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O ptim al tim ing of coronary artery bypass graft surgery after acute m yocardial infarction buy ditropan 5mg online gastritis diet gastritis symptoms. Long-term survival after postinfarction bypass operation: early versus late operation buy ditropan 2.5 mg on-line gastritis diet oatmeal cookies. Jonathan Unsworth-White Aspirin irreversibly inhibits platelet function by blocking the cyclooxygenase pathw ay generic ditropan 2.5 mg with amex stomach ulcer gastritis symptoms. It is a vital adjunct in the prevention of coronary throm bosis1 and is know n to reduce the risk of acute bypass graft closure. Therefore if aspirin w ere discontinued 10 days prior to surgery, the affected platelet pool w ould be com pletely replenished w ith fresh platelets by the tim e of the operation. This how ever leaves the patient vulnerable to an acute m yocardial event during the latter part of this tim e and m ay also m ake graft occlusion m ore likely in the im m ediate postoperative period. Collaborative overview of random ised trials of antiplatelet therapy-1: Prevention of death, m yocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Pre-operative aspirin decreases platelet aggregation and increases post-operative blood loss – a prospective, random ised, placebo controlled, double-blind clinical trial in 100 patients w ith chronic stable angina. Tom Treasure There are three circum stances w hen surgery is required for m itral regurgitation: 1 To save life in the acute case Sudden m itral regurgitation follow ing rupture of degenerative chordae tendineae, papillary m uscle rupture, or endocarditis m ay be very poorly tolerated. The surgeon m ay be presented w ith a patient in pulm onary oedem a, even ventilated, and then an oper- ation m ay be the only w ay to save life. The decision is not alw ays easy but a sensible appraisal of the risks and benefits is w hat is needed. If there is a tolerably good ventricle, and substantial regurgitation to correct, then the benefits are likely to outw eigh the risks. The degree of left venticular dilatation to be tolerated before surgery is required has reduced. Som e patients seem to tolerate m itral regurgitation quite w ell w ith a large ventricle ejecting partly into a large, relatively low pressure left atrium. The left ventricle m ay not be as good as it appears because the high ejection fraction is into low afterload. Im pact of pre- operative sym ptom s on survival after surgical correction of m itral re- gurgitation. Robin Kanagasabay M itral valve repair has been popularised by Carpentier and others and now represents a recognised option in the treatm ent of m itral valve disease. Advocates argue that all m itral valves should be considered for repair first, and only those that are not suitable should be replaced. M itral valve repair offers real advantages over replacem ent, chiefly low operative risk (around 2% 1,2), avoidance of the risks of long term anticoagulation (in patients w ho are in sinus rhythm ), very low risk of endocarditis, and probably better long term preservation of left ventricular function. The last aspect m ay not be as clear cut as once thought as techniques to replace the m itral valve w hile still preserving the sub-valvular chordal apparatus, w hich is so im portant in regulating ventricular geom etry, m ay offer m any of the advantages once held to be the sole preserve of repair techniques. Repair of anterior leaflet prolapse is a m ore com plex undertaking and requires either a transfer of chordae from the posterior to the anterior leaflet, or the use of synthetic chordae. An alternative is to suture the free edges of the tw o leaflets together at their m id-points creating a double orifice valve, the so called Alfieri bow -tie repair. It m ay require a com bination of leaflet augm entation using patches of peri- cardium , and also elongation or replacem ent of any restricted chordae. Restricted leaflet m otion due to poor ventricular function rem ains a particularly difficult problem to correct by repair techniques. Features which indicate a low chance of successful repair These include: • Rheum atic valvular disease • Thickened valve leaflets • M ultiple m echanism s of valve dysfunction • Extensive prolapse of both leaflets • Com m issural regurgitation • Annular calcification • Dissection of valve leaflets com plicating endocarditis. In general all valves that can be repaired should be, although som e patients m ay opt for valve replacem ent to avoid the (sm all) risk of needing further surgery due to failure of the repair. Because of the low operative risk, absence of the need for anticoagulation and avoidance of the risks of prosthetic valve endocarditis follow ing valve repair, a further group of patients m ay be offered valve repair at an early stage of their disease w here, on the balance of risks, valve replacem ent w ould not yet be justified. Long-term results of m itral valve repair for m yxom atous disease w ith and w ithout chordal replacem ent w ith expanded polytetrafluoroethylene sutures. Superiority of m itral valve repair in surgery for degenerative m itral regurgitation. Cost im plications of m itral valve replacem ent versus repair in m itral regurgitation. The Ross procedure, or pulm onary autograft procedure, w as introduced by M r Donald Ross in 1967. The principle is to replace the diseased aortic valve w ith the autologous pulm onary valve. The pulm onary autograft is placed in the aortic position as a root replacem ent w ith interrupted sutures and the coronary arteries are reim planted. Great care m ust be taken during harvesting of the pulm onary root because of the close proxim ity of the first septal branch of the left anterior descending coronary artery. A hom ograft (preferably pulm onary) is used to restore continuity betw een the right ventricular outflow tract and the pulm onary artery. The Ross procedure is the preferred option for aortic valve replacem ent in the grow ing child due to the grow th potential of the im planted autograft. It should also be considered in any patient w here anticoagulation is com pletely or relatively contraindicated. Another possible indication is active endo- carditis because of its “curative” potential. The likelihood of recurrence of endocarditis and of perivalvar leak is low er in patients after a Ross procedure, com pared to m echanical valve replacem ent. The haem odynam ic perform ance of the autograft valve is superior to m echanical valves, w ith m uch low er transvalvar gradients and better regression in ventricular size and hypertrophy in the m id- term. Anticoagulation w ith w arfarin (a m ajor contributor to m echanical valve-related m orbidity and m ortality) is not required 100 Questions in Cardiology 93 after the Ross procedure. M ore than 90% of all patients are free of any com plications (death, degeneration, valve failure, endo- carditis) after ten years. It is the m ethod of choice for aortic valve replacem ent in the young, w ith excellent early postoperative haem odynam ic results and good m id-term results. Tom Treasure The risk of stroke after valve replacem ent is higher in m echanical than tissue valves (in spite of best efforts at anticoagulation) and is higher after m itral than aortic valve replacem ent. I quote from our ow n prospective random ised trial (in press) of St Jude and Starr-Edw ards valves so the inform ation w as deliberately sought and the follow up w as very near com plete. The annual incident rate of com plications (per 100 patient years) is show n in Table 45. Seamus Cullen Indications for surgical closure of a ventricular septal defect in childhood include congestive cardiac failure, pulm onary hyper- tension, severe aortic insufficiency and prior bacterial endo- carditis. It is unlikely that a significant ventricular septal defect w ill be m issed in childhood and therefore ventricular septal defects seen in adulthood tend to be sm all and isolated. The natural history of sm all congenital ventricular septal defects w as thought to be favourable but longer follow up has dem onstrated that 25% of adults w ith sm all ventricular septal defects m ay suffer from com plications over longer periods of tim e. The com plications docum ented w ere: infective endocarditis, aortic regurgitation, arrhythm ias and m yocardial dysfunction. W hilst closure of a ventricular septal defect protects against infective endocarditis, there are no data to suggest a protective effect against the developm ent of late arrhythm ias, sudden death or ventricular dysfunction.

