Successful splint therapy for embouchure dystonia in a trumpet player.

This clinical report describes a straightforward oral device technique that successfully allowed a patient with embouchure dystonia to regain his ability to play the trumpet.

Scrupulous Monitoring of Physician-Assisted Dying: The Case for Mandatory Reporting to Coroners and Medical Examiners of All Physician-Assisted Deaths in Canada.

Although the practice of physician-assisted dying (hereinafter "PAD") will soon be lawful in Canada, opponents of PAD claim that it might result in involuntary deaths. The Supreme Court of Canada in Carter v. Canada (Attorney General) rejected such arguments holding that involuntary deaths are preventable provided that jurisdictions devise stringent limits to the practice of PAD and that these stringent limits are "scrupulously monitored and enforced". This article examines the question of how best to engage in scrupulous monitoring of physician-assisted dying. At present, the province of Quebec has legislated, and three expert groups have proposed the creation of new administrative offices to monitor the practice of PAD (these groups are the Provincial-Territorial Expert Advisory Group on Physician-Assisted Dying, the External Panel on Options for a Legislative Response to Carter v. Canada, and the Canadian Medical Association). This article argues that scrupulous monitoring can be better achieved by requiring explicit mandatory notification of all physician-assisted deaths to coroners and medical examiners, rather than by creating new administrative offices. It is more effective, efficient and prudent to use already existing coroner and medical examiner death reporting and investigative frameworks to report physician-assisted deaths than to create new, untried, parallel and potentially more expensive administrative offices. In Canada, almost all provincial and territorial statutes that govern the official actions of coroners and medical examiners currently require the reporting of non-natural deaths, which include those that will be attributable to PAD. To achieve the scrupulous monitoring of PAD required by the Supreme Court, provincial and territorial governments, in collaboration with the federal government, should. 1. review their coroner and fatality statutes to clarify that physician-assisted deaths (as non-natural deaths) are mandatorily notifiable; 2. encourage forensic pathologists to collaborate on a national basis to agree upon uniform methods of death reporting and monitoring of PAD; and. 3. mandate that coroner and medical examiners offices should be adequately funded and staffed for the new task (which is likely to increase only marginally the caseload in accurate death reporting and monitoring). Such actions will ensure the continued achievement of the legislative goals for coroner and medical examiner offices: to report deaths accurately and to investigate and monitor death for the purposes of protection, prosecution, prevention, health promotion and health planning. By ensuring that PAD is reportable to the statutorily created offices that are expert in accurate death reporting, the public may be better assured that the new practice of PAD is used only to relieve suffering as permitted by law.

Development of real-time PCR assays for the specific detection of Francisella tularensis ssp. tularensis, holarctica and mediaasiatica.

Real-time polymerase chain reaction (PCR) assays were developed to detect Francisella tularensis (Ft), the causative agent of tularaemia in humans. Two real-time PCRs (FTT0376 and FTT0523) were designed in genetic sequences identified by the Insignia genome comparison tool (http://insignia.cbcb.umd.edu/) as being unique to pathogenic subspecies of F. tularensis. Both PCRs identified all pathogenic F. tularensis subspecies but did not cross react with avirulent Francisella philomiragia or F. tularensis ssp. novicida or other environmental bacteria. Limits of detection from DNA purified from pure culture (FTT0376 approximately 80 Ft genome equivalents (GEs) per PCR; FTT0523 approximately 20 Ft GEs per PCR;) and DNA purified from spiked blood samples (4 x 10(4) to 4 x 10(3) cfu ml(-1), both assays) were determined.

Responding to aggression in long term care: lessons from five case studies.

Violence by patients against staff has been a growing concern in hospitals not only in the U.S., but in Canada and the U.K. as well. Such violence is not limited to hospitals, but is on the increase in long term care facilities, thanks, in part, to a growing population of patients with dementia. Very little information about programs that deal with patient violence in long term care facilities has been available. The following article, which describes a multi-year project in five British Columbia nursing homes, provides considerable insight for health care managers on the many different aspects of long term care violence and methods which staff can employ to curb or prevent it.

