Focused cardiac ultrasound training: how much is enough?

BACKGROUND: Focused transthoracic echocardiography (F-TTE) is an important tool to assess hemodynamically unstable patients in the Emergency Department. Although its scope has been defined by the American College of Emergency Physicians, more research is needed to define an optimal F-TTE training program, including assessment of proficiency. OBJECTIVE: The goal of this study was to determine the effectiveness of current standards in post-residency training to reach proficiency in F-TTE. METHODS: Fourteen staff Emergency Physicians were enrolled in a standardized teaching curriculum specifically designed to meet the 2008 American College of Emergency Physicians' guidelines for general ultrasound training applied to echocardiography. This training program consisted of 6 h of didactics and 6 h of scanning training, followed by independent scanning over a 5-month period. Acquisition of echocardiographic knowledge was assessed by an online pre- and post-test. At the conclusion of the study, a hands-on skills test assessed the trainees' ability to perform and interpret F-TTE. RESULTS: Ninety percent of trainees passed the written post-test. Two views, the parasternal long and short axis, were easily obtainable, regardless of the level of training or the number of ultrasounds completed. Other views were more difficult to master, but strong trends toward increased competency were evident after 10 h of mixed didactic and scanning training and > 45 ultrasounds. CONCLUSIONS: A short, 12-h didactic training in F-TTE provided proficiency in image interpretation and in obtaining adequate images from the parasternal window. More extensive training is needed to master the apical and subcostal windows in a timely manner.

Continued Competency Assessment. Its history and role in the health professions.

The concept of an implicit contract between the public and a profession is used as a foundation for the responsibility for professions to develop continued competency assessment and enforcement mechanisms that ensure that the public can expect safe and competent care. The literature in medicine, other health professions, and from other countries is reviewed. There is concern that the fact of continued practice alone does not ensure continued competency in a changing profession and that mandatory continuing education attendance is insufficient. Public-interest groups that have looked at the issue report greater concern among the public than in the professions that effective continued competency mechanism be established and that action be taken where practitioners who are not competent are identified. There has been substantial develop of a variety of approaches in medicine, especially through the specialty boards which account for the majority of medical practitioners, in other health fields, and in several countries.

Continued Competency Assessment. Does it have a necessary role in dentistry?

The responsibility of regulating dental practice in the interest of public safety is vested in the states and is exercised through delegated initial competency evaluation of new graduates, continuing education attendance requirements, and investigations of complaints. Questions have been raised over whether this model can demonstrate effectiveness and whether it ensures continuous professional growth or only identifies the clearly incompetent. There have been reports identifying desireable standards and there are pilot programs for continued competency in dentistry. These are reviewed. A set of criteria for any effective program is presented.

Evolution of dental school clinics as patient care delivery centers.

Dental school clinics, originally envisioned as closely similar to private practice, evolved instead as teaching clinics. In the former, graduate and licensed dentists perform the treatment while undergraduate dental students are assigned treatment within their capabilities. In the latter, dental students provide the treatment under faculty supervision. It is generally recognized that the care provided by the teaching clinics is inefficient. However, in the last quarter of the twentieth century, dental school clinics began to pay much more attention to how treatment is rendered. The comprehensive care movement and quality assurance systems are leading towards more efficient patient-centered care. Case studies at the University of Maryland, Columbia University, and University of Louisville describe activities to make their clinic programs more efficient and patient-friendly. This article explores whether the potential exists for faculty to take a direct patient care delivery role in dental clinics in order for those clinics to become efficient patient care delivery systems as originally envisioned in the early part of the twentieth century.

Interprofessional Collaborative Practice: How Could Dentistry Participate?

There is a remarkable phenomenon occurring among health professionals: the development of ongoing, routine collaboration, both in educating the next generation of providers and in delivering care. These new approaches, commonly referred to as interprofessional education and interprofessional collaborative practice, have been introduced into academic health settings and delivery systems throughout the U.S. and the rest of the world; however, the full integration of dentistry in health care teams remains unrealized. In academic settings, dentistry has found ways to collaborate with the other health professions, but most practicing dentists still find themselves on the margins of new models of care delivery. This article provides a perspective on the history and context of the evolution of collaborative approaches to health care and proposes ways in which dentistry can participate more fully in the future.

Scope of practice comparison: a tool for curriculum decision making.

