Should mentoring be routinely introduced into general dental practice to reduce the risk of occupational stress?

Introduction Occupational stress within general dental practice can potentially have an adverse impact on a practitioner's wellbeing and the quality of healthcare provided by that individual. Mentoring has routinely been utilised in other professions for stress management, however, there is little in the dental literature discussing the benefits of mentorship on the reduction of occupational stress for dental practitioners.Aim The aim of this study was to explore the perceptions of experienced foundation dental trainers within the Health Education, Kent, Surrey and Sussex postgraduate deanery as to the usefulness of routine mentoring as a tool to reduce occupational stress.Methods Using a qualitative approach, six individual semi-structured interviews were undertaken. Recorded interviews were transcribed and transcriptions were analysed using thematic coding to identify overarching themes.Results Both similarities and differences with the existing literature on routine mentoring within professional settings were identified. Foundation dental trainers were positive towards the concept of routine mentoring, although there was also a degree of scepticism regarding the potential uptake among colleagues. There was a perception that mentoring might more practically be used as a reactionary tool. Multiple potential barriers to routine mentoring were identified, included funding, scheduling and a lack of training.Conclusions The analysis identified that currently, experienced foundation dental practitioners do not consider routine mentoring as a practical option in the prevention of occupational stress. The results would suggest that further education is required as to the benefits of routine mentoring as a strategy for occupational stress management. However, with additional resources buying time, a hybrid model of mentoring and coaching has significant potential in general dental practice.

Alarm limit settings for early warning systems to identify at-risk patients.

AIM: This paper is a report of a study conducted to provide objective data to assist with setting alarm limits for early warning systems. BACKGROUND: Early warning systems are used to provide timely detection of patient deterioration outside of critical care areas, but with little data from the general ward population to guide alarm limit settings. Monitoring systems used in critical care areas are known for excellent sensitivity in detecting signs of deterioration, but give high false positive alarm rates, which are managed with nurses caring for two or fewer patients. On general wards, nurses caring for four or more patients will be unable to manage a high number of false alarms. Physiological data from a general ward population would help to guide alarm limit settings. METHODS: A dataset of continuous heart rate and respiratory rate data from a general ward population, previously collected from July 2003-January 2006, was analyzed for adult patients with no severe adverse events. Dataset modeling was constructed to analyze alarm frequency at varying heart rate and respiratory rate alarm limits. RESULTS: A total of 317 patients satisfied the inclusion criteria, with 780.71 days of total monitoring. Sample alarm settings appeared to optimize false positive alarm rates for the following settings: heart rate high 130-135, low 40-45; respiratory rate high 30-35, low 7-8. Rates for each selected limit can be added to calculate the total alarm frequency, which can be used to judge the impact on nurse workflow. CONCLUSION: Alarm frequency data will assist with evidence-based configuration of alarm limits for early warning systems.

Impact of continuous vigilance monitoring on nursing workflow.

BACKGROUND: Increasing nursing time in patient care is beneficial in improving patient outcomes, but this is proving increasingly difficult with the nursing shortage, budgetary constraints, and higher patient acuity. OBJECTIVE: Nursing workflow was evaluated after the implementation of a continuous vigilance monitoring system to determine if the system enhanced patient-centric nursing care. METHODS: Work sampling observations were conducted at 3 hospitals for 6 categories of nursing activities (direct and indirect nursing, documentation, administrative, housekeeping, and miscellaneous) at baseline and at 3 and 9 months. RESULTS: Statistically significant increases in direct (3 months) and indirect nursing care (3 and 9 months) were found, with variability between sites. Statistically significant increases at 3 and 9 months for documentation of patient care activities and decreases in administrative activities were the most consistent findings for all sites. CONCLUSION: Continuous vigilance monitoring enhanced patient-centric care with increases in direct and indirect nursing care and documentation of those activities.

The effect of dynamic intermittent hypoxic conditioning on arterial oxygen saturation.

