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PURPOSE: We sought to ascertain factors associated with the quality of diabetes care, comparing rural vs urban diabetic patients in a large health care system. METHODS: We conducted a retrospective cohort study assessing patients’ attainment of the D5 metric, a diabetes care metric having 5 components (no tobacco use, glycated hemoglobin [A(1c)] level less than 8%, blood pressure less than 140/90 mm Hg, low-density lipoprotein cholesterol level at goal or statin prescribed, and aspirin use consistent with clinical recommendations). Covariates included age, sex, race, adjusted clinical group (ACG) score as a marker of complexity, insurance type, primary care clinician type, and health care use data. RESULTS: The study cohort consisted of 45,279 patients with diabetes, 54.4% of whom resided in rural locations. The D5 composite metric was met in 39.9% of rural patients and 43.2% of urban patients (P

Leukocytes from the maternal-fetal interface are a valuable tool to study local changes in immune function during pregnancy; however, sampling can be challenging due to inadequate tissue availability and the invasive nature of placental bed biopsy. Here, we aim to purify and characterize leukocytes from paired peripheral and uterine blood samples to assess whether a less invasive method of uterine blood collection could yield a population of enriched uterine leukocytes suitable for ex vivo and in vitro analyses.Human peripheral blood mononuclear cells (PBMC) and uterine blood mononuclear cells (UBMC) expressed from surgical gauze post C-section were isolated, and immunophenotypic information was acquired by multi-parameter flow cytometry. PBMC and UBMC were stained for markers used to define T and B lymphocytes, macrophages, regulatory T (TImmunophenotyping revealed that over 95% of both live PBMC and UBMC consisted of CD45Intrauterine leukocytes, especially CD16

Toothwear is becoming increasingly more common for dentists to manage as the population is maintaining its teeth for longer. A large proportion of cases can be managed by means of adhesive dentistry in conjunction with preventive advice. There are, however, patients with severe toothwear alone, or toothwear in conjunction with missing teeth, which would be best served with a removable prosthodontic approach. This is particularly the case where dental implants are not indicated or appropriate. This article illustrates the use of removable prosthodontics for the management of toothwear and highlights the importance of these restorations in certain cases. It also considers the supportive programme required to ensure success of this treatment modality. CPD/Clinical Relevance: Toothwear is a prevalent dental problem that cannot always be addressed with an adhesive restorative or fixed prosthodontic approach, particularly when the toothwear is severe and or in combination with existing missing teeth.

Development of primordial germ cells (PGCs) is required for reproduction. During PGC development in mammals, major epigenetic remodeling occurs, which is hypothesized to establish an epigenetic landscape for sex-specific germ cell differentiation and gametogenesis. In order to address the role of embryonic ectoderm development (EED) and histone 3 lysine 27 trimethylation (H3K27me3) in this process, we created an EED conditional knockout mouse and show that EED is essential for regulating the timing of sex-specific PGC differentiation in both ovaries and testes, as well as X chromosome dosage decompensation in testes. Integrating chromatin and whole genome bisulfite sequencing of epiblast and PGCs, we identified a poised repressive signature of H3K27me3/DNA methylation that we propose is established in the epiblast where EED and DNMT1 interact. Thus, EED joins DNMT1 in regulating the timing of sex-specific PGC differentiation during the critical window when the gonadal niche cells specialize into an ovary or testis.

Background Wilderness travel and rock climbing are increasingly popular. Urban falls from height have been reported from trauma centers; however, there have been no trauma center reports of rock climbing or wilderness falls (WFs) in the United States. We sought to describe the injury pattern of WF and to determine whether rock climbers represent a distinct pattern of injury. Materials and methods The trauma database from our level 1 trauma center was queried from 1/1/06 to 12/31/16 for the diagnosis of “fall from cliff” (ICD9: e884.1, ICD10: w15.xx). Demographics, injury characteristics, and trauma center care were analyzed. Data were analyzed using two sample unequal variance T-tests, two sample Z-tests for proportions, and Fisher's exact tests. Results One hundred fifty-one falls were analyzed (40 climbers, 111 nonclimbers). WF victims were predominantly male (79%), moderately injured (mean injury severity score = 13.2), frequently intoxicated (34%), and fell from an average of 43 feet (7-200 ft). The most frequent injures were soft tissue (55%), spine (50%), head (43%), lower extremity (38%), and chest (39%). Climbers were younger, more often sustained upper extremity and soft tissue injuries, more often flown from the scene, injured during daytime, and were better insured. Helmet use was rare (one climber and one nonclimber). There were 3 (2%) deaths, including one climber. Conclusions WFs have a distinct injury pattern and demographic and occur from a height greater than twice those reported in urban falls. Rock climbing falls involve another distinct demographic and pattern of injury. Injury prevention strategies may include helmet use and avoiding nighttime wilderness travel and drug/alcohol use.

