The rise in health care costs has occasioned a number of initiatives in an attempt to reduce the rate of increase. Despite the growth of health maintenance organizations and preferred provider organizations and the introduction of Medicare's prospective payment system, health care costs have continued to increase. Coincident with these efforts, a number of researchers have shown that there exists wide variation in age-adjusted hospital discharge rates, which translate into significant variation in per capita expenditures. Much of the focus on the reasons for hospital admission variability has been on physician practice variation. If most of the variation in hospital discharge rates is due to physician practice style, then payment systems can be developed (e.g., capitation) that limit physician practice variation without harming patients. We examined socioeconomic factors in Michigan communities to assess their association with hospital discharge rates for patients with musculoskeletal diseases. Data on hospital discharges from 1980 and 1987 were taken from the Michigan Inpatient Data Base. All admissions from the major diagnostic category 8, diagnosis-related group (DRG) 209-256 were included. Zip code-specific hospitalization data were grouped into small geographic areas or hospital market communities (HMCs). Discharge rates were calculated, and profiles of the socioeconomic characteristics of each of the HMCs were developed. A Poisson regression model with an extrasystematic component of variance was used to analyze the association of HMC socioeconomic characteristics with age-adjusted hospital use. We found that four socioeconomic variables, average annual income per capita, percent of the population with four years of college, percent of the population living in an urban area, and percent of families with incomes below the poverty line, explained 26.6% (R2) of the variation in overall hospital discharge rates (p less than 0.001). Moreover, we found that the ability of the model to explain variability was influenced by the type of disease, and that these socioeconomic variables had a consistent effect across the range of DRGs. Finally, we noted that, over the period of 1980 to 1987, socioeconomic factors remained important in explaining hospital use despite the dramatic changes in the delivery of care over this period. Socioeconomic factors play a significant role in explaining the observed variation in hospital discharge rates for musculoskeletal diseases. Models utilizing only physician practice variation to account for the population-based differences in discharge rates are overly simplistic. In order to ensure that vulnerable subsets of the population are not harmed by the introduction of cost-containment strategies based on simplistic models, more attention must be paid to the socioeconomic and epidemiologic factors related to hospital use.

4241 Gemcitabine-based combination regimens have been utilized in the treatment of advanced disease with minimal effect on survival. VEGF and COX-2 overexpression in pancreatic tumor tissue suggest that an anti-angiogenic agent such as thalidomide and a COX-2 inhibitor such as celecoxib may improve response. Addition of celecoxib (C) to thalidomide (T) and gemcitabine (G) was therefore evaluated in a Phase I/II trial. Methods: Twelve patients with unresectable, locally-advanced or metastatic adenocarcinoma of pancreas were enrolled in Phase I/II trial of weekly G(1,000mg/m2) on days 1 and 8 every 21 days. Patients received C 400mg PO BID and T 200mg PO QHS and titrating to 300mg PO QHS if tolerated after one week. C and T were started 2 weeks prior to the first dose of G and continued throughout the treatment. To assess possible response from C and T alone, tumor markers CEA and CA19–9 were followed prior to initiation of G and throughout the course of therapy. Patients were followed closely for major toxicities including neutropenia, renal failure, gastrointestinal hemorrhage, thrombotic events, thrombocytopenia, peripheral neuropathy, somnolence, and rash. Therapy was held or discontinued if significant toxicities developed or if disease had progressed upon clinical or radiographic evaluation. Results: Twelve patients were enrolled. Mean age was 57 years (range 45 to 72) with ECOG status 0,1, or 2 at initiation. Mean number of cycles received was 2.3. Five patients were noted to have a partial biochemical response to C and T alone as evidenced by a decrease in CA19–9 levels. No radiographic responses were noted, although several patients had improvement in metastatic disease or stable disease. Mean survival of patients from time of diagnosis was 10 months. Toxicities included 3 patients with a skin rash and 1 patient with pulmonary embolism. Conclusions: The partial biochemical CA19–9 response of advanced pancreatic cancer to oral C and T alone or in combination with G in a significant fraction of patients suggests anti-tumor activity. Measureable radiographic responses from the combination of G, C and T appear to be no better than single agent G, but the regimen was well tolerated.

TPS3098 Background: Tumor-infiltrating lymphocytes (TILs) play a major role in anti-tumor immune responses, and their presence is correlated with survival in a variety of tumors. These TILs do not reach the pancreatic cancer (PC) cells in significant numbers due to the presence of stroma and a suppressive microenvironment. One of the leading causes for immune suppression is elevated expression of PD-L1 either by the tumor cells or the surrounding regulatory cells, resulting in dysfunction of TILs. There is recent evidence to suggest that CRT can increase the presence of TILs in the PC microenvironment (PCME), leading to production of interferon-γ (IFN-γ), which could increase the expression of PD-L1 through a negative feedback loop. Methods: This is a prospective multicenter randomized trial that will accrue subjects with resectable or borderline resectable PC who had not received prior treatment. The primary objectives of the study are: (1) to determine the safety of neoadjuvant CRT in combination with p...

Background: Mandibular third molars (MTMs) are the most frequently impacted teeth and a common indication for oral surgery. Anatomical root variations can complicate extractions and increase intra- and postoperative risks. Methods: This narrative review analyzes the most frequent MTM root anomalies—supernumerary roots, fusion, taurodontism, C-shaped canals, hypercementosis, and apical dilacerations—focusing on their clinical implications and the diagnostic role of cone-beam computed tomography (CBCT). Results: Root anomalies markedly influence surgical complexity. Supernumerary roots and fusions may hinder elevator use and require modified sectioning. Taurodontism and hypercementosis prolong procedures and increase incomplete extraction risk. C-shaped canals and severe apical curvatures raise the likelihood of root fracture, displacement, or nerve injury. Panoramic radiographs, though common, provide limited two-dimensional detail and may underestimate anomalies. CBCT, by contrast, offers three-dimensional visualization, enhancing diagnosis, planning, and safety. Conclusions: Knowledge of MTM root anomalies, combined with selective CBCT use, is essential for optimizing surgical strategies, minimizing complications, and improving outcomes.

Background/Objectives: This study aimed to assess the long-term clinical performance of full-arch fixed restorations made of fiber-reinforced composite (FRC) supported by four ultra-short implants (4.0 × 5.0 mm) in patients with edentulous, atrophic mandibles. Methods: Ten patients were treated at Sapienza University of Rome and monitored over a 10-year period. Each case involved the placement of four plateau-design implants with a pure conometric connection and a calcium phosphate-treated surface. The final prostheses were fabricated using CAD/CAM-milled Trinia^® fiber-reinforced composite frameworks. Clinical parameters included implant and prosthesis survival, marginal bone level (MBL), peri-implant probing depth (PPD), and patient-reported outcome measures (PROMs). Results: Implant and prosthesis survival reached 100% over the 10-year follow-up. MBL data showed a minor bone gain of approximately 0.11 mm per 5 years (p < 0.0001). PPD remained stable under 3 mm, with a minimal increase of 0.16 mm over the same period (p < 0.0001). PROMs reflected sustained high patient satisfaction. No technical complications, such as chipping or framework fracture, were observed. Conclusions: Rehabilitation of the edentulous mandible with ultra-short implants and metal-free FRC prostheses proved to be a minimally invasive and long-lasting treatment option. The 10-year follow-up confirmed excellent implant and prosthetic outcomes, favorable peri-implant tissue health, and strong patient satisfaction. Nonetheless, further studies with larger sample sizes are needed to confirm these encouraging results and strengthen the clinical evidence.