Assessing the Patient Safety Culture in Dentistry.

OBJECTIVES: Medical errors are among the leading causes of death within the United States. Studies have shown that patients can be harmed while receiving care, sometimes resulting in permanent injury or, in extreme cases, death. To reduce the risk of patient safety incidents, it is imperative that a robust culture of safety be established. The primary objective of this study was to evaluate the patient safety culture among providers at 4 US dental institutions, comparing the results with their medical counterparts in 2016. METHODS: This cross-sectional study uses the Medical Office Survey on Patient Safety Culture that was modified for dentistry and administered at 4 US dental institutions during the 2016 calendar year. All dental team members were invited to complete electronic or paper-based versions of the questionnaire. RESULTS: Among 1,615 invited participants, 656 providers responded (rate, 40.6%). Medical institutions outperformed the dental institutions on 9 of the 10 safety culture dimensions, 6 of the 6 overall quality items, and 8 of the 9 patient safety and quality issues. The surveyed dental institutions reported the strongest average percentage positive scores in organizational learning (85%) and teamwork (79%). CONCLUSION: These findings suggest that the patient safety culture progressed over time. However, there is still heterogeneity within safety culture among academic dental, private (nonacademic), and medical clinics. KNOWLEDGE TRANSFER STATEMENT: Patient safety is the first dimension of quality improvement. Administering the Medical Office Survey on Patient Safety Culture within dental clinics represents a key measure to understand where improvements can be made with respect to patient care safety.

Malignant anal sac melanoma in dogs: eleven cases (2000 to 2015).

OBJECTIVES: To report the signalment, clinical presentation, treatments pursued and outcomes of dogs with malignant anal sac melanoma. METHODS: Medical records from five institutions from January 2000 through December 2015 were reviewed and dogs with cytologically- or histologically-confirmed malignant anal sac melanoma were identified. Signalment, clinical signs, staging, cytology, histopathologic analysis, surgical and non-surgical treatments were extracted from the medical records. The referring veterinarians and owners were contacted for follow-up data. RESULTS: Eleven dogs were included and survival data was available for all. The most common clinical signs were bloody anal sac discharge and perianal licking. Initial treatments pursued included surgery (n=8), chemotherapy (n=1), and palliative treatment with pain medications and stool softeners (n=2). In an adjuvant setting, melanoma vaccine was pursued following surgery in three dogs and chemotherapy in one dog. Regardless of treatment, progression-free survival (mean 92 · 5 days) and overall survival times (median 107 days) were short. CLINICAL SIGNIFICANCE: Dogs in this case series had a guarded to poor prognosis regardless of treatment. Ten of 11 dogs were euthanased due to local or distant disease progression. Only 1 of 11 dogs was alive one year after diagnosis. An understanding of tumour behaviour in this location could lead to improved survival times with earlier diagnosis and treatment.

The use of novel lymphatic endothelial cell-specific immunohistochemical markers to differentiate cutaneous angiosarcomas in dogs.

Lymphangiosarcomas are uncommon vascular neoplasms that arise from lymphatic endothelial cells (LECs). They efface and replace normal subcutaneous tissue and are characterised by arborising, vascular channels lined by a single layer of pleomorphic endothelial cells and a paucity of erythrocytes. Lymphangiosarcomas are architecturally similar to hemangiosarcomas, a common malignancy of vascular origin arising from blood vascular endothelial cells. Common immunohistochemical markers for vascular endothelium, such as Factor VIII-related antigen (F8RA) and CD31, have traditionally been used to confirm the diagnosis of tumours of vascular origin. However, these markers fail to differentiate between lymphangiosarcoma and hemangiosarcoma, which often show overlapping morphologic features, disparate clinical behaviour and require different treatment modalities. Here we describe the use of two novel LEC-specific markers, lymphatic vessel endothelial receptor-1 (LYVE-1) and prospero-related homeobox gene-1 (PROX-1), to further differentiate between vascular tumours of lymphatic (lymphangiosarcoma) and blood (hemangiosarcoma) endothelial cell origin in the dog.

Lymphangiosarcoma in 12 dogs: a case series (1998-2013).