The proportion of claims filed for specific dental procedures (ADA codes # 05110, 05120, 03320, 03330, 04260, 02150) between January 1, 2000 and June 30, 2004 by Texas general practitioners participating in a preferred provider network was compared to the proportion of these procedures performed by students graduating from the three Texas dental schools during the same period. Analysis of the data revealed that Texas dental students provide class two amalgam restorations in permanent teeth (02150) at approximately the same frequency as Texas general practitioners. Both groups provide periodontal osseous surgery (04260) at an extremely low frequency (<0.02% of total procedures). Bicuspid endodontic procedures (03320) were performed at a slightly higher frequency by students (0.43% of all procedures) than by general practitioners (0.36% of all procedures), and molar endodontic procedures (03330) were performed at a slightly higher frequency by general practitioners (0.65%) than by students (0.36%). Significant discrepancies between the groups were noted for the two complete denture procedures (05110, 05120). Students provided these procedures at frequencies fifteen times (05110) and twenty-five times (05120) greater than general practitioners. Dental schools should use data provided by scope of practice analyses to help determine an appropriate breadth and depth for their educational programs.

Evolution of dental school clinics as patient care delivery centers.

Dental school clinics, originally envisioned as closely similar to private practice, evolved instead as teaching clinics. In the former, graduate and licensed dentists perform the treatment while undergraduate dental students are assigned treatment within their capabilities. In the latter, dental students provide the treatment under faculty supervision. It is generally recognized that the care provided by the teaching clinics is inefficient. However, in the last quarter of the twentieth century, dental school clinics began to pay much more attention to how treatment is rendered. The comprehensive care movement and quality assurance systems are leading towards more efficient patient-centered care. Case studies at the University of Maryland, Columbia University, and University of Louisville describe activities to make their clinic programs more efficient and patient-friendly. This article explores whether the potential exists for faculty to take a direct patient care delivery role in dental clinics in order for those clinics to become efficient patient care delivery systems as originally envisioned in the early part of the twentieth century.

Will Large DSO-Managed Group Practices Be the Predominant Setting for Oral Health Care by 2025? Two Viewpoints: Viewpoint 1: Large DSO-Managed Group Practices Will Be the Setting in Which the Majority of Oral Health Care Is Delivered by 2025 and Viewpoint 2: Increases in DSO-Managed Group Practices Will Be Offset by Models Allowing Dentists to Retain the Independence and Freedom of a Traditional Practice.

This Point/Counterpoint article discusses the transformation of dental practice from the traditional solo/small-group (partnership) model of the 1900s to large Dental Support Organizations (DSO) that support affiliated dental practices by providing nonclinical functions such as, but not limited to, accounting, human resources, marketing, and legal and practice management. Many feel that DSO-managed group practices (DMGPs) with employed providers will become the setting in which the majority of oral health care will be delivered in the future. Viewpoint 1 asserts that the traditional dental practice patterns of the past are shifting as many younger dentists gravitate toward employed positions in large group practices or the public sector. Although educational debt is relevant in predicting graduates' practice choices, other variables such as gender, race, and work-life balance play critical roles as well. Societal characteristics demonstrated by aging Gen Xers and those in the Millennial generation blend seamlessly with the opportunities DMGPs offer their employees. Viewpoint 2 contends the traditional model of dental care delivery-allowing entrepreneurial practitioners to make decisions in an autonomous setting-is changing but not to the degree nor as rapidly as Viewpoint 1 professes. Millennials entering the dental profession, with characteristics universally attributed to their generation, see value in the independence and flexibility that a traditional practice allows. Although DMGPs provide dentists one option for practice, several alternative delivery models offer current dentists and future dental school graduates many of the advantages of DMGPs while allowing them to maintain the independence and freedom a traditional practice provides.

Use of fluorescence in situ hybridization to detect minimal residual disease in hematopoietic stem cell assays from peripheral blood stem cells of 2 patients with trisomy 8 acute myeloid leukemia.

Fluorescence in situ hybridization (FISH) was used to analyze peripheral blood stem cells (PBSC) and stem cell assays (SCA) derived from them in 2 patients with acute myeloid leukemia (AML) with trisomy 8 as the sole chromosome abnormality prior to undergoing autologous stem cell transplantation. In both cases, the demonstration of cells containing trisomy 8 in the stem cell product led to significant changes in the patients' treatment. In the initial PBSC collections from each patient, trisomy 8 was found in aspirated granulocyte-monocyte (GM) colonies or aspirated GM clusters but not entire cell populations of SCA dish or uncultured PBSC (one patient). FISH analyses for specific cytogenetic abnormalities in hematopoietic stem cell cultures may be a more useful means of assessing the quality of the stem cell product in patients being considered for autologous stem cell transplantation.

