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Objectives The influence of older age at diagnosis in combination with race/ethnicity on utilization and results of the 21-gene recurrence score (RS) assay for breast cancer (BC) patients is not fully understood. Our objectives were to evaluate the utilization of RS among older women with BC, the likelihood of a high-risk RS, and factors associated with breast cancer-specific mortality (BCSM) among older patients across different races. Materials and methods We utilized the Surveillance, Epidemiology, and Results (SEER) database with linked RS results to evaluate women with estrogen receptor-positive BC diagnosed 2004–2015. Multivariable logistic regression was used to describe the differences in utilization of RS testing and the association of high-risk RS according to patient characteristics. The Cox proportional hazards model was used to analyze factors associated with BCSM. Results We found that 20.4% (109,244/536,555) of all women ≥18 and 14.3% (33,584/235,171) of women ≥65 underwent RS testing. Non-whites had lower odds of RS testing at younger ages whereas among women ≥65 there was no significant difference. After taking into account stage and grade, being ≥65 reduced the odds of high-risk RS in all races except American Indian/Alaskan Native. Age ≥ 65 was independently associated with increased hazard BCSM. Among women ≥65 with high-risk RS, chemotherapy was associated with lower hazard of BCSM in all races. Conclusions Older women are less likely to be tested for RS, but also less likely to have high-risk RS. Older women with high-risk RS, when given chemotherapy have reduced BCSM across all races.

Introduction: The use of dental general anaesthetics (DGAs) remains a cause for concern due to additional strains placed on health services. There are numerous factors influencing the prevalence and use of DGAs, and understanding these is an important first step in addressing the issue.\ud \ud Aim: Conduct a rapid review of current peer-reviewed and grey literature on the variation in the use of DGAs in children.\ud \ud Methods: Electronic searching using Medline via Ovid covering DGA articles from 1998 onwards, written in English. Publication types included primary and secondary sources from peer-reviewed journals and reports, as well as grey literature.\ud \ud Results: From 935 results, 171 articles were included in the final review. Themes emerging from the literature included discussions of DGA variation, variations in standards of service provision by health services, and the socio-demographic and geographical characteristics of children. Prominent socio-demographic and geographical characteristics included age, other health conditions, ethnic and cultural background, socioeconomic status and deprivation, and geographical location.\ud \ud Conclusions: This review identified numerous variations in the patterns associated with DGA provision and uptake at both a health service and individual level. The findings demonstrate the complicated and multifaceted nature of DGA practices worldwide.

Introduction The Equality Act 2010 sets out nine protected characteristics and serves to protect every individual against discrimination. The Act places emphasis on the need to reduce inequalities. An understanding, therefore, of existing barriers to oral healthcare for people with protected characteristics is required to inform policy and the commissioning of services.Aim To conduct a rapid review of current UK literature on barriers to oral healthcare for people with protected characteristics.Methods Electronic searching using Medline via Ovid limited to publications in English from the UK. Publication types included primary and secondary evidence from peer-reviewed journals and reports.Results From a total of 462 citations, 52 articles were included in the final review. Common barriers experienced across the protected characteristic groups were identified in addition to specific barriers experienced by those with protected characteristics.Conclusion This rapid review identified barriers to oral healthcare for people with protected characteristics at individual and organisational levels. Gaps identified in the literature include a lack of information available for barriers experienced by people due to sexual orientation, marital/civil partnership status and gender reassignment. Additionally, there is a gap in the evidence available on policy barriers to oral healthcare for people with protected characteristics.

Background The protective effect of community water fluoridation (CWF) against dental caries may be modified by secular changes in health behaviour. We aimed to determine the contemporary association between fluoride in public water supplies (PWS) and dental caries indicators and inequalities in England. Methods We estimated exposure to CWF and PWS fluoride concentrations from national monitoring data, using Geographic Information Systems and water supply boundaries, categorizing mean period exposure into Results The odds of caries and of severe caries in 5-year-olds fell with increasing fluoride concentration in all SES quintiles (P Conclusions Exposure to fluoride in PWS appears highly protective against dental caries and reduces oral health inequalities.

Aim To review the key determinants of health and wellbeing among dentists working in the UK.Methods Rapid review of the literature (1996-2018) across seven health and social science databases through OVID and the Cochrane Library, professional and health system sources. Records were screened according to agreed inclusion and exclusion criteria by title, abstract and full text. Data extraction and qualitative synthesis of the included studies were performed. Quality assessments for risk of bias were made using a mixed methods appraisal tool.Results Thirty-eight studies met the criteria for inclusion. Fourteen were assessed as high, 22 as medium and two of low quality, most involving cross-sectional research in the form of questionnaire surveys. Whereas overall, the health and wellbeing of dentists within the UK is reported as 'good', recently published evidence suggests a less positive view may be emerging. The health and wellbeing of dentists is associated with a wide range of factors: personal, professional career, relationships, job specification, workplace and system. Emerging evidence suggests additional concerns about the regulation of dentistry. Workplace characteristics were most often explored among researchers and reported as being a key issue.Conclusion Evidence highlights multiple determinants of health and wellbeing, most notably related to workplace characteristics; however, while there is a relative lack of well-founded prospective research investigating the nature and direction of the relationships and comparison across UK health systems, there is increasing evidence of health and wellbeing concerns that require further investigation.