The MacDQoL individualized measure of the impact of macular degeneration on quality of life: reliability and responsiveness.

PURPOSE: To investigate the MacDQoL test-retest reliability and sensitivity to change in vision over a period of one year in a sample of patients with age-related macular degeneration (AMD). DESIGN: A prospective, observational study. METHOD: Patients with AMD from an ophthalmologist's list (n = 135) completed the MacDQoL questionnaire by telephone interview and underwent a vision assessment on two occasions, one year apart. RESULTS: Among participants whose vision was stable over one year (n = 87), MacDQoL scores at baseline and follow-up were highly correlated (r = 0.95; P < .0001). Twelve of the 22 scale items had intraclass correlations of >.80; only two were correlated <.7. There was no difference between baseline and follow-up scores (P = .85), indicating excellent test-retest reliability. Poorer quality of life (QoL) at follow-up, measured by the MacDQoL present QoL overview item, was associated with deterioration in both the better eye and binocular distance visual acuity [VA] (r = 0.29; P = .001, r = 0.21; P = .016, respectively; n = 135). There was a positive correlation between deterioration in the MacDQoL average weighted impact score and deterioration in both binocular near VA and reading speed (r = 0.20; P = .019, r = 0.18; P = .041, respectively; n = 135). CONCLUSION: The MacDQoL has excellent test-retest reliability. Its sensitivity to change in vision status was demonstrated in correlational analyses. The measure indicates that the negative impact of AMD on QoL increases with increasing severity of visual impairment.

Promoting a cultural shift and a system change to respond to agitated and excessive behaviours (REAB).

The Responding to Excessive & Agitated Behaviour (REAB) Program was designedas a system change model to create a healthy work culture and to promote quality, client-centered care. It is a unique program that has integrated best clinical practices with workplace safety policy and criteria promoting continuous assessment ofa facility's ability to meet the requirements of the REAB model. Funding was received from the BC Nursing Directorate. Key clinical and work health leaders in a large BC health authority were supportive of this initiative. Phase I began in 2004 with a review of the literature and environmental scans leading to the development of the REAB model. The model contains ten elements which if addressed promotes the best in clinical practice and working conditions. In Phase II benchmarking data were collected and the REAB process was trialed in fifteen facilities. The findings and the model were validated by a variety of representatives from practice and industry in a one day forum. Phase III was the development of a resource toolkit to guide the implementation process and contained supportive resources. Phase IV, now in progress, consists ofan orientation to the toolkit and access to a facilitator who assists agencies in identifying their own gaps in relation to the model, as wellas guides the implementation of a viable and sustainable plan for improvement. This paper reviews the evolution and the development of this project so that others may incorporate its methodology and resources into their own facility.

Strategies to Avoid Underdiagnosing Pit-and-Fissure Caries.

Traditionally, testing for whether pit-and-fissure caries should be restored involved probing with a sharp explorer and evaluating resistance to withdrawal (ie, "stick"). Alternative visual methods of evaluation and classification have been proposed, validated, and accepted formally in the core curriculum on caries management in both Europe and North America. This article examines the resistance to occlusal breakdown of fluoridehardened enamel despite progression of underlying dentin caries with accompanying difficulty in diagnosis. Traditional methods of pit-and-fissure caries diagnosis, including radiographs or fissure probing with an explorer, have been shown to be inaccurate and potentially destructive. The clinical process of using the visual/tactile International Caries Detection and Assessment System (ICDAS) and/or the Caries Classification System (CCS) is described and illustrated through case examples.

Quality of life and health economic assessments of age-related macular degeneration.

In this article, we review measures of patient-reported outcomes that can show whether a treatment for age-related macular degeneration also provides patient-perceived benefits. In addition, we look at health economic measurements currently being used to develop cost-effectiveness models for age-related macular degeneration.

Dental Anatomy and Occlusion: Mandibular Incisors-Flipped Classroom Learning Module.