Lymphangiosarcoma (LAS) is an uncommon malignant neoplasia arising from lymphatic endothelium; little information exists regarding therapy. Single institutional retrospective review for canine LAS histopathology diagnoses over a 15-year period yielded 12 dogs. Ten dogs were presented for a mass and/or swelling at cervical, trunk or limb regions. Prior to diagnosis, 10 dogs received empiric wound therapy. Cytology performed in 10 consisted of mild inflammation. Survival ranged from 60, 168 and 876 days for three dogs with palliation; 90 days with prednisone in one; 182 days with chemotherapy in one; 240, 267, 487, 630 and 941 days for five receiving surgery; and 574 days for one receiving surgery, radiation and chemotherapy. One dog is alive with recurrence at 243 days following surgery and carboplatin chemotherapy. Clinical improvement existed in LAS dogs receiving multimodal therapies. Early tissue biopsies are recommended for progressive oedematous lesions of unknown origin.

Correlation of nodal mast cells with clinical outcome in dogs with mast cell tumour and a proposed classification system for the evaluation of node metastasis.

Lymph node metastasis in dogs with mast cell tumour has been reported as a negative prognostic indicator; however, no standardized histological criteria exist to define metastatic disease. The primary aim of this study was to determine whether different histological patterns of node-associated mast cells correlate with clinical outcome in dogs with mast cell tumour. A secondary goal was to propose a criteria-defined classification system for histological evaluation of lymph node metastasis. The Colorado State University Diagnostic Medicine Center database was searched for cases of canine mast cell tumours with reported lymph node metastasis or evidence of node-associated mast cells. Additional cases were obtained from a clinical trial involving sentinel lymph node mapping and node extirpation in dogs with mast cell neoplasia. Forty-one cases were identified for inclusion in the study. Demographic data, treatment and clinical outcome were collected for each case. Lymph nodes were classified according to a novel classification system (HN0-HN3) based on the number of, distribution of, and architectural disruption by, nodal mast cells. The findings of this study indicate that characterization of nodal mast cells as proposed by this novel classification system correlates with, and is prognostic for, clinical outcome in dogs with mast cell tumours.

A review of sentinel lymph node evaluation and the need for its incorporation into veterinary oncology.

Being the first lymph node or nodes to which many primary tumours reliably drain, the disease status of the sentinel lymph node/s (SLN) is important in the prediction of survival. SLN identification and biopsy are critical in the staging of human cancers. The status of the SLN helps determine prognosis and shape treatment plans. SLN evaluation is currently not routinely performed in veterinary oncology, not even at specialty oncology practices. Given the prognostic importance of lymph node involvement in tumours such as mammary gland carcinoma, osteosarcoma, synovial cell sarcoma and mast cell tumours, SLN evaluation should be incorporated into routine clinical practice so as to improve our clinical assessment of veterinary oncologic patients.

Developmental regulation of GDNF response and receptor expression in the enteric nervous system.

The development of the enteric nervous system is dependent upon the actions of glial cell line-derived neurotrophic factor (GDNF) on neural crest-derived precursor cells in the embryonic gut. GDNF treatment of cultured enteric precursor cells leads to an increase in the number of neurons that develop and/or survive. Here we demonstrate that, although GDNF promoted an increase in neuron number at all embryonic ages examined, there was a developmental shift from a mitogenic to a trophic response by the developing enteric neurons. The timing of this shift corresponded to developmental changes in gut expression of GFR alpha-1, a co-receptor in the GDNF-Ret signaling complex. GFR alpha-1 was broadly expressed in the gut at early developmental stages, at which times soluble GFR alpha-1 was released into the medium by cultured gut cells. At later times, GFR alpha-1 became restricted to neural crest-derived cells. GFR alpha-1 could participate in GDNF signaling when expressed in cis on the surface of enteric precursor cells, or as a soluble protein. The GDNF-mediated response was greater when cell surface, compared with soluble, GFR alpha-1 was present, with the maximal response seen the presence of both cis and trans forms of GFR alpha-1. In addition to contributing to GDNF signaling, cell-surface GFR alpha-1 modulated the specificity of interactions between GDNF and soluble GFR alphas. These experiments demonstrate that complex, developmentally regulated, signaling interactions contribute to the GDNF-dependent development of enteric neurons.

Trichinella sp. in wolves from interior Alaska.

Tongue samples were collected from 148 wolf (Canis lupus) carcasses during 1993 and 1994 near Fairbanks (Alaska, USA). A standard peptic digestion procedure was used to detect Trichinella sp. larvae. Larvae were found in 54 of 148 (36%) samples. There was no significant difference in sex-specific prevalence. Prevalence was significantly related to age. There was no relationship between the number of larvae/g of host tissue and the age or sex of the host. Trichinella spp. infection may cause illness in individual wolves. However, there was no indication the parasite had any impact on the population.