Background Research has highlighted multiple determinants of dentists' health and wellbeing, and has raised concerns over workforce morale and retention. Limited research has been undertaken on possible solutions. Thus, the aim was to explore the coping strategies used or advocated by dentists to protect and support their health and wellbeing. Methods This qualitative study involved a purposive sample of dentists working in England taking account of age, gender, career stage, work sector, geographical area, position and route of entry to registration. Dentists were approached via gatekeepers across England to participate in semi-structured interviews. A topic guide, informed by past research, was used to guide the discourse. Informants' views were audio-recorded and field notes were made. Data were transcribed and analysed using an interpretative phenomenological approach to generate theory with the support of the framework methodology. Results Twenty dentists were interviewed from a range of backgrounds. Self-reported coping strategies included a range of strategies for 'taking control', including 'embracing self-care' and 'seeking professional support', while drawing on 'supportive personal and social networks'. Managing professional careers included diversifying through greater 'mixing' of NHS with private work, privatising, specialising, or combining dentistry with another role. Strengthening job security and facilitating diversity of experience remain important for supporting the health and wellbeing of dentists. Selling practices or, in the extreme, completely leaving the profession were considered practical options. At organisational level, building sustainable teams and transforming culture were advocated as important; while at systems level, reforming the NHS and bridging the gap between the profession and regulatory body were considered vital. Additionally, the need for strong professional leadership and wider societal debate was advocated as part of a whole systems approach to enable job satisfaction in delivering high-quality, patient-centred, evidence-based care in future. Conclusion While dentists demonstrated a range of coping mechanisms, multi-level action was advocated to enhance the health, wellbeing and retention of dentists. Systems reform at macro- and meso-levels is urgently advocated to enable fulfilling careers within dentistry, particularly for those at the front line of primary dental care in the public sector. Personal resilience alone will not suffice and recommendations for action are explored to avert a public health catastrophe. This is a time for reflection, debate and action., Key points Conducted before the outbreak of COVID-19, this research highlights the urgent need for multi-level action to improve the workplace environment, the dental system and regulation of dentistry in support of professional fulfilment and career retention for dentists to enhance health and wellbeing. Dentists' coping strategies, both emotional and practical, are required where significant meso- and macro-level challenges exist; this may involve drastic action, particularly among early-career dentists and those working in the NHS. Building personal resilience alone is insufficient to raise morale and enhance the wellbeing of early-career dentists; however, there is a place to support active healthy coping mechanisms in those entering the profession.

OBJECTIVES Paediatric hospital admissions for dental extractions remain a cause for concern, despite decreasing levels of dental diseases in some areas of the country. While local investigations have taken place, little is known about national patterns, and how the relationship between the number of hospital admissions and key independent variables differs across England. The aim of this study was to examine spatial differences in the number of paediatric hospital admissions for extractions in relation to four key independent variables: dental caries, deprivation, units of dental activity and child access to dentists. METHODS Hospital admissions data (for all dental-related reasons) were taken from the Hospital Episode Statistics (HES) for England (2017/18) for children and adolescents aged up to 19 years. All data were collected at local authority level. Geographically weighted regression was used to examine associations between the number of hospital admissions and the independent variables, as well as the strength of these associations and how they differed spatially. RESULTS Geographically weighted regression revealed considerable differences in the associations between the number of paediatric hospital admissions and the independent variables across England, with distinct regional clusters identified in the data. Some areas exhibited positive associations between independent variables and the number of hospital admissions, such as in Yorkshire and areas of south-west, south-east and north-west England, where greater mean dmft scores were associated with greater numbers of hospital admissions. Negative associations were also found, such as in south-west, north-west and North East England, where higher deprivation scores were associated with lower admission numbers. Despite the patterns found, a much smaller sample of the associations between the independent variables and the number of hospital admissions was statistically significant. CONCLUSIONS This analysis allows for a better understanding of the spatial associations between the number of hospital admissions and key independent variables, as well as how changes to these independent variables may affect the number of admissions in each local authority. These findings should be considered in the context of the limitations of HES dataset.

Background The relationship between deprivation and oral cancer is complex. We examined magnitude and shape of deprivation-related inequalities in oral cancer in England 2012-2016. Methods Oral cancer was indicated by cancers of the lip and oral cavity (ICD10 C00-C06) and lip, oral cavity and pharynx (C00-C14) and deprivation by the Index of Multiple Deprivation. Deprivation inequality in incidence and mortality rates of oral cancer outcomes was measured using the Relative Index of Inequality (RII). Fractional polynomial regression was used to explore the shape of the relationships between deprivation and oral cancer outcomes. Multivariate regression models were fitted with the appropriate functions to examine the independent effect of deprivation on cancer adjusting for smoking, alcohol and ethnicity. Results Incidence rate ratios (IRRs) and mortality rate ratios (MRRs) were greater for more deprived areas. The RII values indicated significant inequalities for oral cancer outcomes but the magnitude of inequalities were greater for mortality. The relationships between deprivation and oral cancer outcomes were curvilinear. Deprivation, Asian ethnicity and alcohol consumption were associated with higher incidence and mortality rates of oral cancer. Conclusion This is the first study, to our knowledge, exploring the shape of socioeconomic inequalities in oral cancer at neighbourhood level. Deprivation-related inequalities were present for all oral cancer outcomes with a steeper rise at the more deprived end of the deprivation spectrum. Deprivation predicted oral cancer even after accounting for other risk factors.