BACKGROUND: Increases in arterial oxygen saturation (SaO2) in response to intermittent hypoxic exposure (IHE) are well established. However, IHE protocols have historically involved static hypoxic environments. The effect of a dynamic hypoxic environment on SaO2 is not known. OBJECTIVE: The purpose of this study was to examine the effect of dynamic IHE conditioning on SaO2 using the Cyclical Variable Altitude Conditioning Unit. METHODS: Thirteen trained participants (9 males, age 30.1 +/- 9.2 years; 4 females, age 30.3 +/- 8.9 years) residing at or near sea level were exposed to a 7-week IHE conditioning protocol (mean total exposure time = 30.8 hours). Participants were exposed to a constantly varying series of hypobaric pressures simulating altitudes from sea level to 6858 m (22 500 feet) in progressive conditioning tiers, creating a dynamic hypoxic environment. SaO2 was evaluated using pulse oximetry (SpO2) 4 times: at 2740, 3360, and 4570 m, prior to and following the first 3 weeks of IHE, and at 4570, 5490, and 6400 m at the start and end of the final 4 weeks. RESULTS: SpO2 improved 3.5%, 3.8%, and 4.1% at 2470, 3360, and 4570 m, respectively (P < .05), and 3.3%, 3.4%, and 5.9% at 4570, 5490, and 6400 m, respectively (P < .05). At 4570 m, SpO2 increased from 81.7% +/- 6.5% to 89.1% +/- 3.2% over the entire 7-week conditioning period. DISCUSSION: The dynamic intermittent hypoxic conditioning protocol used in the present study resulted in an acclimation response, such that SpO2 was significantly increased at all altitudes tested, with shorter exposure times than generally reported.

Distance learning on the Internet: web-based archived curriculum.

Web-based education through archived educational modules offers a significant opportunity to provide didactic education. By archiving lectures and teaching materials, it reduces the educators' time of preparation, especially when many students will need to take the same curriculum over a long period of time. The site can package educational material in multiple formats including audio, video, and readable text, allowing the student to tailor the educational experience to his/her learning preferences. This can be a stand-alone program, or integrated into a program combining distance and in-person education. Assessment through on-line tests can also be conducted, but these must be considered open-book assessments where collaboration cannot be prevented. As such, this vehicle can be utilized effectively for continuing education programs in health care, where open book is permitted and credits are generally awarded on the honor system. However, tests for certificate courses should only be given with a proctor in attendance. In this instance, on-line tests can be used as pre-tests for the student, while being structured to enhance further learning.

Telehealth: voice therapy using telecommunications technology.

Telehealth offers the potential to meet the needs of underserved populations in remote regions. The purpose of this study was a proof-of-concept to determine whether voice therapy can be delivered effectively remotely. Treatment outcomes were evaluated for a vocal rehabilitation protocol delivered under 2 conditions: with the patient and clinician interacting within the same room (conventional group) and with the patient and clinician in separate rooms, interacting in real time via a hard-wired video camera and monitor (video teleconference group). Seventy-two patients with voice disorders served as participants. Based on evaluation by otolaryngologists, 31 participants were diagnosed with vocal nodules, 29 were diagnosed with edema, 9 were diagnosed with unilateral vocal fold paralysis, and 3 presented with vocal hyperfunction with no laryngeal pathology. Fifty-one participants (71%) completed the vocal rehabilitation protocol. Outcome measures included perceptual judgments of voice quality, acoustic analyses of voice, patient satisfaction ratings, and fiber-optic laryngoscopy. There were no differences in outcome measures between the conventional group and the remote video teleconference group. Participants in both groups showed positive changes on all outcome measures after completing the vocal rehabilitation protocol. Reasons for participants discontinuing therapy prematurely provided support for the telehealth model of service delivery.

Telemedicine: teleproctored endoscopic sinus surgery.

OBJECTIVE/HYPOTHESIS: Teleproctored surgery projects a surgeon's expertise to remote locations. The objective of the present study was to evaluate the safety and feasibility of this technique as compared with the current standard of care. STUDY DESIGN: Prospective. METHODS: A study was conducted in a residency training program comparing conventionally proctored endoscopic sinus surgery cases with teleproctored cases, with the faculty surgeon supervising through audiovisual teleconferencing (VTC) in a control room 15 seconds from the operating room. RESULTS: Forty-two control patients (83 sides) and 45 teleproctored patients (83 sides) were evaluated. There were no internal differences between groups regarding extent of polypoid disease, revision status, procedures per case, degree of difficulty, general or local anesthesia, or microdebrider use. There were no cases of visual disturbance, orbital ecchymosis or hematoma, or cerebrospinal fluid leak. Orbital fat herniation and blood loss were equal between groups. Three teleproctored cases required faculty intervention: two for surgical difficulty, one for VTC problems. Teleproctored cases took 3.87 minutes longer per side (28.54 vs. 24.67 min, P <.024), a 16% increase. This was thought to be a result of nuances of VTC proctoring. Residents had a positive learning experience, with nearly full control of the operating suite combined with remote supervision through telepresence. Faculty thought such supervision was safe but had concerns regarding personal skills maintenance. CONCLUSIONS: Teleproctored endoscopic sinus surgery can be safely performed on selected cases with an acceptable increase in time. Teleproctored surgery with remote sites may continue to be safely investigated. Incorporating remote supervision through telepresence into the curriculum of surgical residency training requires further study.

