Abstract VCAM-1 is a cell surface molecule, which has been shown to mediate leukocyte adhesion to the endothelium and subsequent transmigration. Although VCAM-1 regulates adhesion through its interaction with VLA-4, VLA-4 does not play a role in VCAM-1-dependent diapedesis, an observation suggesting the presence of a second ligand for VCAM-1. We now report a novel interaction between VCAM-1 and secreted protein acidic and rich in cysteine (SPARC), which induces actin cytoskeletal rearrangement and intercellular gaps, physiological processes known to be important for leukocyte transmigration. The binding of leukocyte-derived SPARC to VCAM-1 was demonstrated to be necessary for leukocyte transmigration through endothelial monolayers (diapedesis) in vitro, and furthermore, SPARC null mice have abnormalities in leukocyte recruitment to the inflamed peritoneum in vivo. These findings provide new insight into the mechanisms of transendothelial leukocyte migration and suggest a potential, targetable interaction for therapeutic intervention.
Introduction The purpose of this study was to explore factors that impact patients' ability to access high quality, expeditious oral health care by understanding medical professionals' knowledge of oral health, the care they provide to patients presenting with oral health complaints, and their perceptions of potential interventions to improve oral health care delivery. Methods We conducted in depth qualitative interviews, which were analyzed using an inductive content analytical approach. The study was conducted in Gugulethu, a community located outside of Cape Town, South Africa. Local public sector health services provided free-of-charge are the main source of primary health and dental care for this population. Participants included the following medical providers: doctors, clinical nurse practitioners, professional nurses, and health promoters. Results Identified themes fell within the three broad subject areas: oral health knowledge, patient care, and potential interventions. Themes within oral health knowledge included (1) personal responsibility for hygiene, (2) routine oral health care, (3) lack of knowledge among medical professionals, (4) poverty, and (5) an oral-systemic connection. Participants cited both 'clinical care knowledge' and/or 'uncertainty' about patient care for oral health complaints. Participants independently suggested interventions in three broad areas: (1) education, (2) expanded provider roles, and (3) colocation of services. Conclusions Our findings suggest that a variety of interventions, ranging from high to low resource investment, may impact access to and utilization of oral health services and thereby result in improved patient care. Future studies should develop and evaluate the suggested interventions in a range of care settings.
Early clinical exposure (ECE), defined as any interaction with patients prior to the portion of the curriculum when den- tal students spend most of their time at school as a primary provider, is a growing trend in curriculum reform across U.S. dental schools in the 21st century. The aims of this study were to characterize the types of ECE implementation in U.S. dental schools and determine if ECE correlated with earlier clinical competency assessments. In September 2018, the academic deans of all 66 U.S. dental schools were invited to respond to an eight-item electronic survey about ECE at their schools. Representatives of 40 schools submitted complete responses, for a response rate of 60.6%. Among the respondents, 85% reported their schools started their principal clinical experience (PCE), the portion of the curriculum when students spend most of their time as the primary provider for patients, during the last quarter of Year 2 or the first quarter of Year 3. Respondents at all 40 schools reported offering some form of ECE as part of the formal curriculum, with shadowing and performing dental prophylaxis the most commonly of- fered types. No statistically significant associations were found between specific types of ECE and related Commission on Dental Accreditation (CODA) clinical standards for both formative and summative assessments. Although U.S. dental schools have been incorporating more ECE into their curricula over the past decade, these findings suggest that it has not led to earlier clinical competency assessments.
Background: U.S. practitioners have prescribed opioid analgesics increasingly in recent years, contributing to what has been declared an opioid epidemic by the U.S. Centers for Disease Control and Prevention (CDC). Opioids are used frequently in the preoperative and postoperative periods for patients undergoing total joint replacement in developed countries, but cross-cultural comparisons of this practice are limited. An international medical mission such as Operation Walk Boston, which provides total joint replacement to financially vulnerable patients in the Dominican Republic, offers a unique opportunity to compare postoperative pain management approaches in a developed nation and a developing nation. Methods: We interviewed American and Dominican surgeons and nurses (n = 22) during Operation Walk Boston 2015. We used a moderator’s guide with open-ended questions to inquire about postoperative pain management and factors influencing prescribing practices. Interviews were recorded and transcripts were analyzed using content analysis. Results: Providers highlighted differences in the patient-provider relationship, pain medication prescribing variability, and access to medications. Dominican surgeons emphasized adherence to standardized pain protocols and employed a paternalistic model of care, and American surgeons reported prescribing variability and described shared decision-making with patients. Dominican providers described limited availability of potent opioid preparations in the Dominican Republic, in contrast to American providers, who discussed opioid accessibility in the United States. Conclusions: Our findings suggest that cross-cultural comparisons provide insight into how opioid prescribing practices, approaches to the patient-provider relationship, and medication access inform distinct pain management strategies in American and Dominican surgical settings. Integrating lessons from cross-cultural pain management studies may yield more effective pain management strategies for surgical procedures performed in the United States and abroad.