19-nor-1alpha,25-dihydroxyvitamin D(2) (paricalcitol): effects on clonal proliferation, differentiation, and apoptosis in human leukemic cell lines.

PURPOSE: 19-Nor-1alpha,25-dihydroxyvitamin D(2) (paricalcitol) is an analogue of 1,25(OH)(2)D(3) with reduced calcemic effects that is approved for the suppression of parathyroid hormone in chronic renal failure. Paricalcitol has recently been reported to have anticancer activity in prostate cancer. In order to explore paricalcitol as a potential agent against leukemia, we tested its effects on HL-60 and U937 leukemia cell lines. METHODS: We studied cellular differentiation via expression of CD11b and CD14 surface antigens using flow cytometry, and via the nitroblue tetrazolium (NBT) assay. Cell cycle was analyzed using propidium iodide staining. Apoptosis was assessed with the annexin V assay. Cellular proliferation was determined via colony inhibition on semisolid medium. RESULTS: Paricalcitol induced the maturation of HL-60 and U937 cells, as shown by increased expression of CD11b differentiation surface antigen. CD14 showed increased expression in HL-60 but not in U937 cells. After exposure to paricalcitol at 10(-8) M for 72 h, the ability of HL-60 cells to reduce NBT was markedly increased. Conversely, U937 cells were unchanged. Paricalcitol inhibited colony formation of both HL-60 and U937 cell lines in semisolid medium after a 10-day incubation (estimated IC(50) of 3x10(-8) M in HL-60 cells and 4x10(-8) M in U937 cells). Paricalcitol at 10(-8) M and 10(-7) M caused a significant dose- and time-dependent increase of apoptosis in HL-60 cells ( P<0.05). In both HL-60 and U937 cells, exposure to 10(-7) M paricalcitol for 72 h increased the number of cells in G(0)/G(1) phase, and decreased the number of cells in S phase. CONCLUSIONS: Paricalcitol inhibits colony formation, induces maturation and causes cell cycle arrest in HL-60 and U937 cells. Additionally, paricalcitol induces apoptosis in HL-60 cells. These findings support the further evaluation of paricalcitol as an antileukemia agent.

Length of hospital stay and cost of Staphylococcus and Streptococcus infections among hospitalized patients.

BACKGROUND: Staphylococcus (Staph) and Streptococcus (Strep) infections are important causes of morbidity and mortality worldwide. The economic burden of these infections is also significant, especially among hospitalized patients. OBJECTIVE: The aim of this study was to estimate length of hospital stay (LOS) and total payments for hospital admissions for patients with Staph or Strep infection as a first (primary) or second or higher (comorbid) diagnosis. METHODS: From the 1994-1997 MarketScan inpatient database, admissions with Staph (n = 2,042) or Strep (n = 1,401) infection (905 as primary and 2,538 as comorbid diagnosis) and 89,899 control admissions without a diagnosis of gram-positive infection were identified. Crude and category-specific mean LOS and anti-log mean total payments were compared between admissions with Staph or Strep infection and admissions without a diagnosis of any gram-positive infection within major diagnostic categories and principal surgical procedures (SPs). RESULTS: For admissions with Staph or Strep infection as first (primary) diagnosis (n = 905), the mean LOS was 4.68 days (95% CI, 4.44-4.93) and 4.78 days (95% CI, 4.35-5.26), respectively. The mean total payments were $6,445 (95% CI, $6,045-$6,870) and $6,821 (95% CI, $6,149-$7,566), respectively. In contrast, the average LOS and total payment for the control group were 2.99 days (95% CI, 2.98-3.01) and $6,325 (95% CI, $6,284-$6,365). For admissions with infection as the comorbid diagnosis (n = 2,538), mean LOS and total payment were 4 days longer and $6,000 higher for Staph infections and 1.2 days longer and $1,200 higher for Strep infections than the control group. Within each SP, LOS and total payments were substantially higher for patients with Staph and Strep infections. CONCLUSIONS: The results of this study indicate that infections with the pathogens Staph and Strep substantially increase LOS and total payments among hospitalized patients.