INTRODUCTION: This dental anatomy module is the second in a series that develops skills in analyzing the morphology, function, anomalies, and development of human teeth. Learning the visual details associated with teeth has often proven difficult using the lecture format; thus, we have utilized computer-assisted flipped learning, which has been shown to be just as effective as lectures and frees up class time for active learning. METHODS: In a flipped classroom approach, students learn basic knowledge with a self-paced, interactive tutorial prior to class. In class, students are assigned to small groups and start with a readiness assessment quiz, administered first individually and then to each team. This is followed by a review for the whole class. The teams then practice critical thinking through practical application scenarios; a laboratory exercise follows where students wax tooth #25 and tooth #26. RESULTS: Students rated faculty members who used team-based learning higher than those who used lecture format for similar morphology lectures. For the first 3 years that this flipped classroom technique was used, students consistently scored it higher than the lecture format on a 5-point Likert scale. Multiple positive comments indicated their preference for this method. DISCUSSION: Teaching students to see the subtle variations in tooth morphology takes time and attention. In a lecture, each key point is covered only once, and images appear fleetingly. A key advantage of the self-paced interactive tutorial coupled with flipped classroom activities is that each learner can take the time needed with each image in a tutorial.

Design and development of the MacTSQ measure of satisfaction with treatment for macular conditions used within the IVAN trial.

BACKGROUND: The purpose of the study was to design a measure of patient satisfaction with treatment for macular disease, the MacTSQ, and to carry out psychometric evaluation of the measure. The measure was designed along the lines of the widely used Diabetes Treatment Satisfaction Questionnaire (DTSQ) and sister measures of treatment satisfaction for other conditions including diabetic retinopathy. Information was also gathered during in-depth interviews with 20 people who had experienced one of a range of treatments for macular degeneration. In a prospective study, the newly designed 16-item MacTSQ, was used in a multi-centre, randomised, double-blind clinical trial (the IVAN study) comparing two treatments for neovascular age-related macular degeneration and two treatment schedules: 1. continual monthly treatments (continuous arm), 2. initial 3 monthly treatments then monitoring and retreatment if necessary (discontinuous arm). The MacTSQ was administered after the first three treatments and at 12 and 24 months. Psychometric development was carried out using data from 137 patients. Sensitivity and validity of the MacTSQ were investigated using baseline and 12-month data. RESULTS: Exploratory factor analysis yielded two subscales i) convenience, information and overall satisfaction (6 Items: Cronbach's alpha = 0.740), and ii) safety, efficacy and discomfort (6 Items: alpha = 0.776). Twelve items also loaded on to a single scale (alpha = 0.815). Three items were removed from the scale but retained in the questionnaire for separate analysis where required. Greater satisfaction was reported at time 2 (12 months) than time 1 (after 3 monthly injections) on the safety, efficacy and discomfort subscale (W = 3000.500. p = 0.024, n = 108). Participants whose vision improved reported greater satisfaction than those who had no improvement e.g. U = 1599, p = 0.033. Those in the discontinuous arm reported greater satisfaction on subscale 1 than those in the continuous arm at time one (U = 1870, p = 0.04) and time 2 (U = 1132.5, p = 0.023). This finding suggested a better experience in the discontinuous arm. CONCLUSIONS: The MacTSQ will be valuable in investigating treatment satisfaction in clinical trials of new treatments or in a routine clinic situation and may highlight ways to improve patients' experience of treatment.

Caries Management with the International Caries Detection and Assessment System II: Established Pit and Fissure Lesions.