Telemedicine in otolaryngology.

More research is needed in otolaryngology telemedicine, but it would be a mistake to stop at only determining if telemedicine is as good as an in-person exam. The digital image recorded in a telemedicine encounter can be manipulated to increase diagnostic information not currently available. Radiologists currently take a chest radiograph in which a chest mass or the tip of an nasogastric tube is difficult to visualize, and by inverting the gray scale or viewing other digital manipulations of that image, the mass or tube tip becomes obvious. Examples in otolaryngology might include images of the larynx manipulated to better demonstrate the inflamed tissue of reflux, or images of the tympanic membrane manipulated to better demonstrate early retraction. Despite dramatic and likely continued decreases, equipment cost is still an issue. Current research points to good consumer acceptance, and certainly with each new generation the technology is more readily accepted. As Nesbitt [4] points out, it is certainly not difficult to look to the future and see ubiquitous broadband with video as common as telephone, or even extreme broadband enabling robotics and virtual reality TV with three-dimensional touch. Robotics and genomics will eventually play a greater role in telemedicine and our lives in general. Applications for remote diagnosis in biologic warfare defense and homeland security are currently raising interest in telemedicine. Telemedicine will be combined with new technological advances such as virtual "fly-through" computerized axial tomography examinations. Instead of performing an exploratory tympanotomy, surgeons will use computer programs to "fly through" and examine all aspects of a patient's middle or even inner ear. Spectral imaging of the eardrum, larynx, or oropharynx will immediately identify bacteria without cultures, or gram stain, and potential malignancy without biopsy. By measuring fluorescence emitted from an oropharynx illuminated with a specific visible or nonvisible light spectrum, spectral imaging will be able to provide instant identification of bacteria or evidence of malignant changes. The underlying principles of a successful business model must continue to be applied, with the most critical ingredient for telemedicine's success being the filling of specific health care needs. As long as the need is there, telemedicine in otolaryngology will advance.

Seven Wnt homologues in Drosophila: a case study of the developing tracheae.

Sequencing of the Drosophila genome has revealed that there are "silent" homologues of many important genes-family members that were not detected by classic genetic approaches. Why have so many homologues been conserved during evolution? Perhaps each one has a different but important function in every system. Perhaps each one works independently in a different part of the body. Or, perhaps some are redundant. Here, we take one well known gene family and analyze how the individual members contribute to the making of one system, the tracheae. There are seven DWnt genes in the Drosophila genome, including wingless (wg). The wg gene helps to pattern the developing trachea but is not responsible for all Wnt functions there. We test each one of the seven DWnts in several ways and find evidence that wg and DWnt2 can function in the developing trachea: when both genes are removed together, the phenotype is identical or very similar to that observed when the Wnt pathway is shut down. DWnt2 is expressed near the tracheal cells in the embryo in a different pattern to wg but is also transduced through the canonical Wnt pathway. We find that the seven DWnt genes vary in their effectiveness in specific tissues, such as the tracheae, and, moreover, the epidermis and the tracheae respond to DWnt2 and Wg differently. We suggest that the main advantage of retaining a number of similar genes is that it allows more subtle forms of control and more flexibility during evolution.

Wingless signalling: more about the Wingless morphogen.

Recent work on pattern formation in the Drosophila embryo reveals a new mechanism which shapes the gradient of the secreted morphogen, Wingless: Wingless protein is degraded more rapidly on one side of its source than on the other.

Morphogens: how big is the big picture?

Morphogens are in the front line just now. Here I trace how the concept of a morphogen has evolved over the past 100 years and step a little beyond what we already know.

Effect of alpha-tocopherol supplementation on the ultrastructural abnormalities of peripheral nerves in experimental diabetes.