Background Multiple determinants influence dentists' health and wellbeing. In light of recent concerns, the aim of this research was to explore contemporary influences on dentists' health and wellbeing in England, drawing on their lived experience. Methods Semi-structured interviews were conducted with a purposive sample of dentists working in England, taking into account age, gender, career stage, work sector, geographical area, position and route of entry to registration. A topic guide, informed by the literature, was used to guide the discourse. Dentists were approached via gatekeepers, supported by snowball sampling. Interviews were recorded and transcribed for analysis. Framework analysis was used, taking an interpretative phenomenological approach to develop theory. Results Twenty dentists, from a range of backgrounds, participated in this research. While health and wellbeing was reported to be more positive among dentists in their later career, those in their early career and/or with high NHS work commitments shared concerns about their physical, psychological and emotional health. Influences ranged from macro-level issues relating to professional regulation and health systems, through meso-level, notably their workplace and job specification, to micro-level issues relating to their professional careers, relationships and personal life. Dentists highlighted ethical concerns and feeling driven to deliver, together with being demoralised by a survival culture, all leading to perceived lack of control and reduced professional fulfilment. In contrast, being able to deliver quality care, innovate and effect change, as well as being valued for their delivery, were perceived to positively contribute to general health and wellbeing. Conclusion Dentists have a vital role in providing care for patients, so there are serious public health implications if urgent action is not taken to improve and sustain their health and wellbeing. This study confirms that dentists are affected by multiple contemporary influences, and although greater support is needed for individuals, organisational, system and policy changes may be required to fully address the challenges they face. Supplementary Information Zusatzmaterial online: Zu diesem Beitrag sind unter 10.1038/s41415-021-3130-9 für autorisierte Leser zusätzliche Dateien abrufbar., Key points Highlights the wide range of contemporary influences on dentists' health and wellbeing, from macro- through meso- to micro-level. Raises concerns that dentists, particularly those with high NHS primary care work commitments, are perceiving lack of control in their professional lives. Dentists who were able to use their expertise to the full, in roles where they were able to deliver quality care and felt valued for their delivery, expressed greater confidence in their health and wellbeing. Discusses the implications of retaining the dental workforce in light of the COVID-19 pandemic and its impact on our profession. Supplementary Information Zusatzmaterial online: Zu diesem Beitrag sind unter 10.1038/s41415-021-3130-9 für autorisierte Leser zusätzliche Dateien abrufbar.

A reminder of the guidance for domestic abuse and safeguarding for general dental practices by Sandra White, national lead for dental public health for Public Health England

This is the fourth and final paper of a series of reviews undertaken to explore the relationships between oral health and general medical conditions, in order to support teams within Public Health England, health practitioners and policy makers. This review aimed to explore the most contemporary evidence on whether poor oral health and dementia occurs in the same individuals or populations, to outline the nature of the relationship between these two health outcomes and to discuss the implication of any findings for health services and future research. The review was undertaken by a working group comprising consultant clinicians from medicine and dentistry, trainees, public health and academic staff. Whilst other rapid reviews in the current series limited their search to systematic reviews, this review focused on primary research involving cohort and case-control studies because of the lack of high level evidence in this new and important field. The results suggest that poor oral hygiene is associated with dementia, and more so amongst people in advanced stages of the disease. Suboptimal oral health (gingivitis, dental caries, tooth loss, edentulousness) appears to be associated with increased risk of developing cognitive impairment and dementia. The findings are discussed in relation to patient care and future research.

Objective To explore possible reasons for the reduction in population caries levels among 5-year-old children in England since 2008.Design An ecological study to explore possible reasons for the apparent reduction in dental caries, which included changes in survey methods, deprivation levels and ethnic mix of the population, impact of community level oral health improvement interventions, reductions in sugar intake, and increases in the availability of fluoride.Setting Data were drawn from three consecutive epidemiological surveys undertaken in 2007/8 and 2011/12 (NHS Dental Epidemiology programme for England), and 2014/15 (Public Health England Dental Public Health Epidemiology Programme). Evidence about the possible reasons for the observed reduction in caries levels was drawn from a range of national sources.Main outcomes measures Severity and prevalence of caries at dentinal level as measured by visual means alone among children aged five years.Results Reasons relating to changes in methods used in the survey, deprivation and ethnicity were rejected, along with community level interventions, as reasons for whole population level change. The factor relating to reduced sugar intake was neither rejected nor sustained. Reasons relating to increased fluoride availability, in particular that for increased concentration in children's toothpastes, was sustained.Conclusions The reduction in caries levels among 5-year-olds has most likely been brought about by the wider availability of children's toothpaste containing at least 1,000 ppm fluoride, along with other factors.

Introduction National Health Service (NHS) England dental teams need to consider from a professional perspective how they can, along with their NHS colleagues, play their part in reducing their carbon emissions and improve the sustainability of the care they deliver. In order to help understand carbon emissions from dental services, Public Health England (PHE) commissioned a calculation and analysis of the carbon footprint of key dental procedures.Methods Secondary data analysis from Business Services Authority (BSA), Health and Social Care Information Centre (HSCIC) (now called NHS Digital, Information Services Division [ISD]), National Association of Specialist Dental Accountants (NASDA) and recent Scottish papers was undertaken using a process-based and environmental input-output analysis using industry established conversion factors.Results The carbon footprint of the NHS dental service is 675 kilotonnes carbon dioxide equivalents (CO2e). Examinations contributed the highest proportion to this footprint (27.1%) followed by scale and polish (13.4%) and amalgam/composite restorations (19.3%). From an emissions perspective, nearly 2/3 (64.5%) of emissions related to travel (staff and patient travel), 19% procurement (the products and services dental clinics buy) and 15.3% related to energy use.Discussion The results are estimates of carbon emissions based on a number of broad assumptions. More research, education and awareness is needed to help dentistry develop low carbon patient pathways.

