Primers to highly conserved elements optimized for qPCR-based telomere length measurement in vertebrates.

Telomere length dynamics are an established biomarker of health and ageing in animals. The study of telomeres in numerous species has been facilitated by methods to measure telomere length by real-time quantitative PCR (qPCR). In this method, telomere length is determined by quantifying the amount of telomeric DNA repeats in a sample and normalizing this to the total amount of genomic DNA. This normalization requires the development of genomic reference primers suitable for qPCR, which remains challenging in nonmodel organism with genomes that have not been sequenced. Here we report reference primers that can be used in qPCR to measure telomere lengths in any vertebrate species. We designed primer pairs to amplify genetic elements that are highly conserved between evolutionarily distant taxa and tested them in species that span the vertebrate tree of life. We report five primer pairs that meet the specificity and reproducibility standards of qPCR. In addition, we demonstrate an approach to choose the best primers for a given species by testing the primers on multiple individuals within a species and then applying an established computational tool. These reference primers can facilitate qPCR-based telomere length measurements in any vertebrate species of ecological or economic interest.

CONTRASTING HABITAT ASSOCIATIONS OF SAGEBRUSH-STEPPE SONGBIRDS IN THE INTERMOUNTAIN WEST.

Sagebrush (Artemisia spp.) steppe is one of North America's most imperiled ecosystems, as the result of many factors including grazing, development, fire, and invasion of exotic plants. Threats to sagebrush steppe are expected to increase because of climate change and further human development. Many songbirds use sagebrush steppe opportunistically, but a few obligate species are dependent on it. To quantify the habitat associations of three sagebrush obligates, the Sage Thrasher (Oreoscoptes montanus), Sagebrush Sparrow (Artemisiospiza nevadensis), and Brewer's Sparrow (Spizella breweri), and nine other songbird species that use this habitat, we surveyed across a broad region of Idaho. At each of 104 sites, we selected three plots, one each in relatively poor, moderate, and good condition, defined qualitatively by the cover of native shrubs. We quantified bird abundance by point counts, described the habitat at these points by a line-intercept method, and at each plot calculated the fraction of a circle (radius 1 km) covered in shrubs or grassland. We compared two-scale occupancy models based on these data by the information-theoretic approach. According to the models, our qualitative assessment of habitat condition within a site distinguished birds' use of relatively good habitat from their use of poor habitats only, not from those in moderate condition. Thus the sagebrush-obligate species may tolerate some local habitat degradation, at least up to some unidentified threshold. Occurrence of all three sagebrush obligates correlated well with one or more characteristics of sagebrush such as its cover, height, or heterogeneity in height. They differed in the Sage Thrasher being most sensitive to sagebrush cover, the Sagebrush Sparrow being found more often at lower elevations, and the Brewer's Sparrow being less sensitive to ground cover. The nine other species evaluated were less or negatively associated with attributes of sagebrush. On the basis of these results, we suggest that the three sagebrush obligates are best conserved by promoting shrublands over a broad range of elevations, containing both sagebrush and other shrubs in patches of mixed height, and minimizing invasive annual grasses.

Endovascular embolization in combination with radiosurgery for treatment of arteriovenous malformations.

There are several options for the treatment of patients with arteriovenous malformations (AVMs). Surgical resection, radiosurgery and endovascular embolization can be used alone or in conjunction. In patients with AVMs not amenable to surgical resection due to large size or location, radiosurgery can address some but not all of these issues as cure rates remain low for volumes>10 cm3. Combining endovascular embolization with stereotactic radiosurgery allows potential volume reduction and reduction of risks related to factors that may increase bleeding risks during the latency interval after radiosurgery. The benefit of increased cure rates and possibly lower hemorrhage rates in the latency period may justify the added risk of embolization.

Incisor inclination changes produced by two compliance-free Class II correction protocols for the treatment of mild to moderate Class II malocclusions.

OBJECTIVE: To compare the changes in incisor inclination between two compliance-free Class II correction protocols for the treatment of mild to moderate Class II malocclusions. MATERIALS AND METHODS: Among Class II malocclusion patients a total of 38 consecutive patients treated with the Xbow appliance and later with full brackets (XB) were compared to 36 consecutive patients treated with Forsus connected to the archwire while on full brackets (FO). Evaluated cephalometric variables were overjet, overbite, skeletal Class II, lower incisor inclination, and upper incisor inclination. Factors that were analyzed were gender, treatment type, age at start of treatment (T1), and treatment length. Independent t-tests, χ(2), multiple analysis of variance, and Pearson correlations were applied. RESULTS: No differences in incisor inclination between both treatment protocols were identified. At T1 no statistical difference for any cephalometric variable was demonstrated with regard to gender and treatment type. Gender was also not associated with a different treatment time or age at T1. The mean treatment time was 24.2 months for XB and 30.2 months for the FO group (P  =  .037). XB patients averaged 10 fewer months of fixed edgewise appliances compared to FO patients. Neither gender nor treatment type had any influence on the changes of the evaluated dependent variables between T1 and the end of treatment. Lower incisors proclined more the longer the treatment (P  =  .005). Both overjet and upper incisor inclination were affected by age at T1 (P  =  .001 and P  =  .014, respectively). CONCLUSIONS: Both compliance-free Class II correction protocols for the treatment of mild to moderate Class II malocclusions appear to generate the same amount of incisor inclination. Large variability was identified.