A pilot study of antipsychotic prescribing decisions for acutely-Ill hospitalized patients.

BACKGROUND: Evidence on antipsychotic prescribing decisions is limited. This pilot study quantified factors considered in choosing an antipsychotic and evaluated the influence of metabolic status on treatment decisions. METHODS: Prescribing decisions by 4 psychiatrists were examined based on 80 adult patients initiated on antipsychotic medication diagnosed with schizophrenia, schizoaffective disorder or bipolar disorder by DSM-IV criteria, who were admitted to an acute inpatient psychiatric program of an urban Veterans Affairs Medical Center. The primary analysis examined the association between antipsychotic treatment choice and predictions of symptom control and metabolic risk. Secondary analyses included comparison of the chosen and next best treatments in predicted symptom control and metabolic risk, the frequency of reasons cited for drug choice, and the association between treatment choice and patients' baseline metabolic parameters. Mean differences and odds-ratios (OR) with 95% confidence intervals were used to compare relationships between treatment choice, ratings of risk and metabolic data. RESULTS: Antipsychotic choice correlated significantly with ratings of predicted symptom control (OR = .92, p = 0.02) and metabolic risk (OR = .88, p = 0.01). Mean differences between the chosen and next best drugs were significant but small in predicted symptom control (F = 2.81, df = 3, 76; p<0.05) compared with larger differences in anticipated metabolic risk (F = 14.80, df = 3, 76; p = 0.0001). Nevertheless, among 24 identified reasons influencing drug selection, anticipated metabolic risk of chosen antipsychotics was cited less often than efficacy measures. In contrast to psychiatrists' expectations of metabolic risk with selected treatments, we found that patients' actual baseline BMI, fasting glucose, blood pressure, and Framingham risk levels did not necessarily predict antipsychotic treatment choice independent of other factors. CONCLUSION: In the context of an acute psychiatric hospitalization, pilot data suggest that predictions of symptom control and metabolic risk correlated significantly with antipsychotic choice, but study psychiatrists were willing to assume relative degrees of metabolic risk in favor of effective symptom control. However, prescribing decisions were influenced by numerous patient and treatment factors. These findings support the potential utility of the ATCQ questionnaire in quantifying antipsychotic prescribing decisions. Further validation studies of the ATCQ questionnaire could enhance translation of research findings and application of treatment guidelines.

Development and implementation of an online screening application at the University of Texas Health Science Center at San Antonio Dental School.

This article describes a quality improvement (QI) initiative that is in process at the University of Texas Health Science Center at San Antonio (UTHSCSA) Dental School and the website that grew out of this effort. The process of screening and assignment of patients was selected for improvement in 2006. QI methods were used to develop a website that improves access to care for patients and assists in the matching of patients and students. The website (www.dentalscreening.com) has received more than 15,000 screening applications in the period from May 2007 to January 2010 and has provided unprecedented insight into the needs of our patients. This article outlines the process by which the website was created, the rationale for the design, and the benefits of establishing a screening website for any dental school. The program was developed entirely at UTHSCSA, but it addresses a problem that may affect many dental schools.

A novel composite endpoint to evaluate the gastrointestinal (GI) effects of nonsteroidal antiinflammatory drugs through the entire GI tract.

OBJECTIVE: Nonsteroidal antiinflammatory drugs (NSAID) not only cause damage to the upper gastrointestinal (GI) tract but also affect the lower GI tract. To date, there is no endpoint that evaluates serious GI events in the entire GI tract. The objective of this report is to introduce a novel composite endpoint that measures damage to the entire GI tract - clinically significant upper and lower GI events (CSULGIE) - in patients with NSAID-induced GI damage. METHODS: We reviewed the data from largescale, multicenter, randomized, clinical trials on lower GI toxicity associated with NSAID use. The rationale for using CSULGIE as a primary endpoint in 2 ongoing trials - the Celecoxib vs Omeprazole and Diclofenac for At-risk Osteoarthritis (OA) and Rheumatoid Arthritis (RA) Patients (CONDOR) trial and the Gastrointestinal Randomized Events and Safety Open-Label NSAID Study (GI-REASONS) - is also discussed. RESULTS: Previous randomized trials focused primarily on damage to the upper GI tract and often neglected the lower GI tract. The CSULGIE endpoint extends the traditional "perforation, obstruction, and bleeding" assessment of upper GI complications by including events in the lower GI tract (small/large bowel) such as perforation, bleeding, and clinically significant anemia. CONCLUSION: By providing clinicians with a new, descriptive language for adverse events through the entire GI tract, the CSULGIE endpoint has the potential to become a standard tool for evaluating the GI effects of a range of therapies.