Background Wilderness activities expose outdoor enthusiasts to austere environments with injury potential, including falls from height. The majority of published data on falls while climbing or hiking are from emergency departments. We sought to more accurately describe the injury pattern of wilderness falls that lead to serious injury requiring trauma center evaluation and to further distinguish climbing as a unique pattern of injury. Methods Data were collected from 17 centers in 11 states on all wilderness falls (fall from cliff: International Classification of Diseases, Ninth Revision, e884.1; International Classification of Diseases, 10th Revision, w15.xx) from 2006 to 2018 as a Western Trauma Association multicenter investigation. Demographics, injury characteristics, and care delivery were analyzed. Comparative analyses were performed for climbing versus nonclimbing mechanisms. Results Over the 13-year study period, 1,176 wilderness fall victims were analyzed (301 climbers, 875 nonclimbers). Fall victims were male (76%), young (33 years), and moderately injured (Injury Severity Score, 12.8). Average fall height was 48 ft, and average rescue/transport time was 4 hours. Nineteen percent were intoxicated. The most common injury regions were soft tissue (57%), lower extremity (47%), head (40%), and spine (36%). Nonclimbers had a higher incidence of severe head and facial injuries despite having equivalent overall Injury Severity Score. On multivariate analysis, climbing remained independently associated with increased need for surgery but lower odds of composite intensive care unit admission/death. Contrary to studies of urban falls, height of fall in wilderness falls was not independently associated with mortality or Injury Severity Score. Conclusion Wilderness falls represent a unique population with distinct patterns of predominantly soft tissue, head, and lower extremity injury. Climbers are younger, usually male, more often discharged home, and require more surgery but less critical care. Level of evidence Epidemiological, Level IV.

A 43-year-old male reported with pain and swelling in the maxillary anterior region as a result of iatrogenic perforation of his right maxillary central incisor tooth. After attempted internal repair, surgical management was required due to repair material extrusion. Removal of the extruded material preceded repair of the perforation site with biosilicate cement which had a short initial setting time. The set repair material then allowed Guided Bone Regeneration (GBR) to be performed to reduce the risk of recession in a single surgical process. At 24-month recall, the patient was asymptomatic with no clinical or radiographic evidence of ongoing disease. Additionally, the patient presented with excellent aesthetics after surgical management. CPD/Clinical Relevance: Comprehensive management of endodontic perforations, especially in the anterior dentition, should stretch beyond tooth survival and include the need to maintain and improve the patient's aesthetics.

An adiabatic upward air-water flow experiment was performed on a vertical pipe with 25.4 mm inner diameter to investigate the interface structure and characteristics. Local experiment parameters, including time-averaged void fraction, interfacial area concentration, bubble interfacial velocity and Sauter mean diameter were measured using a four-sensor conductivity probe with a data acquisition frequency of 100 kHz. Experiment data for 19 flow conditions was collected at 3 axial locations (z/D = 15, 78, and 141) and 13 radial positions from r/R = −0.84 to 0.7. In the experimental study, the measuring range of superficial liquid and gas velocity were from 0.3 to 1.0 m/s and 0.03 to 11.0 m/s, respectively. The flow regimes ranged from bubbly flow to the transition of churn-turbulent to annular flow. The local measurement result agreed well with the drift flux model by Ishii (1977) and Kataoka (1987). The different interfacial structures in different flow regimes and two group bubble interfacial transfer were observed from the experiment result. This data will be used for the evaluation and extension of the current interfacial area transport equation.