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All the following would be important Na 146 meq/L + initial steps in the clinical assessment of this patient except K 3 cheap 5 mg ditropan visa chronic gastritis raw vegetables. A patient visited a local emergency room 1 week ago stool osmolality is 170 mosmol/L purchase ditropan 2.5mg overnight delivery gastritis diet 7 up calories. Diagnose her with subclinical pan-hypopituitarism discount ditropan 2.5mg gastritis zwieback, sion, she is found to have a calcium level of 19. A 16-year-old previously healthy teenage boy pre- sents to the local emergency room with a headache that A. Continue therapy with large-volume fluid adminis- has been worsening over the course of 2 months. Continue therapy with large-volume fluid adminis- over the past 2 weeks has been complaining of double vi- tration, but stop furosemide and treat with hydro- sion. Differentiating primary dysmenorrhea from other causes of the following is the most likely cause? Which of the following is the most common site for a treatment of the hypertensive crisis. Postmenopausal estrogen therapy has been shown to lowing physiologic alterations will cause an increase in re- increase a female’s risk of all the following clinical out- nin secretion except comes except A. All the following therapies have been shown to re- finding a pituitary microadenoma at autopsy in the gen- duce the risk of hip fractures in postmenopausal women eral population? A 33-year-old woman presents to the emergency room complaining of headache, palpitations, sweating, and anxi- X-29. These feelings began abruptly about 30 min ago, and she cytoma after presentation with confusion, marked hyper- reports intermittent symptoms similar to these that occur tension to 250/140 mmHg, tachycardia, headaches, and perhaps once per month. His fractionated plasma metanephrines show a with panic attacks and has been prescribed paroxetine 20 normetanephrine level of 560 pg/mL and a metaneph- mg daily. Her symptoms have not improved since initiation rine level of 198 pg/mL (normal values: normetaneph- of this drug, and she believes that her episodes of palpita- rine: 18–111 pg/mL; metanephrine: 12–60 pg/mL). Which of the following statements past year for which she has been prescribed ibuprofen, 600 is true regarding management of pheochromocytoma is mg as needed. Her blood pressure while lying cardia even after adequate alpha-blockade has been down is 170/100 mmHg with a heart rate of 90 beats/min. Immediate surgical removal of the mass is indicated, with a heart rate of 112 beats/min. Her respiratory rate is 22 because the patient presented with hypertensive cri- beats/min, and her temperature is 37. Salt and fluid intake should be restricted to prevent following is most likely to correctly diagnose this patient? No testing is necessary; the patient is suffering from seek medical attention at that time. The mineralocorticoid receptor in the renal tubule is though his appetite has increased lately. His wife adds that responsible for the sodium retention and potassium wast- he has recently taken some time off work due to fatigue; ing that is seen in mineralocorticoid excess states such as despite his time off he has not been able to relax and has aldosterone-secreting tumors. He is admitted to the hospital and screen- characteristic of the mineralocorticoid-glucocorticoid ing tests reveal an undetectable thyroid-stimulating hor- pathways explain this finding? Hyperthyroidism leads to a high-output state for the cently started on methimazole. The patient described above is started on atenolol some low-grade fevers, arthralgias, and general malaise. Which of the fol- Laboratories are notable for a mild transaminitis and a lowing additional therapies is indicated? A patient presents to his primary care physician com- plaining of fatigue and hair loss. A 60-year-old woman is referred to your office for since his last clinic visit 6 months ago but notes markedly evaluation of hypercalcemia of 12. On review of systems, he reports that found incidentally on a chemistry panel that was drawn he is not sleeping well and feels cold all the time. Despite still able to enjoy his hobbies and spending time with his fluid administration in the hospital, her serum calcium at family, and does not believe that he is depressed. Which of the statements re- constipation or bone pain and is now 8 weeks out from garding that diagnosis is correct? Absence of a goiter makes autoimmune hypothy- for Stage 1 hypertension and body mass index of 30 kg/ roidism unlikely. Viral thyroiditis does not induce subsequent au- mia due to the clinical and laboratory findings. Congo red staining of xanthoma biopsy able to extracellular molecules of all size and charge. The parents of a 14-year-old boy want your opinion about treatment of their child’s lipid disorder. A patient is asked to undergo a testing protocol to as- emigrated from South Africa to the United States recently. After 5 days of severe so- The child has had cutaneous xanthomas on the hands, el- dium restriction (10 mmol/day), blood is drawn for bows, heels, and buttocks since childhood. Which hormone abnormality may be detected rica, he underwent thoracotomy for a problem with his using this protocol? Mineralocorticoid excess lipid profile shows a total cholesterol of 734 mg/dL and a E. Genetic test for familial defective apoB100 doctor complaining of fatigue and irritability. Rule out congenital syphilis these symptoms have been worsening over a period of sev- C. Physical examination reveals a drome resting heart rate of 105 beats/min, blood pressure of 136/ 72 mmHg, bilateral proptosis and warm, moist skin. A 16-year-old male is brought to your clinic by his Screening tests are sent and reveal a thyroid-stimulating parents due to concern about his weight. Thyroid-stimulating antibody screen cause of the risk of birth defects associated with its use C. Unbound T3 ring is found, in vitro fertilization should be strongly considered to decrease the risk of ectopic X-47. The prolonged use of oral contraceptives for >10 you began an evaluation for secondary amenorrhea. A 22-year-old male seeks evaluation from his primary roid-stimulating hormone is 3. Serum prolactin care doctor for gynecomastia that has developed over the is elevated. Primary ovarian failure girlfriend is increasingly frustrated by his lack of sexual D. She is having menstrual cycles approximately tional classes to assist him with reading and mathematics.