The prevalence of defensive orthopaedic imaging: a prospective practice audit in Pennsylvania.

BACKGROUND: Defensive medicine has been identified as an area of wasteful health-care spending. Estimates of its prevalence and its contribution to the cost of defensive practices have varied widely. To date, there has been no prospective evaluation of the use of defensive medicine for musculoskeletal conditions. METHODS: Members of the Pennsylvania Orthopaedic Society were queried by means of an anonymous, prospective audit of consecutive imaging decisions in their clinical practice. For each image order, respondents recorded the modality, the body region imaged, and whether the imaging was "required for clinical care" or "ordered for defensive reasons." We evaluated the proportion of images that were ordered defensively, identified demographic differences with use of the chi-square test of independence, and calculated the contribution of defensive imaging to the total cost with use of 2009 Medicare reimbursement rates. RESULTS: Seventy-two orthopaedists recorded 2068 imaging decisions made during the day that their practice was audited. Defensive imaging represented 19.1% (396) of the orders and 34.7% ($113,675) of the total cost ($327,414). Magnetic resonance imaging (MRI) represented 48.7% of the defensive orders, and 38.5% (193) of the 501 MRIs were ordered for defensive reasons. The proportion of defensive imaging ordered by orthopaedists who had been sued for medical malpractice within the previous five years was significantly greater than the proportion ordered by those who had not been sued during the same time frame (24.6% compared with 15.1%, p < 0.001). The proportion of defensive imaging ordered by orthopaedists who had been in practice for more than fifteen years was significantly greater than the proportion ordered by those who had less experience (20.8% compared with 17.1%, p = 0.03). CONCLUSIONS: In a prospective practice audit of orthopaedists, defensive imaging was found to be both common and costly. Recent litigation experiences and longer duration of orthopaedic practice were independent predictors of an increased use of defensive practices in ordering imaging studies. This real-time audit showed that a large proportion of MRI studies were ordered for primarily defensive medicine reasons.

Use of portfolios in otolaryngology graduate medical education.

OBJECTIVES/HYPOTHESIS: Learning portfolios, as defined by the Accreditation Council for Graduate Medical Education (ACGME), are professional development tools for resident education. Moreover, the scope of portfolio use is expanding to become a component of the accreditation system, with likely mandatory implementation by 2016. The objective of this study is to describe the extent of portfolio use in otolaryngology training programs and resident attitudes toward portfolios. STUDY DESIGN: Cross-sectional survey. METHODS: All residents in ACGME-accredited otolaryngology programs were contacted via email linked to an online survey. One follow-up email was sent after initial notification. RESULTS: Three hundred eighteen (22%) of the 1,431 invited residents responded to the survey, representing 65 of 103 ACGME-accredited otolaryngology training programs. Fifty-eight percent of the programs represented had residents who maintained a portfolio. When asked to what extent portfolios enhanced education, 39% of residents who kept a portfolio found them helpful, 27% were neutral, and 35% did not find them helpful, although 60% plan to use their portfolio after residency. For those residents who did not maintain a portfolio, 70% cited they did not maintain a portfolio because it is not a requirement in their program. Twenty-one percent of all respondents felt that portfolios should be mandatory, whereas 61% felt that portfolios should be encouraged, but not required. CONCLUSIONS: Although portfolios are encouraged by the ACGME, and will ultimately become mandatory, they are not yet fully integrated in otolaryngology training programs. Only a minority of residents in this study thought portfolios enhanced education.

Mentoring in otolaryngology training programs.

OBJECTIVE: The Accreditation Council for Graduate Medical Education's focus on outcome-based training has made the mentoring process critical for resident education. It is unknown how otolaryngology training programs mentor residents. Our objective was to determine the current state of mentoring in otolaryngology training programs and describe resident perceptions of mentoring. STUDY DESIGN: Cross-sectional survey. SETTING: Accredited U.S. otolaryngology training programs. SUBJECTS AND METHODS: All U.S. otolaryngology residents and program directors were contacted via e-mail with a link to an online survey. RESULTS: Of the 1411 residents contacted, 27.7 percent responded, representing 71 of the 103 accredited otolaryngology programs. Of the 103 program directors contacted, 37.9 percent responded. Of these programs, 26 had formal mentoring programs, 45 did not have formal mentoring programs, and 12 programs were listed in both categories. Fifty-one percent of male residents and 49 percent of female residents had mentors. The most important mentor characteristics were personality match, good clinical role model, and similar subspecialty interests. Least important characteristics were race, gender, and age. Twenty-six percent of residents felt that mentoring was critical to their training, while 63 percent of residents listed mentoring as important but not critical. Programs with fewer faculty and residents were less likely to offer formal mentoring (P = 0.007 and 0.054, respectively). Of residents who did not have mentors, 80 percent lacked a mentor because their residency had no formal mentoring program. CONCLUSION: Residents perceive mentoring as important, and formal mentoring programs should be incorporated into otolaryngology training programs.