Ultrastructural observations were made on myelinated fibers in the tibial nerves in order to investigate the beneficial effects of alpha-tocopherol administration in streptozotocin-diabetic rats. Male Wistar rats, aged 12 weeks and weighing between 250 g to 300 g were studied. Six onset control rats were used to obtain the baseline parameters for this strain and age. Further 3 groups--untreated diabetic animals, diabetic animals treated with alpha-tocopherol, and age-matched controls--were studied over a 3-month period. In the diabetic animal, administration of alpha-tocopherol resulted in a significant increase (p < 0.05) in total plasma vitamin E levels when compared with other groups. Myelinated fiber cross-sectional area (p < 0.05), axonal area (p < 0.01) and myelin sheath area (p < 0.05) were significantly less in the tibial nerve of diabetic animals than in age-matched controls, but not different from those of onset controls. In the alpha-tocopherol treated diabetic animals, the values for these parameters were intermediate without showing significant difference when compared with age-matched controls and untreated diabetics. The "g" ratio (axon to fiber area) did not differ between any experimental groups. The number of large myelinated fibers were less in the untreated diabetic animals, but in the alpha-tocopherol-treated diabetics, the values were significantly higher (p < 0.05) than with untreated diabetics and were similar to those of age-matched controls. In conclusion, this ultrastructural study reiterated the fact that structural abnormalities of myelinated fibers occur in experimental diabetes and that alpha-tocopherol administration may be useful in preventing the development of these abnormalities.

Neurotransmitters regulating acid secretion in the proventriculus of the Houbara bustard (Chlamydotis undulata): a morphological viewpoint.

Endocrine cells containing somatostatin (Som), gastrin-releasing peptide (GRP), and neuronal nitric oxide synthase (nNOS) and nerve fibers containing choline acetyl transferase (ChAT), tyrosine hydroxylase (TH), galanin (Gal), substance P (SP), and vasoactive intestinal polypeptide (VIP) were immunolocalized in the proventriculus of the Houbara bustard, Chlamydotis undulata. While GRP-immunoreactive (GRP-IR) cells occur in the inner zone, somatostatin (Som-IR) and polyclonal nNOS (nNOS-IR) immunoreactive cells were localized mainly in the peripheral zone of submucosal glands. GRP-IR, Som-IR, and nNOS-IR cells were occasionally observed in the walls of the gastric glands. Endocrine cells are of the closed variety and usually possess apical processes extending along the basal surfaces of adjacent nonreactive cells. Ultrastructural features of these cells are typical. ChAT, Gal, SP, VIP, and TH were immunolocalized in nerve fibers and terminals in the walls of arterioles and capillaries at the periphery of submucosal glands. Immunoreactivity to monoclonal nNOS occurred mainly in neuronal cell bodies in ganglia located around the submucosal glands. ChAT and TH immunoreactive cell bodies were also occasionally seen around the submucosal glands in the peripheral region. Immunoreactivity to Gal, SP, and VIP, but not ChAT or TH, was discernible around the walls of gastric glands. It was concluded that the distribution of neurotransmitters in neuronal structures is similar, but that of the endocrine cells varies from that of some avian species. The roles of these neurotransmitters in the regulation of acid secretion are discussed.

Science or alchemy?

Hyperbole has become a common and accepted practice in science nowadays. We sell our results, we hide our ignorance and we use stock terms that gain spurious weight through repeated use. I illustrate from the field of developmental genetics.

Measuring dimensions: the regulation of size and shape.

Over many years evidence has accumulated that plants and animals can regulate growth with reference to overall size rather than cell number. Thus, organs and organisms grow until they reach their characteristic size and shape and then they stop - they can even compensate for experimental manipulations that change, over several fold, cell number or average cell size. If the cell size is altered, the organism responds with a change in cell number and vice versa. We look at the Drosophila wing in more detail: here, both extracellular and intracellular regulators have been identified that link cell growth, division and cell survival to final organ size. We discuss a hypothesis that the local steepness of a morphogen gradient is a measure of length in one axis, a measure that is used to determine whether there will be net growth or not.

Immunolocalization of collagen types II and III in single fibrils of human articular cartilage.