Introduction - This paper is the third of four rapid reviews undertaken to explore the relationships between oral health and general medical conditions in order to support teams within Public Health England, health practitioners and policymakers.Aims - This review aimed to explore the nature of the association between poor oral health and diabetes when found in the same individuals or populations, having reviewed the most contemporary evidence in the field.Methods - The reviews were undertaken by four groups each comprising consultant clinicians from medicine and dentistry, trainees, public health and academics. The methodology involved a streamlined rapid review process and synthesis of the data.Results - The results identified a number of systematic reviews of low to high quality suggesting that diabetes is associated with periodontal disease, tooth loss and oral cancer in particular, and that the management of oral diseases, most notably periodontal care, has a short term beneficial influence on metabolic outcomes related to diabetes but there is no evidence that this is sustained over the long-term and reduces the prevalence of the long-term complications of diabetes.Conclusion - Current evidence, of mixed quality, suggests a number of associations between oral diseases and diabetes mellitus (diabetes). Further high quality research in this field is required.

Introduction People from vulnerable groups have higher levels of untreated dental disease compared to the general population, yet often experience barriers to accessing care. Difficulties accessing oral healthcare services have been suggested as one of the pathways that contribute to oral health inequalities.Aim To conduct a rapid review of current literature related to barriers to oral healthcare for people from vulnerable groups.Methods Electronic searching u sing MEDLINE via Ovid, covering articles from 2007 to 2017, and limited to the English language. Publication types included primary and secondary evidence from peer-reviewed journals and reports.Results From a total of 536 records, 308 full-text articles were included in the final review. Barriers were summarised at the individual, organisational and policy levels. Common barriers across all vulnerable groups included lack of affordability, difficulties accessing care, lack of availability of appropriate care, and lack of public funding for specialised services. In addition, specific barriers were identified for certain groups. Potential solutions included the provision of training and information to patients and carers about oral health and accessing dental services, training dental professionals in caring for vulnerable groups, and better use of skill mix and guidance to ensure publicly-funded dental services are commissioned to meet the needs of vulnerable groups.Conclusion This rapid review identified barriers to dental care for vulnerable groups at individual, organisational and policy levels to inform policymakers and commissioners.

Acidic mammalian chitinase (AMCase) is known to be induced by allergens and helminths, yet its role in immunity is unclear. Using AMCase-deficient mice, we show that AMCase deficiency reduced the number of group 2 innate lymphoid cells during allergen challenge but was not required for establishment of type 2 inflammation in the lung in response to allergens or helminths. In contrast, AMCase-deficient mice showed a profound defect in type 2 immunity following infection with the chitin-containing gastrointestinal nematodes Nippostrongylus brasiliensis and Heligmosomoides polygyrus bakeri. The impaired immunity was associated with reduced mucus production and decreased intestinal expression of the signature type 2 response genes Il13, Chil3, Retnlb, and Clca1. CD103(+) dendritic cells, which regulate T cell homing, were also reduced in mesenteric lymph nodes of infected AMCase-deficient mice. Thus, AMCase functions as a critical initiator of protective type 2 responses to intestinal nematodes but is largely dispensable for allergic responses in the lung.

The protective effect of community water fluoridation (CWF) on caries is established, but secular changes may modify its impact. Relationships with adverse health outcomes have also been alleged. W...

Objectives The aim of this systematic review was to identify and conceptualize the barriers and enablers to accessing dental services for people experiencing homelessness in the United Kingdom. Methods A literature search for studies relevant to homelessness and dental care was conducted. The PRISMA and ENTREQ guidelines were followed. Electronic databases (EMBASE, MEDLINE, DOSS, CINAHL, SOCINDEX and PsycINFO) and grey literature sources (Electronic Theses Online Service - EThOS, Kings Fund, NICE Evidence, Open Grey, Google and the Health Foundation) were searched up to 28 August 2018. The critical appraisal was conducted using CASP and an adjusted version of a JBI Critical Appraisal tool. Thematic analysis was used to develop the themes and domains. Results Twenty-eight papers were included. Barriers to homeless people accessing dental care stemmed both from the lived experience of homelessness and the healthcare system. Within homelessness, the themes identified included complexity, emotions and knowledge. Regarding the healthcare system, identified themes included staff encounter, accessibility and organization issues. Conclusion Homelessness can actively contribute to both an increased need for dental care and barriers to accessing that care. The arrangement of dental healthcare services can also act as barriers to care. This is the first systematic review to conceptualize the factors associated with access to dental care for people who are homeless. It provides a set of recommendations for overcoming the main barriers for homeless people to accessing dental care. It also offers directions for future research, policy and commissioning.

Fibroproliferative diseases affect a significant proportion of the world's population. Despite this, core mechanisms driving organ fibrosis of diverse etiologies remain ill defined. Recent studies suggest that integrin-alpha V serves as a master driver of fibrosis in multiple organs. Although diverse mechanisms contribute to the progression of fibrosis, TGF-β and IL-13 have emerged as central mediators of fibrosis during type 1/type 17, and type 2 polarized inflammatory responses, respectively. To investigate if integrin-alpha V interactions or signaling is critical to the development of type 2 fibrosis, we analyzed fibroblast-specific integrin-alpha V knockout mice in three type 2-driven inflammatory disease models. While we confirmed a role for integrin-alpha V in type 17-associated fibrosis, integrin-alpha V was not critical to the development of type 2-driven fibrosis. Additionally, our studies support a novel mechanism through which fibroblasts, via integrin-alpha V expression, are capable of regulating immune polarization. We show that when integrin-alpha V is deleted on fibroblasts, initiation of type 17 inflammation is inhibited leading to a deregulation of type 2 inflammation. This mechanism is most evident in a model of severe asthma, which is characterized by a mixed type 2/type 17 inflammatory response. Together, these findings suggest dual targeting of integrin-alpha V and type 2 pathways may be needed to ameliorate fibrosis and prevent rebound of opposing pro-fibrotic and inflammatory mechanisms. Copyright © 2018 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