INTRODUCTION: Operative dentistry addresses the surgical management of caries, a significant portion of dental practice. Dental students, who typically develop their skill sets in this important discipline by creating idealized preparations in plastic teeth, are often confused by the wide variety of tooth anatomy and caries presentation they see when they subsequently treat patients. To address this significant clinical transition issue, we developed this resource on preparing the moderate carious lesion using a stepwise, structured technique. METHODS: This resource consists of a flipped-classroom learning module and associated laboratory activity with an algorithm worksheet to practice critical thinking skills. Prior to the exercise, an interactive tutorial introduces the didactic background. The 4-hour class session starts with a short quiz and review, then learners use the worksheet to prepare and restore their tooth specimens. RESULTS: Learner response has been very positive. Moreover, faculty note that learners' skills in treating patients in clinic are noticeably higher and require less faculty intervention than was previously the case. DISCUSSION: Since new national curriculum standards for caries are currently being introduced, in addition to providing instruction to dental students, this resource presents an excellent opportunity to calibrate faculty members, who are a secondary learner group in this exercise, on a standard clinical protocol.

Setting Expectations About Feedback in Dental Education.

INTRODUCTION: Many dental students find the amount of direct feedback they receive in dental school to be both unfamiliar and uncomfortable, as many new hand-skill courses are added to familiar lecture courses and traditional paper-and-pencil tests. In turn, when students react poorly to routine professional feedback, dental school faculty often complain they are too fragile. To address this clear gap in expectations between students and faculty in regard to feedback activities, this half-day workshop was developed for use during student orientation. METHODS: In this workshop, students learn the theory of deliberate practice and the role that professional feedback will play in their training. Small-group workshops discuss past student experiences with feedback and use an origami exercise to explore student reactions to feedback. As is commonly done in technique courses, discussions about self- and peer assessment raise students' comfort levels with respect to sharing their work with their peers. Additionally, addressing feedback issues early in their professional education makes students aware of feedback's necessity in their professional development and helps them to deal with the emotional impact. RESULTS: When we evaluated this course in 2014 and 2015, students rated this activity significantly higher than other orientation activities. DISCUSSION: After several years of working with students who have had this orientation, faculty and administrators consider it highly valuable for setting expectations about feedback. They have also experienced fewer student concerns and complaints regarding feedback issues.

Quality of life in age-related macular degeneration: a review of the literature.

BACKGROUND: The Age-related Macular Degeneration Alliance International commissioned a review of the literature on quality of life (QoL) in macular degeneration (MD) with a view to increasing awareness of MD, reducing its impact and improving services for people with MD worldwide. METHOD: A systematic review was conducted using electronic databases, conference proceedings and key journal hand search checks. The resulting 'White Paper' was posted on the AMD Alliance website and is reproduced here. REVIEW: MD is a chronic, largely untreatable eye condition which leads to loss of central vision needed for tasks such as reading, watching TV, driving, recognising faces. It is the most common cause of blindness in the Western world. Shock of diagnosis, coupled with lack of information and support are a common experience. Incidence of depression is twice that found in the community-dwelling elderly, fuelled by functional decline and loss of leisure activities. Some people feel suicidal. MD threatens independence, especially when comorbidity exacerbates functional limitations. Rehabilitation, including low vision aid (LVA) provision and training, peer support and education, can improve functional and psychological outcomes but many people do not receive services likely to benefit them. Medical treatments, suitable for only a small minority of people with MD, can improve vision but most limit progress of MD, at least for a time, rather than cure. The White Paper considers difficulties associated with inappropriate use of health status measures and misinterpretation of utility values as QoL measures: evidence suggests they have poor validity in MD. CONCLUSION: There is considerable evidence for the major damage done to QoL by MD which is underestimated by health status and utility measures. Medical treatments are limited to a small proportion of people. However, much can be done to improve QoL by early diagnosis of MD with good communication of prognosis and continuing support. Support could include provision of LVAs, peer support, education and effective help in adjusting to MD. It is vital that appropriate measures of visual function and QoL be used in building a sound evidence base for the effectiveness of rehabilitation and treatment.

Effect of nanolayering of calcium salts of phosphoric acid ester monomers on the durability of resin-dentin bonds.

