K+ efflux agonists induce NLRP3 inflammasome activation independently of Ca2+ signaling.

Perturbation of intracellular ion homeostasis is a major cellular stress signal for activation of NLRP3 inflammasome signaling that results in caspase-1-mediated production of IL-1ß and pyroptosis. However, the relative contributions of decreased cytosolic K(+) concentration versus increased cytosolic Ca(2+) concentration ([Ca(2+)]) remain disputed and incompletely defined. We investigated roles for elevated cytosolic [Ca(2+)] in NLRP3 activation and downstream inflammasome signaling responses in primary murine dendritic cells and macrophages in response to two canonical NLRP3 agonists (ATP and nigericin) that facilitate primary K(+) efflux by mechanistically distinct pathways or the lysosome-destabilizing agonist Leu-Leu-O-methyl ester. The study provides three major findings relevant to this unresolved area of NLRP3 regulation. First, increased cytosolic [Ca(2+)] was neither a necessary nor sufficient signal for the NLRP3 inflammasome cascade during activation by endogenous ATP-gated P2X7 receptor channels, the exogenous bacterial ionophore nigericin, or the lysosomotropic agent Leu-Leu-O-methyl ester. Second, agonists for three Ca(2+)-mobilizing G protein-coupled receptors (formyl peptide receptor, P2Y2 purinergic receptor, and calcium-sensing receptor) expressed in murine dendritic cells were ineffective as activators of rapidly induced NLRP3 signaling when directly compared with the K(+) efflux agonists. Third, the intracellular Ca(2+) buffer, BAPTA, and the channel blocker, 2-aminoethoxydiphenyl borate, widely used reagents for disruption of Ca(2+)-dependent signaling pathways, strongly suppressed nigericin-induced NLRP3 inflammasome signaling via mechanisms dissociated from their canonical or expected effects on Ca(2+) homeostasis. The results indicate that the ability of K(+) efflux agonists to activate NLRP3 inflammasome signaling can be dissociated from changes in cytosolic [Ca(2+)] as a necessary or sufficient signal.

Learning climate in dental hygiene education: a longitudinal case study of a Japanese and Canadian programme.

Educational climates have been found to have important influences on learning, but little feedback has been obtained from dental hygiene students. The purpose of this study was to gain an understanding of the learning climate in Japanese and Canadian dental hygiene programmes for the purpose of making positive changes. A survey instrument with 10 dimensions relating to learning climate was adapted from business and dental models, and designated as the Dental Hygiene Student Learning Climate Survey (DHS-LCS). Higher scores indicated a more positive and supportive learning climate, and lower scores indicated an environment that is potentially less desirable. Students enrolled in a Japanese and a Canadian dental hygiene programme participated in this four-year study from 2005 to 2008. A total of 402 surveys were returned for an average response rate of 62%. The mean total DHS-LCS score of Canadian students was statistically significantly higher than that of Japanese students (P < 0.001) in all years tested, indicating that the Canadian students' perceptions of their learning environment were more favourable than those of the Japanese students. Based on the analyses of the DHS-LCS data, interventions to improve learning climates were designed and implemented. There were statistically significant improvements (P < 0.01) in DHS-LCS scores of Japanese and Canadian students over the years of the study, suggesting that student-centred interventions improved the perceived learning environment. The instrument appears to be helpful in identifying student concerns and can be used to implement interventions to help support a healthier learning climate.

Transcarotid repair of carotid artery pseudoaneurysm after carotid artery endarterectomy with tandem distal internal carotid artery stenosis.

Pseudoaneurysm development after carotid endarterectomy is a rare occurrence. Even rarer is pseudoaneurysm formation associated with a distal carotid artery stenosis. We report the case of stent grafting of a carotid artery pseudoaneurysm and tandem high-grade distal stenosis through a transcarotid approach with active flow reversal. No reported cases of a transcarotid artery approach to address a carotid artery aneurysm with tandem stenosis were found in the literature. We show that it may be a safe alternative to a transfemoral artery approach or open surgery.

Feasibility and usefulness of depression screening in medical outpatients.

Depression is common in medical outpatients, but the diagnosis is frequently missed. We introduced the Beck Depression Index into our clinic as a screening tool to determine the feasibility of depression screening, the prevalence of depression in our patients, and the clinical usefulness of the depression index. The questionnaire was easily implemented and well accepted by the 375 patients screened. Moderate or severe depression was identified in 32% of our patients. By several measures, the Beck Depression Index proved to be a highly useful clinical tool. It provided information significant enough to change the plan in 20% of the entire population of patients screened. The severity or presence of depression would probably have been missed without the screening. Depression screening should be considered in all primary care settings.