This study will examine the links between the historical case of Jack the Ripper, the history of forensic science, and the advancement of policing for the Metropolitan Police and forensic in Victorian Britain. Ripper’s crimes were committed in a ‘pre-forensic science’ period, when there were no fingerprints, DNA, or crime scene investigation units to help Detectives capture sophisticated criminals, but through this case forensic science and the Metropolitan Police Force would develop into a more modern form of policing. Jack the Ripper can be considered the prototype of the definition of a serial killer, and his crimes were of a nature that police had little experience with, which meant the police force would have to develop new techniques in criminal investigation. This study will examine the early history of the Metropolitan Police, how the young police force—less than sixty years old by the first murder of Jack the Ripper—was organized, the tools available for investigating murders, how the case of Jack the Ripper led to advancements in criminal investigation and how these new techniques were used to solve other crimes. The Metropolitan Police and British pathologists—such as Dr. Bernard Spilsbury— developed new ways of catching criminals because of the Jack the Ripper case, such as crime scene preservation, profiling and the use of photography to capture crime scenes that would be used to solve the case of Dr. Crippen in 1910 and the Bathtub Murders in 1915.

Nonalcoholic fatty liver disease (NAFLD) is now the most common progressive liver disease in developed countries and is the second leading indication for liver transplantation due to the extensive fibrosis it causes. NAFLD progression is thought to be tied to chronic low-level type 1 inflammation originating in the adipose tissue during obesity; however, the specific immunological mechanisms regulating the progression of NAFLD-associated fibrosis in the liver are unclear. To investigate the immunopathogenesis of NAFLD more completely, we investigated adipose dysfunction, nonalcoholic steatohepatitis (NASH), and fibrosis in mice that develop polarized type 1 or type 2 immune responses. Unexpectedly, obese interleukin-10 (IL-10)/IL-4-deficient mice (type 1-polarized) were highly resistant to NASH. This protection was associated with an increased hepatic interferon-γ (IFN-γ) signature. Conversely, IFN-γ-deficient mice progressed rapidly to NASH with evidence of fibrosis dependent on transforming growth factor-β (TGF-β) and IL-13 signaling. Unlike increasing type 1 inflammation and the marked loss of eosinophils seen in expanding adipose tissue, progression of NASH was associated with increasing eosinophilic type 2 liver inflammation in mice and human patient biopsies. Finally, simultaneous inhibition of TGF-β and IL-13 signaling attenuated the fibrotic machinery more completely than TGF-β alone in NAFLD-associated fibrosis. Thus, although type 2 immunity maintains healthy metabolic signaling in adipose tissues, it exacerbates the progression of NAFLD collaboratively with TGF-β in the liver.

Oral health is part of general health and well-being and contributes to the development of a healthy child. The most common oral disease affecting young children is dental caries (figure 1), which is largely preventable and is a public health priority. Oral health is one of Public Health England’s (PHE) priorities linking to; getting the best start in life, childhood obesity, nutrition including breastfeeding, weaning and cross-cutting themes such as inequalities and social justice. Poor oral health in children impacts on the children themselves and on their family and society. Dental caries is the most common reason for 5–9 year olds in England to be admitted to hospital, where they have teeth out under general anaesthesia. Over 60 000 children aged 0–19 years were admitted to hospital to have teeth removed under general anaesthesia in 2015/2016.1 Figure 1 Dental caries in the deciduous dentition. Children with dental caries suffer pain and infection and often have difficulties eating, sleeping and socialising.2 They have to take time off school to attend the dentist and hospital, and this is often their first introduction to dental care and can lead to fear and anxiety with lifetime consequences. Poor oral health may be a sentinel marker of wider health and social issues, and dental neglect may be part of a safeguarding issue.3 Dental care is a significant cost with the National Health Service (NHS) spending £3.4 billion on all age dental care and an estimated additional £2.3 billion in the private dental market.4 The National Dental Epidemiology Programme gives support for the ongoing gathering, analysing and disseminating of robust and reliable information of the oral health needs of local populations.5 Although the oral health of 5 year olds in England and across the UK is improving (figure 2), the most recent 5-year-old dental survey6 found that almost …

Introduction - This paper is the second of four reviews exploring the relationships between oral health and general medical conditions, in order to support teams within Public Health England, health practitioners and policymakers.Aim - This review aimed to explore the most contemporary evidence on whether poor oral health and pulmonary disease occurs in the same individuals or populations, to outline the nature of the relationship between these two health outcomes, and discuss the implication of any findings for health services and future research.Methods - The work was undertaken by a group comprising consultant clinicians from medicine and dentistry, trainees, public health, and academics. The methodology involved a streamlined rapid review process and synthesis of the data.Results - The results identified a number of systematic reviews of medium to high quality which provide evidence that oral health and oral hygiene habits have an impact on incidence and outcomes of lung diseases, such as pneumonia and chronic obstructive pulmonary disease in people living in the community and in long-term care facilities. The findings are discussed in relation to the implications for service and future research.Conclusion - The cumulative evidence of this review suggests an association between oral and pulmonary disease, specifically COPD and pneumonia, and incidence of the latter can be reduced by oral hygiene measures such as chlorhexidine and povidone iodine in all patients, while toothbrushing reduces the incidence, duration, and mortality from pneumonia in community and hospital patients.

