this grounded theory study was to understand parents’ emotions and coping strategies regarding their child’s initial placement in an Israeli special education kindergarten. Proper placement is essential to effectively support children with developmental disabilities (DD), yet parents tend to approach assessment procedures with dread. Semi-structured in-depth interviews were held with 60 parents of children with DD (ages 4-6) who underwent placement procedures in the previous two years. Qualitative content analysis revealed three themes: external emotions of worry about the future, shame, fear of stigma, and trust issues towards professional staff; internal coping strategies of rationalisation and denial; external coping strategies of concealment and search for help. Findings revealed parents’ emotions were directed towards their surroundings, whilst coping strategies were directed both inwards and outwards. Therefore, the majority of the parents’ emotions and coping strategies focused on external social aspects. This in-depth understanding of parents’ reactions to the placement process may help educational staff focus their support on external attributes, thereby strengthening the staff-parent partnership and easing the entry process of children with DD into special education kindergartens.

Cost-Efficient Virtual Network Function Placement in an Industrial Edge System: A Proposed Method

Edge computing has been a promising framework to provide effective computing services for edge users in most industrial environments. Due to the limited resources at the edge, it is not suitable for massive requirements such as the virtual reality process, communication, and so on. Cloud computing can provide sufficient resources for those requirements, but it has some latency lags. Industrial edge clouds enable flexible service providers for industrial applications by merging edge and cloud computing. The virtual network function (VNF) is one approach, while placement is a dominant solution. However, this solution may increase the cost of communication as the nodes are more distant. In this article, we investigate the resource allocation problem for VNF placement in industrial edge systems. The aim is to minimize the overall cost of the whole placement procedure, including operating cost, communication cost, and placement cost. We formulate this VNF placement problem as an integer programming problem, and due to the complexity of the problem, we propose a heuristic method to solve it. Numerical simulation shows that our proposed method can significantly cut down the cost while meeting the multiple resource constraints.

How do Specialists Address Contraceptive Care Compared to General Practitioners in a Federally Qualified Health Center in Maryland.

To determine associations between primary provider specialty and the contraceptive care that patients receive in a Federally Qualified Health Center setting in Maryland. A study of reproductive-age patients and their providers was performed from January 2018 to December 2021. A pooled crosssectional survey of electronic medical record data for 44 127 encounters of 22 828 patients was performed to calculate the odds of contraceptive care being addressed by patients who had General Practitioner, OB/GYN, pediatrician, or infectious disease (ID) specialists as their primary providers. In 19 041 encounters (43%), contraception was addressed through either counseling alone, documentation of a contraceptive prescription, or long-acting reversible contraceptive (LARC) placement procedure. After adjusting for insurance status and race/ethnicity, the odds ratio (OR) of contraceptive care delivery was statistically significantly higher for OB/GYN providers compared to General Practitioners-OR 2.42 (CI 2.29-2.53) and statistically significantly lower for ID providers-OR 0.69 (CI 0.61-0.79). There was a non-statistically significant difference for Pediatricians-OR 0.88 (CI 0.77-1.01). The provision of contraceptive care, a critical aspect of comprehensive primary care delivered in an FQHC setting, varies by provider specialty, and may be negatively influenced by Ryan White funding related structures. There is a need to intentionally design robust referral and tracking systems to ensure contraceptive care is equitably accessible to all, regardless of assigned primary care provider specialty or HIV status.

Complication Management in Periodontal Ligament-Mediated Implant Placement with Total Extraction of the Root: A Case Report with 4 Years Follow-up

An increasing number of studies report on periodontal ligament-mediated implant placement procedures to mitigate the biological sequel of total tooth extraction in the esthetic zone. Longitudinal results of these techniques show promising results for ridge dimensional stability achieved by partial extraction of the root followed by immediate implant placement. Nonetheless, because of the recency of these techniques, there is a dearth of clinical documentation of related complications and protocols for their management. In this case report, we present the management of a complication in an implant in the aesthetic zone utilizing the “root-membrane” technique with a four-year followup. Total extraction of the root membrane and guided bone regeneration resolved the dental-related complication

Dynamic Navigation: A Novel Tool for Dental Implant Surgery

Dynamic navigation is an advanced technology that has revolutionized dental implant surgeries. Before being used in implant dentistry, navigation technique has been practiced in neurosurgery for performing minimally invasive brain surgeries. Navigation surgery for implant placement can be broadly categorized as dynamic and static navigation. The static navigation uses a static surgical guide for the sequential drilling of the osteotomy site and the implant placement. The static navigation can either be fully guided or partial/half-guided. Dynamic navigation is a computer-assisted implant placement technique that uses real-time imaging to guide the implant placement procedure. In dynamic navigation, three-dimensional (3D) software monitors and tracks the bone drilling and implant placement in real-time during the entire procedure. This technique involves prosthetically driven virtual implant placement planning with Cone Beam Computed Tomography (CBCT) before the implant surgery. The 3D image of the patient is analyzed in a CBCT scan. This image is then used to plan the placement of the implant and create a surgical guide. A resin guided template is 3D printed or milled which is used during the surgery. The CBCT scan images are transferred into a 3D virtual image using digital software, which allows 3D viewing of the structures using Computer Aided Design (CAD). A calibrated special navigation instrument with specific software guides the bone drilling sequence and the implant placement. The drilling procedure is completely tracked and the patient’s anatomy and the surgical procedures in real time is shown in a 3D software. The use of real-time imaging and computer-aided technology ensures that the implant is placed precisely in the desired location, reducing the risks associated with conventional implant placement. Dynamic navigation is an effective and precise method that allows for more accurate placement of dental implants, which reduces the chance of damaging anatomical structures. It also gives clinicians the possibility to modify the planned surgical approach during the surgery. Additionally, because the implant is placed more accurately, there is less risk of implant failure. However, a learning curve and a training period are required before one masters this novel technology. Dynamic navigation can potentially become a preferred method for dental implant placement in the near future.