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Anybody would be able to go into his local organ bank and cheap 2.5mg ditropan with mastercard gastritis diet , for a not insurmountable sum quality 5 mg ditropan diet untuk gastritis akut, Kahlil Gibran – trade in a weak heart or a feeble brain for a better Syrian writer and painter one cheap 2.5mg ditropan mastercard gastritis diet , or a cirrhotic liver for a healthier one. You may give them your love but not your In Principles and Art of Plastic Surgery with Ralph Millard () thoughts. There is no better training for a surgeon than to be taught observation by a physician. You may house their bodies but not their souls, In Principles and Art of Plastic Surgery with Ralph Millard For their souls dwell in the house of tomorrow, Vol. The great ignominy to the plastic surgeon is his The Prophet ‘On Children’ inability to remove a scar without leaving another one. André Gide – In Principles and Art of Plastic Surgery with Ralph Millard French writer Vol. Hospitals tend to weaken the family tie by awesome and to some terrifying powers over life separating the sick from their homes and their and death—must continue to earn that public relatives, who are often too ready to relieve trust by being absolutely clear that the law as it themselves of the burden of the sick. But when all usefulness is over, when Medicine absorbs the physician’s whole being one is assured of an unavoidable and imminent because it is concerned with the entire human death, it is the simplest of human rights to choose organism. No skill or art is needed to grow old; the trick is to Note written before her suicide,  August () endure it. Attributed The medical student is likely to be one son of the family too weak to labour on the farm, too Oliver St. John Gogarty – indolent to do any exercise, too stupid for the bar and too immoral for the pulpit. Irish politician and author Attributed The Englishman believes that a purgative can fatten or make him thin; he believes that either Thomas Gisborne – there is only one kind of ache or that one English cleric and author medicine can cure various kinds. The Duties of Physicians But the skilful physician distinguishes the symptoms, manures the sterility of nature, or It is frequently of much importance, not to the prunes her luxuriance; nor does he depend so comfort only, but to the recovery of the patient, much on the efficacy of medicines as on their that he should be enabled to look upon his proper application. Letter to Revd Thomas Contarine () The Duties of Physicians Samuel Goldwyn – William E. It is a distinct art to talk medicine in the language Johann Wolfgang von Goethe of the non-medical man. Gordon – The world is so full of simpletons and madmen, English bacteriologist, St. The object of research is the advancement not of the investigator, but of knowledge. I have learned much from disease which life could Attributed have never taught me anywhere else. Conversations with Goethe Johann Peter Eckermann Johannes De Gorter –  March () Medicine discusses diseases which are so rare that Thus I saw that most men only care for science so one does not encounter them more than once or far as they get a living by it, and that they worship twice during a lifetime with a thoroughness as if even error when it affords them a subsistence. Attributed The Difficult Art of Giving by Wilder Penfield Our national inclination is to suffer children William Gilbert (‘W. Cricketer and doctor Scientific Monthly : , () Medicine is my hobby, cricket is my profession. They Horae Subsecivae ‘Locke & Sydenham’ often perform before large audiences with great technical skill, and they have large incomes. Sir John Grugeon – Attributed Health administrator Doctors are and should be natural leaders and Harvey Graham – part of the skill of being a leader is to work with English physician the other leaders in the intricate network of the Venus found herself a goddess National Heath Service. In a world controlled by gods, Hospital Doctor  July () So she opened up her bodice And evened up the odds. Epitaph suggested by Graves himself after emphasizing nutrition in sick patients Sir William Withey Gull – From the very commencement the student should British physician, Guy’s Hospital, London set out to witness the progress and effects of The jejunum is more exempt from morbid sickness and ought to persevere in the daily conditions than any other portion of the observation of