Aim This paper reports on one review of four rapid reviews undertaken to explore the relationships between oral health and general medical conditions, in order to support teams within Public Health England, health practitioners and policy makers. This review aimed to explore the most contemporary evidence on whether poor oral health and cardiovascular disease occurs in the same individuals or populations, to outline the nature of the relationship between these two health outcomes and to discuss the implication of any findings for health services and future research.Methods The review was undertaken by a group comprising consultant clinicians from medicine and dentistry, trainees, public health and academics. The methodology involved a streamlined rapid review process and synthesis of the data.Results The results identified a number of systematic reviews of low to high quality, which suggests that there is: (1) fairly robust evidence of an increased risk of atherosclerotic vascular disease (ASVD) amongst individuals with chronic periodontitis, independent of other established cardiovascular risk factors; (2) there is some evidence that the incidence of caries and tooth loss is higher in patients with cardiovascular disease; and (3) that orofacial pain can presents as the sole symptom of stroke in some patients. The findings are discussed in relation to implications for service and future research.Conclusion There is high quality evidence to support an association between cardiovascular disease and oral health. This evidence is mainly related to the association between chronic periodontitis and atherosclerotic heart disease, and is independent of confounding factors as drawn from epidemiological observational studies.

Objectives To determine the impact of education on nurses’ knowledge of delirium, knowledge and perception of a validated screening tool, and delirium screening in the ICU. Methods A quasi-experimental single group pretest-post-test design. Setting A 16 bed ICU in a Canadian urban tertiary care centre. Main outcome measures Nursing knowledge and perception were measured at baseline, 3-month and 18-month periods. Delirium screening was then assessed over 24-months. Results During the study period, 197 surveys were returned; 84 at baseline, 53 at 3-months post education, and 60 at the final assessment period 18-months post intervention. The significant improvements in mean knowledge scores at 3-months post intervention (7.2, SD 1.3) were not maintained at 18-months (5.3, SD 1.1). Screening tool perception scores remained unchanged. Improvements in the perception of utility were significant at both time periods (p = 0.03, 0.02 respectively). Physician value significantly improved at 18-months (p = 0.01). Delirium screening frequency improved after education (p Conclusion Multifaceted education is effective in improving delirium knowledge and screening; however, without sustained effort, progress is transient. Education improved perceived tool utility and over time utility perception and physician value improved.

Thymic stromal lymphopoietin (TSLP), interleukin-25 (IL-25), and IL-33 are important initiators of type 2–associated mucosal inflammation and immunity. However, their role in the maintenance of progressive type 2 inflammation and fibrosis is much less clear. Using chronic models of helminth infection and allergic lung inflammation, we show that collective disruption of TSLP, IL-25, and IL-33 signaling suppresses chronic and progressive type 2 cytokine–driven inflammation and fibrosis. In a schistosome lung granuloma model or during chronic Schistosoma mansoni infection in the liver, individual ablation of TSLP, IL-25, or IL-33/ST2 had no impact on the development of IL-4/IL-13–dependent inflammation or fibrosis. However, significant reductions in granuloma-associated eosinophils, hepatic fibrosis, and IL-13–producing type 2 innate lymphoid cells (ILC2s) were observed when signaling of all three mediators was simultaneously disrupted. Combined blockade through monoclonal antibody (mAb) treatment also reduced IL-5 and IL-13 expression during primary and secondary granuloma formation in the lungs. In a model of chronic house dust mite–induced allergic lung inflammation, combined mAb treatment did not decrease established inflammation or fibrosis. TSLP/IL-33 double-knockout mice treated with anti–IL-25 mAb during priming, however, displayed decreased inflammation, mucus production, and lung remodeling in the chronic phase. Together, these studies reveal partially redundant roles for TSLP, IL-25, and IL-33 in the maintenance of type 2 pathology and suggest that in some settings, early combined targeting of these mediators is necessary to ameliorate progressive type 2–driven disease.

To investigate the respective contributions of TLR versus IL-1R mediated signals in MyD88 dependent control of Mycobacterium tuberculosis, we compared the outcome of M. tuberculosis infection in MyD88, TRIF/MyD88, IL-1R1, and IL-1β–deficient mice. All four strains displayed acute mortality with highly increased pulmonary bacterial burden suggesting a major role for IL-1β signaling in determining the MyD88 dependent phenotype. Unexpectedly, the infected MyD88 and TRIF/MyD88-deficient mice, rather than being defective in IL-1β expression, displayed increased cytokine levels relative to wild-type animals. Similarly, infected mice deficient in caspase-1 and ASC, which have critical functions in inflammasome-mediated IL-1β maturation, showed unimpaired IL-1β production and importantly, were considerably less susceptible to infection than IL-1β deficient mice. Together our findings reveal a major role for IL-1β in host resistance to M. tuberculosis and indicate that during this infection the cytokine can be generated by a mechanism that does not require TLR signaling or caspase-1.