UNLABELLED: To investigate the contribution of nanolayering on resin-dentin bond durability, two phosphoric acid ester resin monomers, 10-methacryloyloxy-decyl-dihydrogen-phosphate (10-MDP) or its analog, methacryloyloxy-penta-propyleneglycol-dihydrogen-phosphate (MDA), were examined for their affinity for mineralized dentin powder in a column chromatography setup. Hydroxyapatite (HA) powder was dispersed in experimental primers consisting of 10-MDP or MDA solvated in ethanol/water and examined with FTIR, (31)P MAS-NMR and XPS. Light-curable 10-MDP or MDA primers were used for bonding to dentin, and examined after 24h or one-year of water-aging by TEM for evidence of nanolayering, and for microtensile bond strength evaluation. Primer-bonded dentin was examined by thin-film XRD to identify short-range order peaks characteristic of nanolayering of resin monomer-Ca salts. Although 10-MDP had better affinity for mineralized dentin than MDA, both monomers completely eluted from the mineralized dentin powder column using ethanol-water as mobile phase, indicating that the adsorption processes were reversible. This finding was supported by chemoanalytic data. XRD of 10-MDP-bonded dentin showed three diffraction peaks hat were absent from MDA-bonded dentin. Nanolayering was identified by TEM in 10-MDP-bonded dentin, but not in MDA-bonded dentin. Significant drop in bond strength (in MPa) was observed for both groups after one-year of water-aging compared with 24-h: 10-MDP group from 48.3±6.3 to 37.4±4.6; MDA group from 50.7±5.0 to 35.7±3.8 (P<0.05), with no significant difference between the two groups at the same time-point. Because both functional monomer-primed, resin-bonded dentin exhibited similar bond strength decline after water-aging, presence of nanolayering is unlikely to contribute to the overall resin-dentin bond durability. STATEMENT OF SIGNIFICANCE: The durability of resin-dentin bonds in 10-MDP containing self-etching adhesives has been anecdotally attributed to the presence of nanolayering of 10-MDP-calcium salts in the resin-dentin interface. Results of the present work indicate that such a claim cannot be justified. Complete elution of the phosphoric acid ester monomer from mineralized dentin powder in the column chromatography experiments using ethanol-water mobile phase to simulate the solvent mixture employed in most 10-MDP-containing dentin adhesives further challenges the previously proposed adhesion-decalcification concept that utilizes chemical bonding of phosphoric acid ester monomers to apatite as a bonding mechanism in 10-MDP containing dentin adhesives.

+Psychometric evaluation of the MacDQoL individualised measure of the impact of macular degeneration on quality of life.

BACKGROUND: The MacDQoL is an individualised measure of the impact of macular degeneration (MD) on quality of life (QoL). There is preliminary evidence of its psychometric properties and sensitivity to severity of MD. The aim of this study was to carry out further psychometric evaluation with a larger sample and investigate the measure's sensitivity to MD severity. METHODS: Patients with MD (n = 156: 99 women, 57 men, mean age 79 +/- 13 years), recruited from eye clinics (one NHS, one private) completed the MacDQoL by telephone interview and later underwent a clinic vision assessment including near and distance visual acuity (VA), comfortable near VA, contrast sensitivity, colour recognition, recovery from glare and presence or absence of distortion or scotoma in the central 10 degrees of the visual field. RESULTS: The completion rate for the MacDQoL items was 99.8%. Of the 26 items, three were dropped from the measure due to redundancy. A fourth was retained in the questionnaire but excluded when computing the scale score. Principal components analysis and Cronbach's alpha (0.944) supported combining the remaining 22 items in a single scale. Lower MacDQoL scores, indicating more negative impact of MD on QoL, were associated with poorer distance VA (better eye r = -0.431 p < 0.001; worse eye r = -0.350 p < 0.001; binocular vision r = -0.419 p < 0.001) and near VA (better eye r = -0.326 p < 0.001; worse eye r = -0.226 p < 0.001; binocular vision r = -0.326 p < 0.001). Poorer MacDQoL scores were associated with poorer contrast sensitivity (better eye r = 0.392 p < 0.001; binocular vision r = 0.423 p < 0.001), poorer colour recognition (r = 0.417 p < 0.001) and poorer comfortable near VA (r = -0.283, p < 0.001). The MacDQoL differentiated between those with and without binocular scotoma (U = 1244 p < 0.001). CONCLUSION: The MacDQoL 22-item scale has excellent internal consistency reliability and a single-factor structure. The measure is acceptable to respondents and the generic QoL item, MD-specific QoL item and average weighted impact score are related to several measures of vision. The MacDQoL demonstrates that MD has considerable negative impact on many aspects of QoL, particularly independence, leisure activities, dealing with personal affairs and mobility. The measure may be valuable for use in clinical trials and routine clinical care.