Bone height and width evaluation before dental implant placement on panoramic radiographs: a scoping review

Objectives: The aim of this study is to evaluate the bone height and its width on panoramic radiography prior to dental implant placement.&#x0D; Review: This study was carried out using scoping review methods. The referenced articles were published between 2010-2021 in English or Indonesian. The search was performed using PubMed and PMC database with keywords “(((Evaluation) AND (Presurgical)) AND (Dental Implant)) AND (Radiograph)) AND (Panoramic)” and Science Direct with keywords "presurgical evaluation dental implant in panoramic radiograph". Preferred Reporting Items for Systematic Review and Meta-analysis Scoping Review (PRISMA-Scr) was utilized to perform the article finding process. It is found that the height of alveolar bone after being assessed by panoramic radiograph is between 7.95-23.42 mm while the alveolar bone width is between 7.04-10.41 mm.&#x0D; Conclusion: Panoramic radiograph can be performed to evaluate bone height and width before the dental implant placement procedure.

Facial implant gingival level and thickness changes following maxillary anterior immediate tooth replacement with scarf-connective tissue graft: A 4-13-year retrospective study.

A scarf-shaped connective tissue graft can be placed at the facial and proximal aspect of the peri-implant soft tissue zone during immediate implant placement and provisionalization (IIPP) procedures in the esthetic zone to optimize implant esthetics without the need of flap reflection. This retrospective study evaluated soft tissue stability after scarf-connective tissue graft (S-CTG) in conjunction with IIPP procedures in the esthetic zone. Patients who received IIPP with S-CTG with a minimum 1-year follow-up were evaluated. Mid-facial gingival level (MFGL) change and mid-facial gingival thickness (MFGT) change were measured and compared at the pre-op (T0), IIPP + S-CTG surgery (T1), follow up appointment with MFGT measurement (T2), and latest follow-up appointment (T3). Implant success rate and graft necrosis were also recorded. A total of 22 IIPP and S-CTG procedures in 20 patients were evaluated in the study. After a mean follow-up of 8.2 years (3.9-13.4) (T3), all implants remained osseointegrated (22/22 [100%]), with statistically insignificant mean midfacial gingival level change of -0.19 mm (-1.5 to 0.8). Statistically significant difference in midfacial gingival thickness (MFGT) was noted (2.5 mm [1.8-3.5 mm]) after a mean follow-up time (T2) of 2.3 years (1-8.6) when compared with MFGT at baseline (1.1 mm [0.6-1.3 mm]) (T1). Necrosis of S-CTG during initial healing phase was noted in 9% (2/22) of the sites. Within the confines of this study, scarf-connective tissue graft at time of immediate implant placement and provisionalization can thicken the gingiva and maintain the gingival level at the critical soft tissue zone. Managing the soft tissue zone is as important as that of the hard tissue zone for peri-implant esthetics. Connective tissue graft is one of the methods that can enhance the final esthetic outcomes. This retrospective study has demonstrated that Scarf-CTG technique is an effective treatment modality to maintain soft tissue stability.

The Role of G-tube Placement for Neurologic Injury Patients

Neurologic injury often influences various bodily functions associated with digestion. It is imperative for an individual to obtain proper nutrients to maintain a healthy lifestyle and recover from injury. In this review, we explore variables and methods of enteral tube placement in neurologic injury patients influencing recovery, specifically G- and J-tubes. We will first review the patient population by identifying leading causes for enteral tube placement among both pediatric and adult neurologic patients. We will then discuss the general procedures for placement and safety considerations for specified patient populations. We will explore interventions limiting placement of the G- and J-tubes by focusing on two interventions: ventriculoperitoneal shunt (VPS) and intrathecal baclofen (ITB). Then, we will highlight nutritional enhancers that may influence general treatment. Finally, we discuss proper weaning procedures and eJective methods fitting patient needs.

A Comparative Clinical Evaluation of Effectiveness of Platelet-Rich Plasma, Synthetic Allograft, and Bioresorbable Xenograft During Immediate Implant Placement.

The use of an appropriate graft material helps in an adequate amount of osseointegration. The objective of this study was to compare the efficacy of platelet-rich plasma (PRP), a synthetic allograft (PerioGlas), and Bio-Oss, a bioresorbable xenograft in immediate implant procedures. In this randomized, prospective study, 90 patients were categorized into three groups with 30 samples in each asGroup A:patients who received PRP with an immediate implant; Group B: immediate implants with synthetic allograft (PerioGlas); and Group C: patients with immediate implants placed using bioresorbable xenograft (Bio-Oss). Postoperative follow-up was done based on plaque and gingival index, measurement of probing depths, and resorption of bone. Obtained data were statistically analyzed using the "one-way analysis of variance (ANOVA)" test. Inter-group statistical comparisons between gingival and plaque indices at three, six, and 12 months of follow-up in the study groups demonstrated no statistical significance (p > 0.05). The mean probing depths and resorption of bone at three, six, and 12 months of follow-up were statistically nonsignificant (p > 0.05) on the inter-group comparison. It could be concluded from the present study that there is no statistical superiority observed among PRP, PerioGlas, or Bio-Oss in terms of their usage as a graft material along with immediate implant placement procedure.