Two-phase flow is ubiquitous in industrial, chemical and thermal plants alike. The current state-of-the-art system-code model for predicting fluid transport in two-phase flows is the two-fluid model. In the two-fluid transport model, the coupling of mass, momentum and energy transfer between phases is highly dependent on interfacial area transfer terms. Several research efforts in the past have been focused on the development of an interfacial area transport equation model (IATE) in order to eliminate the drawbacks of static regime flow maps currently used in best-estimate thermal-hydraulic system codes. The IATE attempts to model the dynamic evolution of the vapor/liquid interface by accounting for the different interaction mechanisms affecting gaseous phase transport. The further development and validation of IATE models has been hindered by the lack of adequate experimental data in regions beyond the bubbly flow regime. At the Helmoltz-Zentrum Dresden-Rossendorf (HZDR) experiments utilizing wire-mesh sensors have been performed over all flow regimes, establishing a database of high-resolution (in space and time) data. A 52.3 mm diameter pipe with a 16 by 16 wire-mesh sensor operating at 2.5 kHz is utilized in the air-water experimental database used in this work. There are a total of 37 tests (with varying superficial gas and liquid velocities, at approximately 0.25 MPa). Analysis of IATE performance in the bubbly flow and slug flow regimes is presented. The performance of the Fu-Ishii two-group IATE model is evaluated. In all regions, the interfacial area concentration for small bubbles is predicted well. The model performs poorly in high void fraction regimes, in which large irregularly shaped bubbles are present. The interaction mechanisms that support and deter performance of the IATE model are highlighted. A sensitivity analysis of the coefficients indicates modification of the coefficient of group-2 wake entrainment may extend the validity of the Fu-Ishii model. An optimization study is presented to further explore improving IATE performance. It is concluded that the availability of accurate data at high void fractions from the HZDR facility provides a path to improve IATE performance.

In view of the importance of two-group interfacial area transport equation and lack of corresponding accurate downward flow database that can reveal two-group interfacial area transport, a systematic database for adiabatic, air-water, vertical downward two-phase flow in a round pipe with inner diameter of 25.4 mm was collected to gain an insight of interfacial structure and provide benchmarking data for two-group interfacial area transport model. Four-sensor conductivity probes were used to measure the local two phase flow parameters at high data sampling frequency to ensure the accuracy. Axial development of local flow parameter profiles including void fraction, interfacial area concentration, and Sauter mean diameter were presented. Drastic inter-group transfer of void fraction and interfacial area as well as the wall peaked interfacial area concentration profiles were observed and discussed.

Microdontia is a dental abnormality that will often present to the dental practitioner due to the aesthetic concerns of the patient. Treatment is therefore aimed at addressing the aesthetics issue of the patient and this can present a number of challenges which may require a multidisciplinary approach in its management. This article presents the restorative management of localised and generalised microdontia.

OBJECTIVE Point-of-care testing (POCT) is a commonly used technology that hastens the time to laboratory results in emergency departments (ED). We evaluated an ED-based POCT program on ED length of stay (LOS) and time to care, coupled with qualitative interviews of local ED stakeholders. METHODS We conducted a mixed-methods study (2012-2016) to examine the impact of POCT in a single, community ED. The quantiative analysis involved an observational before-after study comparing time to laboratory test result (POC troponin or POC chemistry) and ED LOS after implementation of POCT, using a propensity-weighted interrupted time series analysis (ITSA). A complementary qualitative analysis involved five semistructured interviews with staff using grounded theory on the benefits and challenges to ED POCT. RESULTS A total of 47,399 ED visits were included in the study (24,705 in the preintervention period and 22,694 in the postintervention period). After POCT implementation, overall laboratory testing increased marginally from 61% to 62%. Central laboratory troponin and chemistry declined by > 50% and was replaced by POCT. Prior to POCT implementation, time to troponin and chemistry had declined steadily due to other improvements in laboratory efficiency. After POCT implementation, there was an immediate 20-minute further decline (p

The use of 3D printing is expanding and it is envisaged that it will have an increasing presence within dentistry. Having an appreciation and understanding of such technology is therefore paramount. It is currently used to produce a variety of dental objects/ prostheses. This paper briefly looks at 3D printing in dentistry and specifically describes the use of the direct metal laser sintering 3D printing technique in the production of cobalt chromium removable prosthesis frameworks. CPD/Clinical Relevance: Understanding the different technologies that can and are being used within the dental field is important, particularly as it is a rapidly changing field. Having an understanding of such technologies will allow practitioners to utilize such technologies appropriately in the management of their patients.