The RET-glial cell-derived neurotrophic factor (GDNF) pathway stimulates migration and chemoattraction of epithelial cells.

Embryonic development requires cell migration in response to positional cues. Yet, how groups of cells recognize and translate positional information into morphogenetic movement remains poorly understood. In the developing kidney, the ureteric bud epithelium grows from the nephric duct towards a group of posterior intermediate mesodermal cells, the metanephric mesenchyme, and induces the formation of the adult kidney. The secreted protein GDNF and its receptor RET are required for ureteric bud outgrowth and subsequent branching. However, it is unclear whether the GDNF-RET pathway regulates cell migration, proliferation, survival, or chemotaxis. In this report, we have used the MDCK renal epithelial cell line to show that activation of the RET pathway results in increased cell motility, dissociation of cell adhesion, and the migration towards a localized source of GDNF. Cellular responses to RET activation include the formation of lamellipodia, filopodia, and reorganization of the actin cytoskeleton. These data demonstrate that GDNF is a chemoattractant for RET-expressing epithelial cells and thus account for the developmental defects observed in RET and GDNF mutant mice. Furthermore, the RET-transfected MDCK cells described in this report are a promising model for delineating RET signaling pathways in the renal epithelial cell lineage.

Outcomes associated with advanced nursing practice prescriptive authority.

Thirty-three advanced practice nurses (APNs) in 25 different primary care sites in one state participated in a study of the safety and effectiveness of APN prescriptive authority. Data were analyzed on 1,708 patients seen during a 2-month period. Outcomes of care were studied using three different measures as well as patient satisfaction. Evaluation of patient outcome by APN and physician indicated that in 76% of the cases, the patient's condition stabilized or improved. Patients evaluated their own outcomes positively. Participating physicians were unanimous in their evaluation of APN prescriptive authority as beneficial to their patients.

Glial cell line-derived neurotrophic factor-dependent RET activation can be mediated by two different cell-surface accessory proteins.

Glial cell line-derived neurotrophic factor (GDNF)-dependent activation of the tyrosine kinase receptor RET is necessary for kidney and enteric neuron development, and mutations in RET are associated with human diseases. Activation of RET by GDNF has been shown to require an accessory component, GDNFR-alpha (RETL1). We report the isolation and characterization of rat and human cDNAs for a novel cell-surface associated accessory protein, RETL2, that shares 49% identity with RETL1. Both RETL1 and RETL2 can mediate GDNF dependent phosphorylation of RET, but they exhibit different patterns of expression in fetal and adult tissues. The most striking differences in expression observed were in the adult central and peripheral nervous systems. In addition, the mechanisms by which the two accessory proteins facilitate the activation of RET by GDNF are quite distinct. In vitro binding experiments with soluble forms of RET, RETL1 and RETL2 demonstrate that while RETL1 binds GDNF tightly to form a membrane-associated complex which can then interact with RET, RETL2 only forms a high affinity complex with GDNF in the presence of RET. This strong RET dependence of the binding of RETL2 to GDNF was confirmed by FACS analysis on RETL1 and RETL2 expressing cells. Together with the recent discovery of a GDNF related protein, neurturin, these data raise the possibility that RETL1 and RETL2 have distinctive roles during development and in the nervous system of the adult. RETL1 and RETL2 represent new candidate susceptibility genes and/or modifier loci for RET-associated diseases.

Survey of free-ranging elk from Wyoming and Montana for selected pathogens.

From December 1991 through January 1995, a disease survey was conducted on herds of free-ranging, hunter-killed elk (Cervus elaphus nelsoni) from three areas in proximity to Yellowstone National Park (YNP), Wyoming (USA), after tuberculosis caused by Mycobacterium bovis was discovered in a captive herd of elk in the area. Complete or partial sets of specimens from 289 elk collected between December 1991 and January 1993 were examined histologically; no mycobacterial lesions were observed. Lesions of tuberculosis were not detected in tonsils or lymph nodes of the head from an additional 99 hunter-killed, adult elk from one area (area 2) collected in January 1995. Neither M. bovis nor M. paratuberculosis were isolated from any of the specimens cultured. Antibodies to Brucella abortus were detected in serum samples from 0%, 1%, and 1% of elk from three areas sampled (areas 1, 2 and 3), respectively. Brucella abortus biovar 1 was isolated from multiple tissues from one seropositive animal from area 3. Larvae with morphology consistent with Dictyocaulus sp. were found in 12%, 14%, and 0% of fecal specimens tested from areas 1, 2, and 3, respectively. Pasteurella multocida and Actinomyces pyogenes were isolated from a lung with purulent bronchopneumonia and abscesses.