Liver extract-folic acid-cyanocobalamin vs placebo for chronic fatigue syndrome.

Chronic fatigue syndrome is a recently defined entity for which clinical criteria were proposed by the Centers for Disease Control, Atlanta, Ga. A frequently advocated treatment in Southern California is an injectable solution of bovine liver extract containing folic acid and cyanocobalamin (LEFAC). We conducted a double-blind, placebo-controlled, crossover trial of intramuscular LEFAC in 15 patients who met the Centers for Disease Control criteria for chronic fatigue syndrome. Although patients responded to placebo and LEFAC by several criteria of functional status, no significant difference was apparent between response to placebo and that to LEFAC. The placebo response appeared to be strong.

Efficacy of the routine admission urinalysis.

The clinical efficacy of routine admission urinalyses was evaluated in 301 patients admitted to the internal medicine wards of a university teaching hospital. Using a consensus analysis approach, three Department of Medicine faculty members reviewed the patients' charts to determine which tests were performed routinely and which test results led to diagnostic or therapeutic management changes. Of the 243 urinalyses performed, 123 (51 percent) were ordered routinely for patients without recognizable medical indications. Results of the routine urinalyses were abnormal in 42 (34 percent) of the patients and led to additional laboratory testing in 20 (16 percent) of the cases. However, the test results led to therapeutic changes in only three (2.4 percent) of the patients, and in two of these patients, the treatment instituted probably was unnecessary. It is concluded that the impact of routine admission urinalysis on patient care is very small and that there is little justification for ordering this test for all patients admitted to the hospital.

Impact of an ambulatory care clerkship on the attitudes of students from five classes (1985-1989) toward primary care.

This study was designed to evaluate the effects of a required ambulatory care clerkship during the fourth year of medical school on the students' knowledge of primary care medicine and their subsequent career choices. A questionnaire was mailed to the graduates of the Albert Einstein College of Medicine classes of 1985-1989. Fifty-six percent (408) of the questionnaires were returned. An average of 74% of the respondents answered yes to six items that asked whether the clerkship had successfully introduced them to basic concepts and practices of outpatient medicine (range from 58% to 93%, depending on the item). In addition, 90% reported that the clerkship had enhanced their understanding of primary care medicine, while 41% indicated that the rotation had wholly or partially influenced their career choices. The survey findings suggest that exposure to outpatient medicine during medical school plays an important role in facilitating students' knowledge of primary care medicine and influencing their career choices.

The primary care specialties working together: a model of success in an academic environment.

In today's environment of decreasing resources and increasing competition among clinical delivery systems, survival and ultimate success require interdisciplinary cooperation and, if possible, integration. Academic leaders at the University of California, Irvine (UCI), have developed a collaborative model in which faculty in family medicine, general internal medicine, and general pediatrics cooperate extensively in education, research, and patient care. Generalist faculty jointly administer and teach both a four-year "doctoring" curriculum for medical students and an array of integrated curricula for primary care residents, including a communication skills course. Several primary faculty jointly developed a collaborative unit for health policy and research, now an active locus for multidisciplinary research. Other faculty worked together to develop a primary care medical group that serves as a model for interdisciplinary practice at UCI. Recently, the university recruited an associate dean for primary care who leads the new UCI Primary Care Coalition, reflecting and promoting this interspecialty cooperation. This coalition does not represent a step toward a generic primary care specialty; UCI's generalist disciplines have preserved their individual identities and structures. Yet interdisciplinary collaboration has allowed primary care faculty to share educational resources, a research infrastructure, and clinical systems, thus avoiding duplicative use of valuable resources while maximizing collective negotiating abilities and mutual success.

Financial barriers to medical care: a prospective study in a university-affiliated community clinic.

Access to medical care in the United States is deteriorating, particularly for the poor. The authors evaluated patients who could not afford medical care recommended by physicians in a university-affiliated clinic that serves a predominantly indigent population. The authors determined the patients' demographic characteristics, their medical problems, and the types of care for which financial barriers existed. In addition, the authors compared the patients' demographic characteristics and medical illnesses with those of a control group of patients from the clinic who did not experience financial barriers to medical care. Of the 1,950 patients evaluated, 94 (4.8%) were unable to afford care recommended by their physicians. Sixty-seven percent were US citizens, 73% were unemployed, 63% had monthly family incomes of less than $500, and only 33% had health insurance. The patients had a variety of medical problems, ranging from hearing loss, for which they could not obtain hearing aids, to breast masses, for which they could not obtain mammographies or biopsies. When compared to patients who did not experience financial barriers to recommended care, the study patients tended to be poorer, more likely to be undocumented, more likely to be uninsured, and less likely to have acute, self-limited illnesses. Our findings support the argument that the nation's current piecemeal approach to providing indigent health care may lead to serious financial barriers to access in some localities.