disease during the whole period of alimentary canal. Bartholomew’s Hospital Reports :  () Introductory Lectures () Diseases are but parts of a course of natural Greek proverb history. British Medical Journal :  () A blind man leaned against a wall; ‘This is the boundary of the world’, he said. The road to medical knowledge is through the pathological museum and not through an Major Greenwood? Attributed Do not forget there is a research laboratory greater even than the Cavendish, the streets, Never forget that it is not a pneumonia, but the homes, the factories in which common people a pneumonic man who is your patient. Pemberton in ‘Will Pickles of Wensleydale Bles, a profession, ought to be a religion. London () Attributed Germaine Greer – Savages explain, science investigates. Australian-born writer and feminist Attributed The management of fertility is one of the most I do not say no drugs are useful, but there is not important functions of adulthood enough discrimination in their use. London Attributed In my experience it is most exceptional to see an The progress of biology in the next century will old case of albuminuric retinitis; this latter lead to a recognition of the innate inequality of affection seems to occur at a late stage of the man. This is today most obviously visible in general disease, so that death supervenes before the United States. Sir Peter Hall – British theatre director Thomas Guthrie – Scottish social reformer We do not necessarily improve with age; for better or worse we become more like ourselves. If you want to keep a dead man, put him in whisky; The Observer ‘Sayings of the Week’,  January () if you want to kill a live man put whisky in him. Attributed John Halle – Ernst Haeckel – English surgeon German professor of zoology A surgeon should have three diverse properties in The cell never acts; it reacts. That is to say, a heart as the heart of a Generelle Morphologie lion, his eyes like the eyes of a hawk, and his hands the hands of a woman. Epistle to the Reader in the translation of Lanfranchi’s Heinrich Haeser – Chirurgia Parva Medicine is as old as the human race, as old as the But chiefly the anatomy necessity for the removal of disease. Ye ought to understand; Lehbruch der Geschichte der Medizin Erste Periode If ye will cure well any thing, That ye do take in hand. Bulletin of the Johns Hopkins Hospital :  () Organon of Homeopathic Medicine (rd American edn), The only weapon with which the unconscious p. William Radde, New York () patient can immediately retaliate upon the Similar diseases are cured by similar things. Haldane – British geneticist and author Alexander Hamilton – I wish I had the voice of Homer Professor of Midwifery, Edinburgh To sing of rectal carcinoma, It is particularly observed in surgical wards that Which kills a lot more chaps, in fact, there is such a state of the air sometimes as Than were bumped off when Troy was sacked. Ltd, London () If a man has knocked out the teeth of a man of For the honour of the Profession to continue to the same rank, his own teeth shall be knocked out. Trust Deed to the Royal College of Physicians  June () Number  statement from the  provisions to the fees due to Medical Practitioners in the Code of Hammurabi Lady Flora Hastings – British poet Garrett Hardin – Grieve not that I die young. Certainly pregnancy is a form of servitude if Swan Song continued to term it results in parenthood, which is also a kind of servitude to be endured for the Lord Havers – best years of a woman’s life. British lawyer and politician I am also satisfied that a person who has a duty of George Harley – care may be guilty of murder by omitting to fulfill Scottish physician that duty, as much as by committing any positive act. Harrell – A bodily disease, may after all, be but a symptom The physician’s continuing education, whether he of some ailment in the spiritual part. Sir John Hawton – Journal of Medical Education :  () British politician The British Government have announced that they intend to establish a comprehensive Health William Harvey – Service for everyone in the country. Exercitatio Anatomica de Motu Cordis et Sanguinis in William Hazlitt – Animalibus British writer The heart of animals is the foundation of their Death is the greatest evil, because it cuts off hope. Exercitatio Anatomica de Motu Cordis et Sanguinis in The most rational cure after all for the inordinate Animalibus fear of death is to set a just value on life.