Use of fenbendazole for long-term control of protostrongylid lungworms in free-ranging Rocky Mountain bighorn sheep.

In an effort to control Protostrongylus spp. in a Rocky Mountain bighorn sheep herd (Ovis canadensis canadensis) of approximately 30 animals, fenbendazole-medicated salt was placed on the Stillwater bighorn winter range in southcentral Montana (USA) for four consecutive winters, 1990 to 1993. Sheep of all age and sex classes were observed using the medicated salt throughout the study period. Prevalence and average number of lungworm larvae per gram of bighorn feces declined significantly (P < 0.05) from pretreatment levels (1987 to 1989), and remained low throughout the study period. Free-choice availability of fenbendazole-medicated salt is a potentially effective management tool for long-term control of protostrongylid lungworm.

Effects of heredity, age, weight, puberty, activity, and calcium intake on bone mineral density in children.

Osteoporosis is a disease that plagues older individuals, particularly women. At the usual age of diagnosis, limited therapy is available. By further delineating the factors that influence bone mineral acquisition before peak bone density is achieved, individuals at risk may be identified at an earlier age when therapies may be more effective. This was a study of 16 family units, 16 mothers, eight fathers, and their 28 children between the ages of 5 and 20 years. The evaluation consisted of a focused history, Tanner staging of adolescents, anthropometric data (height, weight), and spinal bone mineral density (BMD) by DEXA (dual-energy x-ray absorptiometry). Bone mineral density in the children was compared with multiple environmental factors. Bone mineral density Z-scores were then compared between children and their parents. Variables found to be positively correlated with children's BMDs were: age (r = 0.94, P < 0.001), Tanner stage (r = 0.90, P < 0.001), weight (r = 0.88, P < 0.001), height (r = 0.81, P < 0.001), and body mass index (r = 0.77, P < 0.001). No association was found between calcium intake and BMD, owing possibly to increased calcium intake among children with a family history of osteoporosis. Activity was not significantly associated with BMD. Significant correlations were noted between the children's BMD and that of their father's (r = 0.83, P = 0.01), premenopausal mother's (r = 0.58, P = 0.03), and midparental (the mean value of both parents' BMDs) (r = 0.86, P = 0.01). These data suggest that children who have parents affected by low BMD may be at risk for low BMD themselves.

Epidemiology of Ostertagia in the Northwestern USA.

The two most significant environmental factors that influence the epidemiology of Ostertagia are temperature and moisture. These factors vary more in the west and northwest than in any other part of the USA because of extreme regional differences in climate, topography, and land use. Consequently, patterns of Ostertagia transmission and inhibition also vary widely from region to region and from year to year. Recent data require revisions of previously accepted concepts of northern/southern transmission and inhibition. In particular, the flaw of liberal extrapolation of information from one region to another has now been recognized. Inhibition may not occur along the coast of the Pacific Northwest. Although not completely delineated, the transition zone between northern and southern patterns of inhibition appears to be significantly wider and more variable than previously recognized; Oregon data suggest a possible indeterminate and variable band extending north of the 45th parallel and south of the 43rd parallel. Summer inhibition has now been documented in areas of Oregon and Montana. Other than the recent Oregon and Montana studies, data on this transition zone in the Rocky Mountain region and high plains are sparse to non-existent. In contrast to previously accepted doctrine, the fall rise in egg count generally exceeds the traditionally accepted spring rise in many areas. From the Pacific Northwest to the Midwest, year-round transmission patterns have been observed. The presence of geothermal ground water sources produces microclimates that favor larval survival in many areas.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of Montana and Alaska isolates of Echinococcus multilocularis in gerbils with observations on the cyst growth, hook characteristics, and host response.

To assess its biological distinctness, an isolate of Echinococcus multilocularis from Montana was compared with an isolate from Alaska in gerbils (Meriones unguiculatus) by means of intraperitoneal inoculations with protoscoleces. The cysts formed by the Montana isolate were entire, hyaline, and translucent, whereas those produced by the Alaska isolate were granular, yellowish, and opaque. Vesicles of the Montana isolate were larger, produced protoscoleces more slowly but in greater numbers, and required a longer period to develop surfacial germ cell protrusions, which were of smaller size. Also delayed was invasion of the laminate layer by granulocytes and macrophages, and a longer time was required for the appearance of pulmonary metastases. The 2 isolates differed also in characteristics of rostellar hooks, those from the Montana isolate being fewer and larger, often with accessory hooks.