Abstract The aim of this study was to evaluate the feasibility and preliminary outcomes of immersive integrated experiential and didactic courses in strengthening competency‐based global health learning in dental education. To address global inequities in oral health and student interest in global health, the Harvard School of Dental Medicine introduced two global health courses in 2017‐18. The first was a didactic course in the core predoctoral curriculum, and the second, in collaboration with the Inter‐American Center for Global Health, was a five‐day elective experiential learning course in rural Costa Rica. The experiential course was an extension of the didactic course. All 33 second‐year dental students completed the didactic course, and three of those students completed the experiential course. A pre‐post survey and a six‐month follow‐up survey on self‐reported knowledge based on course learning objectives were administered. The experiential course students also completed journals and interviews for qualitative analysis. Thirty‐two students completed the pre‐post didactic course surveys, for a response rate of 94%. There was a 100% response rate on the pre‐post didactic surveys by those students who participated in the experiential learning course. While the experiential learning group scored similarly to the class average before the didactic course, they had higher scores than the class averages both immediately after and at the six‐month follow‐up. All three students reported that the experiential learning course was “extremely effective” in building on what they learned in the didactic course. Qualitative analysis of the journals and interviews suggested enhanced learning from the combination of didactic and experiential methods. These preliminary results support the Global Health Learning Helix Model, a theoretical competency‐based teaching model for ethical student global health engagement to better prepare the future generation in tackling oral health disparities both locally and worldwide.
The use of phage-displayed peptide libraries is a powerful method for selecting peptides with desired binding properties. However, the validation and prioritization of "hits" obtained from this screening approach remains challenging. Here, we describe the development and testing of a new analysis method to identify and display hits from phage-display experiments and high-throughput enzyme-linked immunosorbent assay screens. We test the method using a phage screen against activated macrophages to develop imaging agents with higher specificity for active disease processes. The new methodology should be useful in identifying phage hits and is extendable to other library screening methods such as small-molecule and nanoparticle libraries.
Advanced osteoarthritis and total joint replacement (TJR) recovery are painful experiences and often prompt opioid use in developed countries. Physicians participating in the philanthropic medical mission Operation Walk Boston (OpWalk) to the Dominican Republic have observed that Dominican patients require substantially less opioid medication following TJR than US patients. We conducted a qualitative study to investigate approaches to pain management and expectations for postoperative recovery in patients with advanced arthritis undergoing TJR in the Dominican Republic. We interviewed 20 patients before TJR about their pain coping mechanisms and expectations for postoperative pain management and recovery. Interviews were conducted in Spanish, translated, and analyzed in English using content analysis. Patients reported modest use of pain medications and limited knowledge of opioids, and many relied on non-pharmacologic therapies and family support to cope with pain. They held strong religious beliefs that offered them strength to cope with chronic arthritis pain and prepare for acute pain following surgery. Patients exhibited a great deal of trust in powerful others, expecting God and doctors to cure their pain through surgery. We note the importance of understanding a patient’s individual pain coping mechanisms and identifying strategies to support these coping behaviors in pain management. Such an approach has the potential to reduce the burden of chronic arthritis pain while limiting reliance on opioids, particularly for patients who do not traditionally utilize powerful analgesics.
Dental education has seen increases in global health and international educational experiences in many dental schools' curricula. In response, the Consortium of Universities for Global Health's Global Oral Health Interest Group aims to develop readily available, open access resources for competency-based global oral health teaching and learning. The aim of this study was to develop and evaluate a Global Health Starter Kit (GHSK), an interdisciplinary, competency-based, open access curriculum for dental faculty members who wish to teach global oral health in their courses. Phase I (2012-17) evaluated longitudinal outcomes from two Harvard School of Dental Medicine pilot global health courses with 32 advanced and 34 predoctoral dental students. In Phase II (2018), the Phase I outcomes informed development, implementation, and evaluation of the open access GHSK (45 enrollees) written by an interdisciplinary, international team of 13 content experts and consisting of five modules: Global Trends, Global Goals, Back to Basics: Primary Care, Social Determinants and Risks, and Ethics and Sustainability. In Phase III (summer and fall 2018), five additional pilot institutions (two U.S. dental schools, one U.S. dental hygiene program, and two dental schools in low- and middle-income countries) participated in an early adoption of the GHSK curriculum. The increase in perceived knowledge scores of students enrolled in the pilot global health courses was similar to those enrolled in the GHSK, suggesting the kit educated students as well or better in nearly all categories than prior course materials. This study found the GHSK led to improvements in learning in the short term and may also contribute to long-term career planning and decision making by providing competency-based global health education.
Purpose: Volunteer service learning activities, including Student Run Clinics (SRCs), are becoming an increasingly popular extracurricular component of medical education. While there are reports that student clinicians generally enjoy their educational experiences at SRCs, it is not understood how to optimize and measure student engagement in them. To identify key drivers of student engagement a tool was created to measure volunteer experience at the Crimson Care Collaborative (CCC), a primary care SRC.Methods: CCC volunteers were asked to complete an online engagement survey. Cross-sectional survey data were collected for 149 CCC volunteers (53% response rate).Results: Multivariate linear regression showed that overall 'likelihood to recommend CCC to a friend' was significantly associated with students' perception of the clarity of their role within the clinic, frequency of interprofessional interactions, and overall quality of medical education. Students who volunteer more frequently and for longer periods of time had higher engagement scores.Conclusions: Measuring engagement is feasible in volunteer settings. Engagement appears to be dependent on both structural and experiential components. Easily modifiable components of job design (role definition, expected frequency of volunteering), are key drivers of volunteer engagement.