N-acetylcysteine reduces contrast-associated nephropathy but not clinical events during long-term follow-up.

BACKGROUND: Contrast-associated nephropathy (CAN) is associated with increased morbidity and mortality following percutaneous coronary intervention (PCI). N-acetylcysteine (NAC) has been shown to reduce the risk of nephropathy; however, the impact of NAC on long-term clinical outcomes has not been assessed. METHODS: This randomized, double-blind, placebo-controlled trial enrolled 180 patients with moderate renal dysfunction undergoing PCI or coronary angiography with a high likelihood of ad hoc PCI; 171 patients completed the clinical follow-up. Patients received oral NAC (2000 mg/dose, n = 95) or placebo (n = 85) twice a day for 3 doses if randomized the night prior to the procedure, and 2 doses if randomized the day of the procedure. The primary end point was the incidence of a > or =25% increase in serum creatinine level 48 to 72 hours after PCI. Secondary end points were the inhospital incidence of death, nonfatal myocardial infarction, or urgent dialysis, and the 9-month incidence of death, nonfatal myocardial infarction, need for dialysis, or repeat hospitalization for cardiac reasons. RESULTS: CAN occurred in 9.6% of patients assigned to NAC and 22.2% of patients assigned to placebo (P =.04); 1 patient receiving NAC required urgent dialysis. The inhospital composite end point occurred in 7 (7.4%) NAC-treated and 3 (3.5%) placebo-treated patients, P = NS. At 9 months, the composite end point occurred in 23 (24.2%) NAC-treated patients and 18 (21.2%) placebo-treated, P = NS. CONCLUSION: Although high-dose NAC prevented periprocedural CAN, this benefit did not translate into a decrease in adverse outcomes over 9 months. Further studies to determine the clinical utility of this drug are required.

The effect of initial irrigation with two different sodium hypochlorite concentrations on the erosion of instrumented radicular dentin.

OBJECTIVE: This study evaluated the effects of different NaOCl concentrations and contact times on removal of the organic phase from mineralized dentin with and without the adjunctive use of EDTA, and the effect of NaOCl concentrations on canal wall erosion after the use of EDTA as the final active irrigant. METHODS: Dentin powders were immersed in 5.25% or 1.3% NaOCl for different contact periods and then rinsed with 17% EDTA for 2 min. Before and after the use of 17% EDTA as the final rinse, the NaOCl-treated dentin powders were examined using ATR-FT-IR spectroscopy to analyze the relative loss of organic and inorganic components. Scanning (SEM) and transmission electron microscopy (TEM) were used to examine the erosion of instrumented canal walls irrigated with 5.25% NaOCl/EDTA or 1.3% NaOCl/EDTA. RESULTS: Compared with 1.3% NaOCl, less intact collagen remained within the subsurface of the mineralized dentin powder after the use of 5.25% NaOCl, irrespective of subsequent rinsing with 17% EDTA. Canal wall erosion was apparent only under SEM when root canals were irrigated 5.25% NaOCl followed by 17% EDTA. Under TEM examination, subsurface erosion extended 10-15 microm beneath the sealer-bonded dentin surface after the use of 5.25% NaOCl for 20 min. CONCLUSION: The superficial destructive effect of NaOCl on mineralized dentin is irreversible and is present irrespective of whether EDTA is subsequently employed as the final active irrigant. The EDTA removes the collagen-depleted apatite phase to expose the underlying cause of destruction that is morphologically perceived as canal wall erosion.