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.

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.

Surgical magnification in dental hygiene practice.

The potential for improving the occupational health of dental clinicians has expanded as increasingly sophisticated equipment enters the marketplace, yet there has been little improvement to the ergonomics with which dental hygienists operate. The use of surgical magnification has great potential to increase the quality of dental hygiene clinical care and to support the musculoskeletal health of dental hygienists. Although the research evidence to support a relationship between the use of surgical magnification and increased quality of dental hygiene care is extrapolated from parallel studies in dentistry, specific dental hygiene studies suggest that the integration of surgical magnification would be helpful in reducing the incidence of musculoskeletal symptoms experienced by dental hygienists. This is not to suggest that the integration of surgical magnification is a panacea for the musculoskeletal problems experienced by dental hygienists. In fact, improperly selected or adjusted surgical magnification systems can promote positions that place clinicians at increased risk for such problems. Clinicians must first determine the optimal working position that supports their musculoskeletal health and then select magnification systems that will support that position. The working distance, depth of field and optical declination angle of the chosen system must correspond to the musculoskeletal needs of the clinician.

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.

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.

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.

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.

A comparison of the methods and criteria used by traditional and primary care internal medicine programs to select residents.

OBJECTIVE: To determine whether there are differences in the methods and criteria used by primary care and traditional internal medicine programs to select first-year residents. DESIGN: A questionnaire was sent to primary care and traditional internal medicine program directors, who were asked to rank in importance ten documents of an applicant's file and to score the relative importance, on a scale of -5 to +5, of 21 candidate traits of four types: academic, demographic, personal, and career goal. SETTING: Programs at institutions (n = 54) that have categorical residency programs in both traditional and primary care internal medicine. PARTICIPANTS: Of 108 questionnaires, the overall response rate was 81%, with 40 pairs (74%) of matched respondents. Seventy-two percent of the responding institutions were university-administered. RESULTS: Primary care and traditional programs use similar methods to process applicants, rank similarly ten documents in an applicant's file, and value academic success during the clinical years as the most important candidate trait. Compared with traditional tracks, primary care tracks place greater emphasis on a candidate's career goals and select for candidates planning to pursue primary care careers (3.9 +/- 1.4 vs 0.9 +/- 1.5, p < 0.001), enter practice (1.4 +/- 1.5 vs 0.1 +/- 1.2, p < 0.001), or serve medically indigent populations (2.7 +/- 1.5 vs 1.2 +/- 1.2, p < 0.001). Primary care programs rate negatively candidates who intend to subspecialize, whereas traditional programs view them almost neutrally (-1.8 +/- 2.2 vs 0.5 +/- 1.5, p < 0.001). CONCLUSION: Primary care and traditional track internal medicine programs use similar methods to select residents and both rank academic achievement during the clinical years as a candidate's most important attribute. However, only primary care programs strongly select for candidates on the basis of their career plans and in particular prefer candidates who are committed to pursuing primary care careers and serving the medically indigent.

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.

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.

Palpation as a method for evaluating occlusal discrepancies.

In this study, 30 dentists were surveyed about their methods of palpating teeth for the evaluation of premature contacts. Thirty-eight dentists were then tested to determine their ability to discriminate degrees of prematurity using each of two different methods of palpation. The degree of digital pressure used by each dentist during palpation was also measured. The majority of dentists chose the same method for palpation: a single forefinger overlaying the facial surfaces of the central incisors being evaluated. In the discrimination test, the majority of dentists were able to identify reliably occlusal interference of greater than or equal to 50 microns regardless of the palpation method used.

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.

Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics.

OBJECTIVE: To determine the prevalence of domestic violence among patients seen in three university-affiliated ambulatory care internal medicine clinics and to assess the personal characteristics of those patients affected by domestic violence. DESIGN: Survey using a self-administered, anonymous questionnaire. SETTING: Three university-affiliated internal medicine clinics at the University of California Irvine Medical Center. PARTICIPANTS: We asked all patients on randomly selected days during the three-month study to participate. 453 (72%) of the 629 eligible English- and Spanish-speaking patients completed the questionnaire. MEASUREMENTS AND MAIN RESULTS: 28% of participants had experienced domestic violence at some time in their lives, and 14% were currently experiencing domestic violence. Logistic regression analysis showed that female gender, unmarried status, and poverty were important predictors of domestic violence. However, domestic violence occurred in all groups regardless of sex, ethnicity, age, or socioeconomic status. CONCLUSIONS: The study found an unexpectedly high prevalence of domestic violence in the three internal medicine clinics. Physicians should ask their patients routinely about domestic violence and, when domestic violence is present, should offer emotional support, information about social service agencies, and psychological care.