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Throughout the preparation of this report ditropan 2.5mg otc gastritis upper right quadrant pain, the creative effort was conducted with great independence discount 2.5mg ditropan mastercard gastritis vs pregnancy symptoms. The ideas expressed herein are not necessarily those of proven ditropan 2.5mg gastritis cancer, nor endorsed by, the American Dental Association. This document is a vital tool for dentistry as the profession grows and evolves in these beginning years of the 21st century. The information and recommendations in this report provide the tools we need to mold, paint and shape the strong future that all of us want for our profession and certainly for our patients. As we take up this task, we should be mindful of the legacy developed by the actions of those who came before us. Our strong public image came not from outside forces but from dentists–all giving, sacrificing and working for the good of the public and the profession. Together, we can determine the wisest steps to take and then commit ourselves to the actions necessary to strengthen dental education, research, practice, access to care for the underserved, our role in governmental affairs, and other key aspects of this profession. It is equally difficult to discern the problems that will confront our profession. The 2001 Future of Dentistry report attempts to create a vision of challenges that are likely to emerge in the coming years. The report is based upon reasonable evaluation and interpretation of current information and observable trends. This project, while commissioned by the American Dental Association, is not a policy document of the organization. It has been designed to reach out to all parties interested in the betterment of health through- out the world and, more specifically, to those who are able to contribute to improving the delivery of dental care in order to achieve the optimal oral health of the public. The many who contributed to this report––giving enormously of their time and expertise––hope that future generations will look back on it as a landmark document. It represents their commitment to excellence and an understanding that the profession and its partners must set aside parochial agendas to fulfill their social responsibility. The authors want the report to be read and believe firmly that all who do so will develop a bet- ter understanding of the issues facing the dental profession in its pursuit of excellence in serving the public. It is meant to stimulate thoughts and actions that will move the dental profession forward into the new century. In order for it to have the lasting impact, the report must become a living document that can be amended and redesigned as circumstances evolve. It is clear that in this complex and ever- changing world, isolation is not a viable option. Plans for the future must take into account that advances in the diagnosis and treatment of oral disease are being made throughout the world. Sophisticated informational technology will be emerging to benefit both the public and dental professionals. Instead, interaction can occur almost instantly among persons separated by continents. Political will, social responsibility and the willingness to set aside cultural differences are also necessary. The dental profession has a bright and excit- ing future that can be achieved only by a commitment to think creatively, eliminate barriers, and forge new alliances. All people, whatever their status, what- ever their age, wherever they live, should have the right to good oral health. It requires a clear-eyed assessment of the past, of what impeded progress at one point, what propelled it at another. It also requires an appreciation of an axiomatic truth: that tomor- row belongs to those who prepare for it today. With that in mind, the dental profession has begun the process of evaluation that, given the complexity of the world in the 21st century, will ensure the most desirable future for dentistry and the public it serves. Beyond its own borders, the profession must respond to a range of out- side influences, including government and commercial interests. Satisfaction of the oral health needs of the public becomes the ultimate goal of the process. Professional organizations have a wider responsibility than just their own memberships. They also have a responsibility to a trusting public and must be in a position to meet any new developments with confidence. Looking to the future and predicting what will confront the dental profession are formidable tasks. Dentists, as scientists, cannot purport to have visionary capabilities or to be fortunetellers. Thus, the observations and predictions contained in this document are based on measurable trends that can be extended legitimately into the years ahead. Clearly, much must be done to guarantee the most desirable future for the profession and the public. To achieve that goal, all issues that touch dentistry must be identified and addressed. Its authors have been committed to the belief that the duty of the profession and its partners require them to put aside any personal agendas and to focus on the future, in seeking to fulfill their responsibility to protect the viability of a respected profes- sion and effectively serve a deserving public. The 1983 Future of Dentistry Report In 1983, the American Dental Association published a report on the future of dentistry that explored the state of the profession at that time and offered predictions on the challenges dentistry would likely face in the years ahead. That first report also provided a number of broad recommendations and laid the ground- work for a strategic planning process that continues to this day. As the future became the present, many of the forecasts contained in the 1983 document proved accurate; others did not. More important than the document itself was the profession-wide self-examination it kindled. The complex act of preparing the report forced the profession to explore its mission and structure and to address difficult issues and confront them with its best wisdom. The charge was essentially the same this time as last: Look unflinchingly into the future; recommend actions and activities that will help the profession meet its responsibilities in the years ahead. The 1999 House of Delegates approved the plan and com- missioned preparation of a new Future of Dentistry report. Assessing the sheer enormity of the project before it, the committee decided to separate the task into log- ical parts. Panelists were to pinpoint trends; to separate what is known from pure speculation; and to offer reasonable, logical predictions for the future, defined as the next 5 to 15 years, depending on the area of interest. Finally, each panel was to forge recommendations aimed at helping the profession meet future challenges. The report was written by several authors and reflects the style of those authors. During the editing process, some standardization of format was developed, but no attempt was made to develop a uniform style. This final report, almost two years in the making, is meant to serve the entire dental community and the public. Thus, the insights and recommendations are directed to assist any individual or organization which seeks to ensure and protect the oral health of the public. Throughout the preparation of this report, the creative effort was conducted with great inde- pendence.