Radiation dose reduction for augmentation mammography.

OBJECTIVE: Patients who undergo cosmetic augmentation have larger and denser breasts and receive higher radiation doses during mammography than women without implants. In this study we evaluated the dose increase and techniques for dose reduction. SUBJECTS AND METHODS: Mean glandular dose to the breast during screening mammography was measured for 206 women who had undergone breast augmentation. For 13 of these women, mean glandular dose from preoperative mammography also was measured. Effective tube current, peak kilovoltage, and breast thickness were measured, and mean glandular dose was calculated for 1,632 images. Two screen-film combinations and three target-filter combinations were studied. RESULTS: For four-view augmentation mammography with a molybdenum-molybdenum (Mo-Mo) target-filter combination, mean glandular dose was reduced 35%, from 10.7 to 7.0 mGy, by changing the screen-film combination from 100 to 190 speed. For four-view augmentation mammography, mean glandular dose was reduced 24% by changing the target-filter combination from Mo-Mo to rhodium-rhodium (Rh-Rh) for full views of breasts containing implants. For four-view augmentation mammography, mean glandular dose was reduced 50% by changing the screen-film combination from 100 to 190 speed and changing the target-filter combination from Mo-Mo to Rh-Rh for implant-full views. CONCLUSION: Mean glandular dose per breast from four-view augmentation mammography with the 100-speed screen-film and Mo-Mo target-filter combinations averaged 10.7 mGy, which is 3.1 times higher than the 3.4 mGy for conventional two-view mammography of breasts without implants. In 40 years of screening, this number represents a more than tripled lifetime attributable risk of radiation-induced breast cancer--an unacceptable level. Use of faster screen-film combinations, use of Rh-Rh target-filter combinations, and acquisition of three rather than four views are dose-reduction methods that together result in a 66% dose reduction, from 10.7 to 3.6 mGy. Mean glandular dose should be kept less than 7.0 mGy per breast for screening mammography of patients with breast implants.

The Ghana community-based health planning and services initiative for scaling up service delivery innovation.

Research projects demonstrating ways to improve health services often fail to have an impact on what national health programmes actually do. An approach to evidence-based policy development has been launched in Ghana which bridges the gap between research and programme implementation. After nearly two decades of national debate and investigation into appropriate strategies for service delivery at the periphery, the Community-based Health Planning and Services (CHPS) Initiative has employed strategies tested in the successful Navrongo experiment to guide national health reforms that mobilize volunteerism, resources and cultural institutions for supporting community-based primary health care. Over a 2-year period, 104 out of the 110 districts in Ghana started CHPS. This paper reviews the development of the CHPS initiative, describes the processes of implementation and relates the initiative to the principles of scaling up organizational change which it embraces. Evidence from the national monitoring and evaluation programme provides insights into CHPS' success and identifies constraints on future progress.

Orthodontic treatment with a series of removable appliances.

BACKGROUND: In the United States, the demand for straight white teeth has never been more important to patients. Crowded, poorly aligned teeth are not esthetically pleasing and are difficult to keep clean. However, until recently, the process of straightening the teeth typically has involved appliances involving bands, brackets and wires that also can be difficult to clean. The desire for a cosmetic solution to misaligned teeth has led to an increase in the number of patients seeking veneers, crowns and other laboratory-fabricated cosmetic restorations. Some clinicians are not aware that there are other ways to align teeth without either significant enamel reduction or conspicuous fixed orthodontic appliances. DESCRIPTION OF TECHNIQUE: An alternative method of treatment, involving a series of clear removable appliances, circumvents this shortcoming and enables tooth alignment while avoiding deterioration in the cosmetics of the smile during treatment. This article describes a method of treatment, Invisalign (Align Technology, Santa Clara, Calif.), that clinicians can use in conjunction with 3-D computer models to accomplish the esthetic and oral hygiene objectives during and after treatment. CASE DESCRIPTIONS: The authors present three case reports, all involving a chief concern of crowding. The first case involved treatment of both arches by interproximal reduction, alignment of teeth and leveling the curve of Spee. The second case involved treatment of both arches by proclination, expansion and minor interproximal reduction. The final case shows relief of lower-arch crowding via lower-incisor extraction. CLINICAL IMPLICATIONS: In addition to satisfying the patient's chief concern of desiring straight teeth, this method of treatment satisfies additional objectives of esthetic treatment and esthetic results with significant oral hygiene benefits. Clinicians can address a patient's chief concern effectively without requiring an inventory of appliances (such as bands, brackets, wires and instruments). Furthermore, the use of 3-D computer models can give clinicians additional information to make more complete decisions regarding treatment.