Endoscopic ulcer rates in healthy subjects associated with use of aspirin (81 mg q.d.) alone or coadministered with celecoxib or naproxen: a randomized, 1-week trial.

AIM: To determine the rate of endoscopic gastric/duodenal ulcers (GDUs) associated with use of aspirin (81 mg q.d.) alone or coadministered with celecoxib or naproxen. METHODS: In this multicenter, double-blind study, healthy subjects were randomized to receive daily aspirin (81 mg q.d.) plus celecoxib 200 mg q.d., naproxen 500 mg b.i.d., or placebo. Upper endoscopy was performed at baseline and day 7. The primary end point was incidence of GDUs >or=3 mm diameter. RESULTS: Incidence of GDUs was significantly lower in subjects receiving celecoxib plus aspirin (7%) compared with naproxen plus aspirin (25.3%; relative risk [RR], 0.28 [95% confidence interval (CI), 0.17-0.45]; P < 0.001), but significantly higher than placebo plus aspirin (1.6%; RR, 4.78 [95% CI, 1.12-20.32]; P = 0.016). CONCLUSION: In a healthy population taking aspirin (81 mg q.d.), coadministration of celecoxib resulted in fewer GDUs than naproxen, but significantly more mucosal damage than aspirin alone.

Preoperative parenteral parecoxib and follow-up oral valdecoxib reduce length of stay and improve quality of patient recovery after laparoscopic cholecystectomy surgery.

UNLABELLED: In this randomized, double-blinded, placebo-controlled study, we evaluated the effects of preoperative IV parecoxib sodium (parecoxib) followed by postoperative oral valdecoxib on length of stay, resource utilization, opioid-related side effects, and patient recovery after elective laparoscopic cholecystectomy. Patients were randomized to receive a single IV dose of parecoxib 40 mg (n = 134) or placebo (n = 129) 30-45 min before the induction of anesthesia. Six to 12 h after the IV dose, the parecoxib group received a single oral dose of valdecoxib 40 mg, followed by valdecoxib 40 mg once daily on postoperative Days 1-4 and then 40 mg once daily as needed on Days 5-7. Patients in the parecoxib/valdecoxib group had a shorter length of stay in the postanesthesia care unit (78 +/- 47 min) compared with those taking placebo (90 +/- 49 min; P < 0.05). Patients in the parecoxib/valdecoxib group also had reduced pain intensity and, after discharge, experienced a significant reduction in vomiting in the first 24 h, slept better, returned to normal activity earlier, and expressed greater satisfaction than placebo patients (P < 0.05). Preoperative parecoxib followed by postoperative valdecoxib is a valuable adjunct for treating pain and improving patient outcome after laparoscopic cholecystectomy. IMPLICATIONS: The administration of preoperative IV parecoxib followed by oral valdecoxib after surgery resulted in a shorter length of stay in the postoperative anesthesia care unit, a better quality of postoperative recovery, and a faster return to normal activity, with greater patient satisfaction, after laparoscopic cholecystectomy.

The prevalence of pituitary adenomas: a systematic review.

BACKGROUND: Pituitary adenomas display an array of hormonal and proliferative activity. Once primarily classified according to size (microadenomas, < 1 cm; macroadenomas, > or = 1 cm), these tumors are now further classified according to immunohistochemistry and functional status. With these additional classifications in mind, the goals of the current study were to determine the prevalence of pituitary adenomas and to explore the clinical relevance of the findings. METHODS: The authors conducted a metaanalysis of all existing English-language articles in MEDLINE. They used the search string (pituitary adenoma or pituitary tumor) and prevalence and selected relevant autopsy and imaging evaluation studies for inclusion. RESULTS: The authors found an overall estimated prevalence of pituitary adenomas of 16.7% (14.4% in autopsy studies and 22.5% in radiologic studies). CONCLUSIONS: Given the high frequency of pituitary adenomas and their potential for causing clinical pathologies, the findings of the current study suggest that early diagnosis and treatment of pituitary adenomas should have far-reaching benefits.