Endodontic retreatment can be a challenging task that can result in many complications if not approached cautiously. Many of these difficulties revolve around regaining access to the pulp chamber through extensive coronal restorations and removing residual root filling material, the commonest being gutta-percha (GP), from within obturated canals. This can often be an untidy, time consuming process that places teeth at a greater risk of iatrogenic injury and inhibits the operator achieving the necessary chemical disinfection required to eliminate the persistent apical disease. Therefore the following article aims to aid practitioners, particularly those who are unfamiliar, with accessing and removing GP from endodontically treated teeth. The outlined systematic approach is accessible in general practice, where the vast majority of endodontic treatment is conducted, requires basic equipment and with the correct experience can be applied to both straight and curved canals. By overcoming this initial stage of retreatment, subsequent chemical disinfection, which is critical to success, can be carried out to a higher standard reducing risks of re-infection.

Implant retained overdentures are being increasingly utilised in both general and specialist practice to rehabilitate patients with missing teeth, particularly those that are edentate. This article aims to inform the reader of a variety of retention systems that are available to retain an implant overdenture and to understand how these systems work, their advantages and disadvantages and to outline some of the clinical and treatment planning considerations involved in selecting the most appropriate retention system for patients.

Objective To evaluate the management of deep carious lesions with vital pulp therapy in permanent teeth by dental practitioners within Wales.Design Postal questionnaire.Setting General practitioners (GDS), community (CDS) and hospital-based dentists (HDS) in Wales.Methods Community and hospital dental services with a remit for provision of restorative dentistry (CDS = 71; HDS = 46) and general dental practitioners (N = 510) were approached regarding their management of deep carious lesions with vital pulp therapy in permanent teeth. The postal questionnaire took the form of an anonymous survey. Questions covered usage parameters, training issues and reasons for material choice.Results The response rate was 29%. The majority of HDS (89%) used MTA or Biodentine for vital pulp therapy in contrast to GDS (41%) and CDS (32%). The main reasons cited for avoiding the use of MTA or Biodentine included cost, lack of training and difficulty in material handling.Conclusion Usage of MTA or Biodentine for vital pulp therapies is low in the general dental and community dental settings. Cost and lack of training are the main barriers for the uptake of these materials. Postgraduate training may be useful in addressing these barriers. Increasing their adoption would be advantageous as they have been shown to produce a more predictable outcome compared to traditional materials (for example, calcium hydroxide).

The latest in GE heavy duty gas turbine combustion technology is now available on Frame 7E/EA and 9E machines. Late Fuel Staging (LFS) delivers innovative flexibility, providing value to customers in turndown, efficiency, emissions, and operability. Until now, these machines were characterized by a compliant load range from ∼60% to 100%. Late Fuel Staging delivers additional turndown to ∼35% through physics-based understanding, advanced modeling, and state-of-the-art testing.

Root fractures that occur at the cervical margin do not always heal predictably, even following a period of splinting. This often leaves margins either sub-gingival or sub-crestal. This provides an unsatisfactory situation for restoring the remaining root as restorations will impinge on the biological width. Provided a root is long enough to support a post crown, then orthodontic extrusion to provide sufficient supra-gingival tooth tissue is a useful treatment option to consider. A review of the literature on orthodontic extrusion is considered in conjunction with a case report of the management of a young male who fractured a canine and lateral incisor whilst playing cricket. CLINICAL RELEVANCE: Trauma to upper anterior teeth is frequently seen in practice. One treatment option in the management of sub-crestal cervical root fractures is orthodontic extrusion, rather than removal of the tooth. [References: 27]

A case is presented of soft tissue damage resulting from inadvertent injection of sodium hypochlorite through a perforation created during root canal treatment of a mandibular incisor. The importance of access cavity design to help avoid such complications is highlighted and the anatomy of the mandibular incisor is discussed. Measures to minimize the risk of a hypochlorite accident and its potentially serious complications are proposed.

