Implementation of an evidence-based management algorithm for patients with chronic pancreatitis (COMBO trial): study protocol for a stepped-wedge cluster-randomized controlled trial

Background Chronic pancreatitis (CP) is an inflammatory disease that may be complicated by abdominal pain, pancreatic dysfunction, nutritional deficiencies, and diminished bone density. Importantly, it is also associated with a substantially impaired quality of life and reduced life expectancy. This may partly be explained by suboptimal treatment, in particular the long-term management of this chronic condition, despite several national and international guidelines. Standardization of care through a structured implementation of guideline recommendations may improve the level of care and lower the complication rate of these patients. Therefore, the aim of the present study is to evaluate to what extent patient education and standardization of care, through the implementation of an evidence-based integrated management algorithm, improve quality of life and reduce pain severity in patients with CP. Methods The COMBO trial is a nationwide stepped-wedge cluster-randomized controlled trial. In a stepwise manner, 26 centers, clustered in 6 health regions, cross-over from current practice to care according to an evidence-based integrated management algorithm. During the current practice phase, study participants are recruited and followed longitudinally through questionnaires. Individual patients contribute data to both study periods. Co-primary study endpoints consist of quality of life (assessed by the PANQOLI score) and level of pain (assessed by the Izbicki questionnaire). Secondary outcomes include process measure outcomes, clinical outcomes (e.g., pancreatic function, nutritional status, bone health, interventions, medication use), utilization of healthcare resources, (in) direct costs, and the level of social participation. Standard follow-up is 35 months from the start of the trial. Discussion This is the first stepped-wedge cluster-randomized controlled trial to investigate whether an evidence-based integrated therapeutic approach improves quality of life and pain severity in patients with CP as compared with current practice

Casting Metals in Dentistry: Past - Present - Future

This article deals mainly with the development of dental casting techniques and formulation of the different groups of alloys used in the fabrication of ceramo-metal restorations. It is recognized that in order for the quality of dental cast restorations to be improved, having alloys with the proper composition is not enough. Biocompatibility, good mechanical and physical properties, longevity of the restoration, compatibility with porcelain, and a simple manipulative technique are as important. Researchers have contributed to different aspects of dental castings and have made cast restorations what they are today. Unfortunately, much of the original basic research has been overlooked by present investigators, who have duplicated studies conducted in the past without realizing that the study had already been performed and the research had been published. The main reason for this is that abstracts of articles published prior to 1975 are not available through a library computer-search system. To obtain copies of articles published prior to 1975, one has to search the literature to know where they were published. This article provides references for much of the past work in this area. Also, dental libraries do not carry copies of U.S. patents. This places the majority of researchers located at dental schools at a disadvantage. They are not familiar with what the patents claim, what is taught, and why certain elements are added or eliminated from alloys and investment materials. This article also provides the numbers of many U.S. patents. By having the patent number, one can obtain the text of the patent from the U.S. Patent Office in Washington, DC. Since esthetics plays an important role in today's society, emphasis will be given only to alloys designed for fabrication of ceramo-metal restorations. Many ceramo-metal alloys are available today, and they are classified differently by different individuals. In this article, classification will be based on the major components of these alloys, as well as on a chronological introduction of one group leading to the development of the next group. Based on this, one can classify these alloys into six major groups. Chemical composition, properties, and the developers of these alloys, along with their U.S. patents, are given. Recently, two types of all-ceramic restorations have been introduced. The main advantage of the all-ceramic restoration is its superior esthetic quality compared with that of ceramo-metal restorations. Their main disadvantages are low strength and ductility. Their strength, however, is sufficient for single-unit restorations, but not for bridgework. The use of titanium for dental restorations has also been studied, and it has been found to be suitable. Future Studies - Future work should be devoted to the following: (1) the development of stronger and more ductile ceramic materials: (2) further study of the promising palladium alloys from the noble metal group and titanium alloys from the base metal group; (3) the development of easier and less-time-consuming techniques for the fabrication of dental appliances; (4) the development of a powder technique rather than a cast technique for future fabrication methods; and (5) the development of new laboratory equipment, e.g., a single sintering oven capable of sintering both ceramic and metallic particles, which would be accepted if the powder technique is developed.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/67759/2/10.1177_08959374880020011701.pd