Local advocacy for the medically indigent: strategies and accomplishments in one county.

Because no national health program assures entitlement to basic services, advocates must cope with barriers to access on the local level. The authors report several strategies that a community-based coalition has used to improve indigent care in one county. Research strategies have involved short-term investigations of barriers to needed services. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor. Legal strategies have involved the participation of attorneys who represent clients unable to receive care. Although such advocacy efforts do not guarantee access, they can substantially improve the availability of local services.

Porcelain and resin veneers clinically evaluated: 2-year results.

A clinical comparison of two different types of dental veneers--baked porcelain veneer and heat-and-pressure processed urethane resin veneer--was made after 2 years. Although the esthetic appearance and gingival response were equal for both systems, the resin veneers had a greater tendency to chip and fracture. By the end of 2 years, 20% of the resin veneers had failed, whereas all of the porcelain veneers remained.

Declination angle and its role in selecting surgical telescopes.

BACKGROUND: Clinicians usually expect manufacturers to provide properly adjusted surgical telescope products. However, to ensure optimal selection and adjustment, the clinician must understand certain contributing factors, particularly the optical declination angle. METHODS: The authors have developed a simple, stepwise approach for determining a clinician's optimal working posture and declination angle. This information is then applied to each specific surgical telescope to assist the clinician in ascertaining whether the telescopes comply, or can be made to comply, with the individual needs of the clinician. RESULTS: After the optimal working posture and declination angle have been identified and defined, any surgical magnification system can be evaluated for suitability and proper adjustment. CONCLUSIONS: Declination angle is a key feature in the selection and adjustment of surgical telescope systems, permitting telescopes to be adjusted to meet the clinician's needs instead of forcing the clinician to make compromises to fit the telescopes. CLINICAL IMPLICATIONS: Properly selected and well-adjusted surgical telescopes can enhance dental operating postures and positions, resulting in sound clinical ergonomics. Poor selection and adjustment can result in poor postures and positions.

Local advocacy for the medically indigent: strategies and accomplishments in one county.

Access to health care for the medically indigent has emerged as a major policy issue throughout the United States. Because no national health program assures entitlement to basic services, practitioners and patients must cope with barriers to access on the local level. The authors report several separate but integrated strategies that a community-based coalition has used to achieve improvements in indigent care within a single county. Research strategies have involved short-term investigations of barriers to needed services, so that local awareness of the problem would increase rapidly. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor, to modify the practices of local health care institutions, and to influence statewide and national policies affecting local conditions. Legal strategies have involved the participation of attorneys who represent clients unable to receive care and who could initiate litigation as appropriate. Each of these strategies contains weaknesses as well as strengths. Although such advocacy efforts do not achieve a coherent system guaranteeing access, they can substantially improve the availability of local services.

Effects of immediate introduction of indirect vision on performance and posture.

When students are taught psychomotor skills in the mandibular arch and transfer to the maxillary arch, there is a continued desire to depend upon direct vision, which results in early acquisition of poor postural habits. This study examined differences in psychomotor performance between dental students beginning with direct and indirect vision exercises. The investigation was conducted in a preclinical Performance Simulation Laboratory that allowed a high degree of accuracy in the evaluation of operator posture. No significant differences in performance were found between the groups. Within group variances indicated that there was a more uniform transition from maxillary to mandibular preparations than from the lower to upper arch preparations. Analysis of the postural data showed no significant relationship to the quality of cavity preparation, but indicated that student posture was better for the arch in which they first learned. The study was unable to substantiate the assumption that mirror management is better taught after direct vision skills are learned.

Technology meets ergonomics in the dental clinic: new toys for old games?

Although there have been considerable advances in dental equipment, the introduction of such technology has often been piecemeal and "rushed to market." As a result there has been insufficient attention paid to ergonomic considerations and a systematic approach to, and theory of, dental ergonomics have not yet emerged.

The infinity of opportunity: breaking barriers to technological change in dentistry.

This essay characterizes the nature of the technologically current dental office and identifies challenges to be overcome in accelerating the introduction of technology. These challenges include dentists' preference for serial introduction of incremental change, lack of a network for communicating information on technology, the dental market of small and independent offices that make it difficult for manufacturers to finance innovative products, and the need to integrate technological change in dental education.