All-terrain vehicle (ATV) accidents are considerable sources of morbidity and mortality for children and adolescents. This study was done to investigate the types and severity of injuries and the role of age and body mass index on the types of fractures sustained in children younger than 16 years.A retrospective chart review was done on 96 consecutive children who sustained injuries in ATV-related accidents during a 30-month period. Sixty-four patients were boys and 32 were girls. The mean age of the children was 11.0 years. To determine differences in fracture type, Glasgow Coma Scale, Pediatric Trauma Score, and length of hospitalization, the 96 patients were divided into 2 groups: group A, 54 children (56%) 12 years or younger, and group B, 42 children (44%) 13 years or older.Sixty-one children (64%) required hospital admission. No statistically significant difference between the 2 groups was noted. Fifty-four (56%) children required surgical treatment. One fatality occurred. No statistically significant differences between the 2 groups were noted regarding the Glasgow Coma Scale and the Pediatric Trauma Score. Orthopaedic injuries were the most common, occurring in 58 (60%) children, followed by head injury in 34 (35%) and intraabdominal/intrathoracic injuries in 23 (24%). Nineteen (20%) children had more than 1 system involved, and 1 had 3 systems involved. Sixty-eight fractures occurred in 58 children (38 in group A and 30 in group B) including 9 open fractures. As expected, older children had a significantly increased body mass index compared with younger children (P0.02). Age-related patterns of fracture were observed. Younger children (or=12 years) were more likely to sustain an isolated fracture (odds ratio 2.9, P0.02) and were more likely to sustain a lower extremity fracture (odds ratio 3.2, P0.03), specifically a femoral fracture (odds ratio 6.5, P0.01), than older children (or=13 years). Older children were more likely to sustain a pelvic fracture (odds ratio 1.108, P0.04).To our knowledge, this is the first study to evaluate age-related patterns of fractures in ATV-related accidents. It is our hope that increased awareness of the severity and types of injuries and fracture patterns will lead to more rapid diagnosis and help to bring about improved safety measures, increased public awareness, and even legislation concerning the use of ATVs by children.Level IV.

Macrodontia is a relatively rare but cosmetically challenging dental anomaly with different aetiologies. Where surgical interventions are inappropriate, minimal restorative interventions may be indicated. A case is described of a teenager with macrodontic central incisors who was treated with indirect composite 'double veneers'. The aesthetic outcome was excellent without unnecessary loss of teeth. CLINICAL RELEVANCE: Knowledge of the use of indirect composite veneers provides another treatment option for aesthetic problems in the management of tooth anomalies, including macrodontia.

Emergency departments (EDs) across the country are inundated with patients and they struggle to provide the expected standard of care while meeting set benchmarks. A shortage of emergency medicine physicians further complicates the situation, and many facilities are utilizing nurse practitioners to bridge the gap. A clinical case study was conducted at Touro Infirmary, a large urban hospital in New Orleans, LA, to provide an in-depth look at the implementation and positive outcomes of nurse practitioners in one ED. The model used at this facility included a nurse practitioner in the "fast track" area of the ED as well as a nurse practitioner in triage. Overall, the door-to-provider time decreased from 59.25 min in 2012 to 32.08 min in 2013. The bed-to-provider time decreased by an average of 9.17 min, with a 22.92-min average seen in 2012 and a 13.75-min average seen in 2013. An average decrease of 18.3 min was seen in the overall length of stay from 2012 to 2013. The percentage of left without treatment dropped by 3.77%, from 5.07% in 2012 to 1.3% in 2013. In addition to the improved statistics, an increase in the number of patients was also seen. The number of daily visits increased by an average of 2.25 patients per day or 51.4 patients per month. The acuity of the patients did not change, with an average admission rate of 21% noted in both 2012 and 2013. Patient satisfaction remained high at more than 90% during both years. The percentage of significant returns also remained constant at less than 1% in both 2012 and 2013. Assessment of the CMS (Centers for Medicare & Medicaid Services) Quality Measures and PRQS (Physician Quality Reporting System) Indicators do not reveal any change of statistical significance. The average of all providers was shown to be at or above the benchmark set for each measurement/indicator.