Type II and III fibrillar collagens were localized by immunogold electron microscopy in resin sections of human femoral articular cartilage taken from the upper radial zone in specimens from patients with osteoarthritis. Tissue samples stabilized by high-pressure cryofixation were processed by freeze-substitution, either in acetone containing osmium or in methanol without chemical fixatives, before embedding in epoxy or Lowicryl resin, respectively. Ultrastructural preservation was superior with osmium-acetone, although it was not possible to localize collagens by this method. In contrast, in tissue prepared by low-temperature methods without chemical fixation, collagens were successfully localized with mono- or polyclonal antibodies to the helical (Types II and III) and amino-propeptide (Type III procollagen) domains of the molecule. Dual localization using secondary antibodies labeled with 5- or 10-nm gold particles demonstrated the presence of Types II and III collagen associated within single periodic banded fibrils. Collagen fibrils in articular cartilage are understood to be heteropolymers mainly of Types II, IX, and XI collagen. Our observations provide further evidence for the complexity of these assemblies, with the potential for interactions between at least 11 distinct collagen types as well as several noncollagenous components of the extracellular matrix.

hedgehog and engrailed: pattern formation and polarity in the Drosophila abdomen.

Like the Drosophila embryo, the abdomen of the adult consists of alternating anterior (A) and posterior (P) compartments. However the wing is made by only part of one A and part of one P compartment. The abdomen therefore offers an opportunity to compare two compartment borders (A/P is within the segment and P/A intervenes between two segments), and ask if they act differently in pattern formation. In the embryo, abdomen and wing P compartment cells express the selector gene engrailed and secrete Hedgehog protein whilst A compartment cells need the patched and smoothened genes in order to respond to Hedgehog. We made clones of cells with altered activities of the engrailed, patched and smoothened genes. Our results confirm (1) that the state of engrailed, whether 'off' or 'on', determines whether a cell is of A or P type and (2) that Hedgehog signalling, coming from the adjacent P compartments across both A/P and P/A boundaries, organises the pattern of all the A cells. We have uncovered four new aspects of compartments and engrailed in the abdomen. First, we show that engrailed acts in the A compartment: Hedgehog leaves the P cells and crosses the A/P boundary where it induces engrailed in a narrow band of A cells. engrailed causes these cells to form a special type of cuticle. No similar effect occurs when Hedgehog crosses the P/A border. Second, we look at the polarity changes induced by the clones, and build a working hypothesis that polarity is organised, in both compartments, by molecule(s) emanating from the A/P but not the P/A boundaries. Third, we show that both the A and P compartments are each divided into anterior and posterior subdomains. This additional stratification makes the A/P and the P/A boundaries fundamentally distinct from each other. Finally, we find that when engrailed is removed from P cells (of, say, segment A5) they transform not into A cells of the same segment, but into A cells of the same parasegment (segment A6).

The hedgehog morphogen and gradients of cell affinity in the abdomen of Drosophila.

The adult abdomen of Drosophila is a chain of anterior (A) and posterior (P) compartments. The engrailed gene is active in all P compartments and selects the P state. Hedgehog enters each A compartment across both its anterior and posterior edges; within A its concentration confers positional information. The A compartments are subdivided into an anterior and a posterior domain that each make different cell types in response to Hedgehog. We have studied the relationship between Hedgehog, engrailed and cell affinity. We made twin clones and measured the shape, size and displacement of the experimental clone, relative to its control twin. We varied the perceived level of Hedgehog in the experimental clone and find that, if this level is different from the surround, the clone fails to grow normally, rounds up and sometimes sorts out completely, becoming separated from the epithelium. Also, clones are displaced towards cells that are more like themselves: for example groups of cells in the middle of the A compartment that are persuaded to differentiate as if they were at the posterior limit of A, move posteriorly. Similarly, clones in the anterior domain of the A compartment that are forced to differentiate as if they were at the anterior limit of A, move anteriorly. Quantitation of these measures and the direction of displacement indicate that there is a U-shaped gradient of affinity in the A compartment that correlates with the U-shaped landscape of Hedgehog concentration. Since affinity changes are autonomous to the clone we believe that, normally, each cell's affinity is a direct response to Hedgehog. By removing engrailed in clones we show that A and P cells also differ in affinity from each other, in a manner that appears independent of Hedgehog. Within the P compartment we found some evidence for a U-shaped gradient of affinity, but this cannot be due to Hedgehog which does not act in the P compartment.