THE OBSTRUCTIVE SLEEP APNEA/HYPOPNEA SYNDROME (OSAHS) CAUSES DAYTIME SLEEPINESS ASSOCIATED WITH LOUD SNORING IN APPROXIMATELY 4% of middle-aged men and 2% of middle aged women. Patients with OSAHS are at increased risk of road traffic accidents1,2 have increased blood pressure3–5 and an increased risk of cardiovascular complications such as strokes and myocardial infarction.6 The treatment of choice for obstructive sleep apnea/hypopnea syndrome (OSAHS) is continuous positive airway pressure (CPAP) which initially delivered a preset pressure determined on an overnight titration study. More recently CPAP devices which can vary the pressure delivered during the night have become available. Such variable pressure devices have the theoretical advantages of being able to cope with changes in pressure requirements due to both short term (posture, alcohol, nasal congestion) and long term (weight change, ageing) effects. Variable-pressure variable pressure devices tend to be more expensive. Anecdotally some patients have reported preference for variable pressure devices and others for fixed pressure devices. When the study was initiated a meta-analysis showed no clear evidence whether variable-pressure devices give better outcomes than fixed pressure devices in the average patient with OSAHS.7 However even this inconclusive meta-analysis included only 282 patients, and averaged data from 9 studies and 6 manufacturers' differing variable-pressure CPAP devices, both factors which may have decreased the clarity of any difference. In addition there is evidence that in some sub-groups of patients, including those requiring a higher CPAP pressure > 10 cm H2O8 and those with high within-night pressure variability,9 variable pressure devices may deliver better patient outcomes,8 but this cannot be generalized to other patient populations. We therefore performed a blinded, randomized controlled crossover trial in 200 consecutive patients across a range of severities of OSAHS to determine whether 6 weeks of treatment with variable-pressure CPAP produced better outcomes than 6 weeks of treatment with fixed-pressure CPAP.

Transpiration (E) is regulated over short time periods by stomatal conductance (Gs) and over multi-year periods by tree- and stand-structural factors such as leaf area, height and density, with upper limits ultimately set by climate. We tested the hypothesis that tree structure, stand structure and Gs together regulate E per ground area (Eg) within climatic limits using three sites located across a steep climatic gradient: a low-elevation Juniperus woodland, a mid-elevation Pinus forest and a high-elevation Picea forest. We measured leaf area : sapwood area ratio (Al : As), height and ecosystem sapwood area : ground area ratio (As : Ag) to assess long-term structural adjustments, tree-ring carbon isotope ratios (δ13C) to assess seasonal gas exchange, and whole-tree E and Gs to assess short-term regulation. We used a hydraulic model based on Darcy's law to interpret the interactive regulation of Gs and Eg. Common allometric dependencies were found only in the relationship of sapwood area to diameter for pine and spruce; there were strong site differences for allometric relationships of sapwood area to basal area, Al : As and As : Ag. On a sapwood area basis, E decreased with increasing elevation, but this pattern was reversed when E was scaled to the crown using Al : As. Eg was controlled largely by As : Ag, and both Eg and Gs declined from high- to low-elevation sites. Observation-model comparisons of Eg, Gs and δ13C were strongest using the hydraulic model parameterized with precipitation, vapour pressure deficit, Al : As, height, and As : Ag, supporting the concept that climate, Gs, tree- and stand-structure interact to regulate Eg. Copyright © 2008 John Wiley & Sons, Ltd.

Aim: Patients receiving primary dental care may occasionally require conscious sedation as an adjunct to care. It is one of a range of options to support anxious patients or those undergoing difficult procedures. The aim of this study was to examine patterns of conscious sedation within primary dental care in relation to patient demography, deprivation status, geography (local authority, region) and type of care (Band) within England to examine equity in distribution of service provision. Materials and Methods: Descriptive analysis of cross-sectional primary dental care data, obtained from national claims held by the National Health Service (NHS) Business Services Authority, on patients who had received one or more courses of care involving sedation. Results: Just under 137,000 episodes of care involving sedation are provided for over 120,000 patients per year, the majority of which are for adults. Four out of ten (41%) patients were children, with 6–12-year-olds forming the largest group; 6% were aged under six years. Eleven per cent of patients had more than one course of care involving sedation, with adults aged 25–34 years having the highest rate: 1.17 (s.d.: 0.887) in 2012/2013 and 1.16 (s.d.: 0.724) in 2013/2014. There was a clear social gradient, whereby the most deprived quintile had the highest volume of patients that had received sedation at least once in primary dental care in both years (31.5%). Whilst there was a clear social gradient amongst children and young adults who received sedation, the gradient flattened among middle-aged and was flat amongst older adults. The majority of courses of care involving sedation were associated with Band 2 claims for care (88.6% in 2012/2013; 88.8 in 2013/2014). Whilst one or more patients in all higher tier local authorities received care involving sedation, there were marked geographic inequalities. Discussion: Patients receive sedation in support of NHS primary dental care across the life course and social spectrum. Whilst the pattern of uptake of care parallels the social gradient in younger age groups overall, there are clear geographical inequalities in provision. As sedation is only one of a series of adjuncts to care which may be provided across different sectors of the health system, a wider systems analysis should be undertaken as the findings raise important issues about equitable access to appropriate care. Furthermore, there should be a greater emphasis on prevention to reduce the need for care. The implications for child oral health, access and quality are discussed.

Increasing evidence suggests that asthma is a heterogeneous disorder regulated by distinct molecular mechanisms. In a cross-sectional study of asthmatics of varying severity (n = 51), endobronchial tissue gene expression analysis revealed three major patient clusters: TH2-high, TH17-high, and TH2/17-low. TH2-high and TH17-high patterns were mutually exclusive in individual patient samples, and their gene signatures were inversely correlated and differentially regulated by interleukin-13 (IL-13) and IL-17A. To understand this dichotomous pattern of T helper 2 (TH2) and TH17 signatures, we investigated the potential of type 2 cytokine suppression in promoting TH17 responses in a preclinical model of allergen-induced asthma. Neutralization of IL-4 and/or IL-13 resulted in increased TH17 cells and neutrophilic inflammation in the lung. However, neutralization of IL-13 and IL-17 protected mice from eosinophilia, mucus hyperplasia, and airway hyperreactivity and abolished the neutrophilic inflammation, suggesting that combination therapies targeting both pathways may maximize therapeutic efficacy across a patient population comprising both TH2 and TH17 endotypes.