The 'Conzen School' of Urban Morphology identified by Kostof in his book The City Shaped, is a western way of looking at parcels of land, lots, and the street grid from above in a geometric manner imposed on the land, then analysing this in terms of land use pattern, town plan, and building form. This model of analysis and development lends itself to flat sites, and separated, isolated developments, and forms the basis for the existing model of development in western colonial nations. This thesis investigates whether an alternate development approach based on aggregative design can provide a viable alternative to the standard model of Medium Density Housing found in New Zealand. Investigation in the frame of Christopher Alexander's New Theory of Urban Design, Lucien Kroll, and The New Urbanists addresses a new way of approaching these sites through the use of organic geometries and accumulative principals. Accompanying and informing this approach is a case study of vernacular Cycladic Architecture. In balance with the Cycladic case study the thesis addresses the acceptance of this model of development in a New Zealand context. In particular, with reference to the physical aspects of privacy, view, shared space as well as perceptions of ownership, individuality and identity in a higher density environment. The aggregative approach is similar to that explored through Ian Athfield's Home in Khandallah; Athfield House. This housing and office complex is an early experiment into the same principles that this thesis addresses. The thesis develops a methodological approach to testing the aggregative nature of development and simulates this through the use of in studio design exercises. These exercises will be a combination of external input from other designers and internal; single author input. The final design outcome will be addressing the results of this simulation, the design principals, guidelines and rules, rather than producing a stand-alone design artifact.

In the international community, human dependence on plastic is increasing. Meanwhile, global petroleum reserves are diminishing. The cost of this demand on petroleum use is not only economic; there are also escalating human and animal health concerns, environmental implications, and the inherent obligation to prepare feasible alternatives in the event that petroleum depletion occurs. While the bioproduct industry is heavily invested in finding fuel substitutes, innovative efforts in other petroleum-dominated industries, such as plastics, may be worthwhile. Fortunately, there are naturally-occurring compounds in bacteria with structures analogous to those currently derived from petroleum. These compounds offer potentially sustainable and healthier alternatives to petroleum. One such compound gaining attention today is polyhydroxyalkanoate (PHA). PHA has several attractive properties as an achievable bioplastic source material, either as a direct substitute or as a blend with petroleum. Genetic modification (GM) may be necessary to achieve adequate yields; accordingly, source and host genetics, agronomic practices, and industry-related technology must be examined in this context. This review will compare properties of petroleum-based to PHA-derived plastics, as well as summarize the obligations of, mechanisms by, and implications with which PHA is being introduced to the plastic industry.

Objectives: To assess adoption of endodontic nickel-titanium rotary technology (NiTi) by community and hospital dental clinicians within Wales and identify factors that may restrict uptake. Design: Postal questionnaire. Setting: Community and hospital-based dentists in Wales. Methods: Community and hospital-based dentists with a remit for provision of restorative dentistry (community dental setting = 32; hospital dental setting = 36) were approached regarding their usage or otherwise of nickel-titanium rotary instrumentation for endodontic treatments. The postal questionnaire took the form of an anonymous survey comprising 12 questions. These questions covered usage parameters, satisfaction and training and broached reasons for NiTi avoidance. Results: The response rate was 77%. NiTi rotary instruments were used routinely by an encouraging 82% of those in the hospital-based restorative dental services but only 13% of community staff. Factors cited as being implicated in the decision to avoid their use included cost (62% of responses) lack of training and the perceived lack of benefit. Conclusion: The adoption of rotary NiTi endodontic technology by the hospital dental practitioners of Wales is encouraging with the majority having converted to such systems in excess of three years prior to the survey. There was, however, a significant disparity in NiTi usage between community and hospital settings, the implications for which and possible solutions for increased training and uptake are discussed.

Perhaps not. Less frequent measurements may be appropriate for some patients. Our study reveals when you may be able to safely extend the monitoring cycle.