Trichinella spiralis: genetic evidence for synanthropic subspecies in sylvatic hosts.

Isolates of the nematode genus Trichinella from sylvatic hosts differ in their potential to reproduce in domestic swine. The structure of the genomic DNA from 13 sylvatic isolates from North America and 5 pig isolates, 4 from North America and 1 from Asia, was examined and correlated with the infectivity of the isolate for domestic pigs. DNA restriction fragment length differences, identified by ethidium bromide staining and by hybridization with 32P-labeled ribosomal RNA, served as molecular markers to classify each isolate. All 5 pig isolates and 8 of 13 sylvatic isolates had a high infectivity and reproductive capacity in pigs. All isolates that were highly infectious for pigs regardless of host origin had similar DNA characteristics and were classified operationally as T. spiralis spiralis (pig) and those of the second group as T. spiralis ssp. A DNA clone of repetitive DNA from T. s. spiralis, pBP2, was selected from a library of genomic DNA in plasmid pUC8. When used as a probe, pBP2 hybridized only to the DNA of T. s. spiralis isolates, thus making it a useful diagnostic reagent to predict whether new isolates are highly infectious for pigs (i.e., T. s. spiralis). These results show that T. s. spiralis occurs in wild mammals and this should be considered a serious obstacle to efforts to eradicate trichinellosis from domestic swine.

Survival of sylvatic Trichinella spiralis isolates in frozen tissue and processed meat products.

The ability of Trichinella spiralis larvae to survive at subfreezing temperatures encysted in the musculature of wild carnivorous mammals was assessed by evaluating motility and infectivity (to rodents) of trichinae at various intervals after storage in frozen skeletal muscle. Fifty to 60% of the larvae in grizzly bear meat were alive after storage for 27 months at -6.5 to -20 C, and 30% to 50% were still alive at 34 months. However, none survived for 38 months, on the basis of infectivity in mice and larval motility. Trichinella larvae survived up to 4 months in frozen (-6.5 to -20 C) wolverine tissue. Viable larvae were not recovered from mountain lion or fisher muscle frozen for 1 month. The effect of postslaughter processing on Trichinella larvae encysted in bear meat was evaluated by use of a similar bioassay procedure. Viability of larvae recovered from black bear meat that had been processed into ham or jerky was not affected by dry curing with a commercial salt mixture. Trichinae from both preparations induced infections in mice (58 to 90 larvae/g of tissue). However, a combination of curing and smoking was consistently lethal to encysted larvae. Viable trichinae were not recovered from ground bear meat preparations (pepperoni, salami, or sausage) processed according to commercial standards.

Characterization of Lotus tetragonolobus fucolectin components for differences in hemagglutinating and macrophage activating activities.

The fucose binding proteins (FBP) extracted from Lotus tetragonolobus seeds were isolated by affinity chromatography and compared with affinity purified commercial preparations for physical, antigenic, and biological properties. All preparations contained three protein components as determined by polyacrylamide gel electrophoresis, each with a subunit molecular weight of approximately 27 Kd. FBP preparations were also found to be antigenically identical by immunodiffusion analysis and possessed similar biological activities for hemagglutination of group 0 erythrocytes and macrophage activation in the migration inhibition assay. A reversible temperature dependent hemagglutination characteristic was found; FBP agglutinated erythrocytes at 4 degrees and 22 degrees C but not at 37 degrees C, which was reversed by decreasing the incubation temperature from 37 degrees C to 22 degrees C. Temperature dependent binding of FBP for macrophages was also demonstrated. Adsorption of crude FBP by group 0 erythrocytes preferentially removed hemagglutinin without loss of macrophage activating properties. Similarly adsorption of FBP with macrophages preferentially removed macrophage activating component. Separation of the lectin components by DEAE cellulose chromatography yielded two major fractions: a potent hemagglutinin with weak macrophage activating properties and a potent macrophage activator with weak hemagglutinating activity. Separation of the crude lectin by ultrafiltration indicated that the macrophage activating component exists in a highly aggregated form which may determine its macrophage activating properties. Our results indicate that L. tetragonolobus consists of two distinct classes of components which correspond to tetrameric glycoproteins of 118-120 Kd with potent temperature dependent hemagglutinating activity and a highly aggregated dimeric component of 58 Kd with macrophage activating properties.