Study objectives Continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea hypopnea syndrome (OSAHS) is conventionally started after in-laboratory overnight titration. This use of sleep laboratory space is both costly and limits access for diagnostic studies. This study aimed to evaluate whether automated CPAP titration in the home produced patient outcomes equal to those following laboratory-based automated CPAP titration. The main outcomes were Epworth Sleepiness Scale score, objective daytime sleepiness (Oxford SLEep Resistance test or OSLER test), and CPAP use; we also performed quality-of-life questionnaires: Functional Outcomes of Sleep Questionnaire and SF-36. Design Prospective, randomized, single-blind, parallel-group, controlled trial Setting Regional sleep center and patients' homes. Patients Two hundred CPAP-naive patients with OSAHS requiring CPAP treatment. Interventions One hundred patients were randomly assigned to a standard 1-night in-hospital CPAP titration and 100 to 3 nights' home CPAP titration and then issued with fixed pressure CPAP. Data were analyzed on an intention-to-treat basis. Measurements and results The patient groups did not differ at baseline. The CPAP pressures defined at titration (mean+/- SEM: 10.6+/-0.2, 10.4+/-0.2 cm H20, p = .19), number of mask leaks, and initial acceptance rates were similar in the sleep-laboratory and home-titrated groups. At 3-month follow-up, there was no significant difference in CPAP use (mean+/-SEM: 4.39+/-0.25, 4.38+/-0.25 h/night; p > .9), Epworth Sleepiness Scale score (9.5+/-0.5, 8.5+/-0.5, p = .14), OSLER, Functional Outcomes of Sleep Questionnaire, or SF-36 between the sleep-laboratory and home-titrated groups. Conclusions Home-based automated CPAP titration is as effective as automatic in-laboratory titrations in initiating treatment for OSAHS.

This article describes an innovation in baccalaureate nursing education that is intended to assist in the preparation of nursing students for careers in which evidence-informed practice is an imperative. The innovation involves the combination of central aspects of the internationally recognized Registered Nurses’ Association of Ontario Best Practice Guidelines Program with existing curricular goals and themes in a baccalaureate nursing program at a small university in southern Ontario in Canada. [ J Nurs Educ . 2014;53(3, Suppl.):S55–S58.]

A diverse suite of effector immune responses provide protection against various pathogens. However, the array of effector responses must be immunologically regulated to limit pathogen- and immune-associated damage. CD4+Foxp3+ regulatory T cells (Treg) calibrate immune responses; however, how Treg cells adapt to control different effector responses is unclear. To investigate the molecular mechanism of Treg diversity we used whole genome expression profiling and next generation small RNA sequencing of Treg cells isolated from type-1 or type-2 inflamed tissue following Leishmania major or Schistosoma mansoni infection, respectively. In-silico analyses identified two miRNA “regulatory hubs” miR-10a and miR-182 as critical miRNAs in Th1- or Th2-associated Treg cells, respectively. Functionally and mechanistically, in-vitro and in-vivo systems identified that an IL-12/IFNγ axis regulated miR-10a and its putative transcription factor, Creb. Importantly, reduced miR-10a in Th1-associated Treg cells was critical for Treg function and controlled a suite of genes preventing IFNγ production. In contrast, IL-4 regulated miR-182 and cMaf in Th2-associed Treg cells, which mitigated IL-2 secretion, in part through repression of IL2-promoting genes. Together, this study indicates that CD4+Foxp3+ cells can be shaped by local environmental factors, which orchestrate distinct miRNA pathways preserving Treg stability and suppressor function., Author Summary The diversity of pathogens that the immune system encounters are controlled by a diverse suite of immunological effector responses. Preserving a well-controlled protective immune response is essential. Too vigorous an effector response can be as damaging as too little. Regulatory T cells (Treg) calibrate immune responses; however, how Treg cells adapt to control the diverse suite of effector responses is unclear. In this study we investigated the molecular identity of regulatory T cells that control distinct effector immune responses against two discrete pathogens, an intracellular parasitic protozoa, Leishmania major, and an extracellular helminth parasite, Schitsosoma mansoni. The two Treg populations studied were phenotypically and functionally different. We identified molecular pathways that influence this diversity and more specifically, we identified that two miRNAs (miR-182 and miR-10a) act as “regulatory hubs” critically controlling distinct properties within each Treg population. This is the first study identifying the upstream molecular pathways controlling Treg cell specialization and provides a new platform of Treg cell manipulation to fine-tune their function.

Objective: Clinical isolates of Candida were tested for the presence of catalase and susceptibility to hydrogen peroxide.Methods: MIC was tested by broth dilution technique and catalase was determined by a spectrophotometric procedure.Results: All 38 strains tested were inhibited by hydrogen peroxide in concentrations ranging from 4.4 to 88 mM/l, with non-albicans isolates generally requiring higher concentrations of hydrogen peroxide for inhibition. Growth media consisting of glucose and protein diminished the antifungal effectiveness of hydrogen peroxide, as did the presence of hemoglobin, in incubation mixtures. However, hydrogen peroxide exerted greater inhibition at pH 4 than at pH 7. Although all Candida isolates tested possessed catalase, there was no apparent correlation between the catalase activity of individual isolates and the minimal antifungal concentration of hydrogen peroxide.Conclusions: This study suggested that, despite the production of catalase by vaginal microorganisms, hydrogen peroxide may exert a regulating influence which may be further modified by the proteins found in the vaginal milieu.