Successful hydraulic fracturing requires proper proppant placement within an adequate fracture length. To accomplish this, one must design a fracturing fluid that can achieve effective proppant placement and retain desirable fluid properties under hydraulic fracturing conditions within the reservoir. Recently, there have been reports that increased pressure on the fluid may reduce the viscosity of borate-crosslinked fracturing fluids. Depending on fluid composition and operating temperature, the effects of applied pressure vary from slightly influencing to completely reducing the viscosity of the crosslinked sample to its un-crosslinked state (linear gel). Thus, a good understanding of the impact of applied pressure on viscosity of fracturing fluids in the laboratory is critical to designing and tailoring fluid formulations. This work describes the equipment and experimental procedures for high pressure rheology testing of selected seawater and higher density brine-based borate crosslinked fracturing fluids in the shear rate range of 20 to 80 s-1, up to 20,000 psi and 180°F.

The aim of this article was to carry out a prospective audit on a convenience sample of all new patients referred to the toothwear clinic at Cardiff University Dental Hospital to establish the prevalence of undiagnosed periapical pathology. Clinical Relevance: The low prevalence value for undiagnosed periapical pathology in patients with advanced toothwear suggests that, for many patients, toothwear is a slow process which allows the defence mechanisms of the pulp to counteract the effects of wear. It also questions the necessity of taking routine radiographs of teeth with wear into dentine, in the absence of clinical symptoms. This would reduce the total radiation dose delivered to the patient and preserve valuable healthcare resources.

This article describes the evolution of a multiprofessional group in a psychiatric nursing home for older people with mental illness and challenging behaviours. The nursing home has gained a reputation for excellence, and we believe the group has contributed to this. To analyse how the group has helped, a staff survey was carried out. As a result, we suggest that groups like this should be a standard part of community liaison services for residential homes for older people.

Background: Twin and family studies have demonstrated that adolescent alcohol use and behavior problems are influenced by a combination of genetic and environmental factors. More recently, studies have begun to investigate how genetic and environmental influences may interact, with efforts underway to identify specific environmental variables that moderate the expression of genetic predispositions. Previously, we have reported that community-level factors, including urban/rural residency, migration rates, and prevalence of young adults, moderate the importance of genetic effects on alcohol use in late adolescence (ages 16 to 18). Here, we extend these findings to test for moderating effects of these socioregional factors on alcohol use and behavior problems assessed in a younger sample of adolescent Finnish twins. Methods: Using data from the population-based Finnish twin study, FinnTwin12, biometric twin models were fit to data on >1,400 twin pairs to examine the significance of each of the socioregional moderating variables on alcohol use measured at age 14, and behavior problems, measured at age 12. Results: We find no evidence of a moderating role of these socioregional variables on alcohol use; however, there was significant moderation of genetic influences on behavior problems, with effects limited to girls. Genetic influences assumed greater importance in urban settings, communities with greater migration, and communities with a higher percentage of slightly older adolescents. Conclusions: The moderation effects observed on behavior problems in early adolescence paralleled the effects found on alcohol use late in adolescence in an independent sample, providing further support for the idea that behavior problems may represent an earlier manifestation of the predisposition to subsequent alcohol problems. Our findings also support the growing body of evidence suggesting that females may be more susceptible to a variety of environmental influences than males.

Henri de Lubac argues that, in early modern times, a pernicious concept began to become commonplace in Roman Catholic theology: this concept is 'pure nature.' Pure nature is human nature, considered without reference to grace or to the supernatural destiny of personal union with God. Further, de Lubac argues that Catholic theology, in assimilating this idea, has departed from the sound tradition represented by St Augustine and St Thomas Aquinas. He holds that the notion of pure nature leads inevitably to the self-exclusion of Christianity from the affairs of the world-when, in fact, the light of the Gospel ought to be shed on all aspects of human existence. This dissertation tests de Lubac's thesis concerning the history of the idea of pure nature, showing that this notion is not, in fact, a modern novelty. This study examines the role of the idea of pure nature in the Bible and early Church, in the theology of Thomas Aquinas, in the early modern Jansenist controversy, in the theology of Henri de Lubac, and in the theology of the contemporary Radical Orthodoxy movement, paying particular attention to the historical circumstances which made the repudiation of 'pure nature' attractive. Today, some theologians follow de Lubac in contending that Catholic doctrine must eschew the idea of pure nature in order to resist secularism and maintain Christianity's relevance to all aspects of human life. This dissertation contends that the idea of pure nature is not only traditional, but necessary for Christian theology. It argues that a Christian 'integralism' which refuses to prescind from grace when considering nature can do justice neither to nature nor to grace.