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Inadequate training in tobacco cessation counseling (TCC) is a recognized, but mutable, barrier to implementation of tobacco cessation education (TCE) and intervention strategies in dental practice. The objective of this study was to identify the opinions and practices of senior dental hygiene (DH) students in North Carolina regarding their didactic training in TCE and integration of TCE into their clinical curricula. A pilot-tested questionnaire designed by the authors was administered to a cross-sectional, non-random convenience sample of 241 graduating senior DH students enrolled in all twelve North Carolina DH educational programs. Response rate was 65 percent (n=156). Of the respondents, 99 percent agreed that hygienists should be trained to provide TCE. Nearly all respondents (99 percent) had one or more patients who smoked, and 81 percent had one or more patients who used spit tobacco. Eighty-nine percent had one or more patients who had expressed a desire to quit. Most students were comfortable providing TCC to both smokers (92 percent) and spit tobacco users (93 percent); however, 26 percent reported that they were not comfortable providing quit messages to patients unwilling to quit. Enhancements to TCE in DH curricula may increase hygienists' incorporation of TCE into their future practice.

Joint occurrence of two or more diseases may impact their transmission, clinical presentation, management approaches, and treatment efficacy. Although oral candidiasis (OC) and oral hairy leukoplakia (OHL) are the most commonly occurring opportunistic oral diseases of HIV-infected patients, literature describing their joint occurrence is sparse. The purpose of this project was to develop an explanatory multivariable model for joint occurrence of OC and OHL (OC-OHL). This cross-sectional study examined 631 adult dentate HIV-1 seropositive persons for OC and OHL from 1995-2000 at the University of North Carolina Hospitals in Chapel Hill, NC. Data collected from medical record review, interviews and clinical examinations were analyzed using chi(2) tests, t itests, and nonparametric tests. Multivariable proportional odds models were developed, using the likelihood ratio test and adjusting for several demographic, behavioral, and biological factors. Thirteen percent of participants had OC only; 12.8% had OHL only; 4.6% had OC-OHL; whereas 69.7% had neither. Occurrence of OC-OHL was independently associated with CD4+ counts less than 200 cells per microliter (adjusted odds ratio [OR] (95% confidence interval {CI}) = 13.4 (6.6, 27.2) and CD4+ counts 200-499 cells per microliter (OR = 3.9 [1.9, 8.1]); current smokers (OR = 2.3 [1.4, 3.8]); and whites (OR = 1.7 [1.1, 2.5]). Combination antiretroviral therapy was protective (OR = 0.5 [0.3, 0.9]). In an HIV-1-infected population, lower CD4+ cell counts and smoking were important independent risk indicators for joint occurrence of OC and OHL.

Unlabelled: Many oral and pharyngeal cancers (OPC) are preventable. Early detection improves survival rates. Hygienists have opportunities to help reduce the oral cancer burden among their patients., Purpose: The purpose of this project was to qualitatively assess North Carolina dental Hygienists' views regarding OPC prevention and early detection., Methods: Sixteen practicing dental hygienists participated in 2, 8-person focus groups. Focus groups were taped, transcribed, and analyzed qualitatively for content., Results: Four major themes arose: 1) The charge of the dental hygienist was not necessarily to diagnose cancer, but to recognize abnormalities and initiate referral when necessary; 2) The dental hygienist is only helpful in the tobacco cessation process if the patient has a desire to quit; 3) The dental hygienist is most effective if the patient believes the provider is genuine and truly cares about the patient's well-being; 4) There is always a need for continued education in oral cancer screenings and tobacco cessation, specifically for hands-on courses. Barriers to performing OPC exams included: financial, time, and insufficient dentist support. Barriers for dental hygienists in providing tobacco cessation counseling included: lack of patient interest, lack of patient education materials and resources, smoking parents of adolescents, personality issues, and provider-patient diversity in age, gender, ethnicity, and culture., Conclusions: Dental hygienists felt their most important contribution to oral cancer control was patient education and oral cancer awareness. Professional continuing education is important and barriers need to be addressed to improve oral cancer control efforts.

Objective: To assess the educational preparedness of medical and dental professionals to reduce the burden of OPC through planning effective cancer control strategies such as reducing tobacco consumption, suggesting healthy lifestyle and diet, and performing early detection through screening examinations and appropriate follow-up., Methods: Self-reported adequacy of training in oral and pharyngeal cancer (OPC) early intervention activities was compared among 4 health care provider groups in North Carolina. Pretested surveys were mailed to random samples of licensed professionals., Results: Nearly all providers agreed that early detection improves 5-year survival rates from OPC. Compared with 567 medical providers (273 family physicians and 294 nurse practitioners), 1235 dental providers (584 dentists and 651 hygienists) were significantly less likely to feel adequately trained in tobacco and alcohol cessation and to palpate neck nodes, but were significantly more likely to feel adequately trained to perform oral cancer examinations. Among dental providers, those who felt they had adequate training in tobacco and alcohol cessation were significantly more likely to assess these risk factors on patient medical histories., Conclusions: Education is needed to prepare dental providers to undertake OPC prevention activities, whereas medical providers would benefit from enhanced oral examination skills to improve their performance in early detection.

Objectives: To assess knowledge of oral and pharyngeal cancer (OPC) clinical signs and risk factors, the association between the risk factors and OPC, and the experience with OPC screening between newly diagnosed OPC patients and controls among a population of veterans in North Carolina., Study Design: A case-control study with 31 OPC cases and 30 frequency-matched controls recruited from 2003 to 2004. Bivariate analysis using chi-square statistics and multivariate logistic regression was implemented to estimate the association with OPC., Results: Only 34% of respondents knew 1 clinical sign and 4 or 5 risk factors for OPC. The lifetime accumulation of tobacco had a significant relationship with OPC (>20 pack-years; OR, 3.2; 95% CI, 1.01-10.3). Many respondents had not had an oral cancer examination within 3 years, mostly through ignorance. Most VA OPC patients were diagnosed by physicians, rather than by dentists., Conclusions: A considerable knowledge deficit on OPC was found among North Carolina veterans. Use of tobacco was a risk factor for OPC in this population.

Background: Appropriately trained dental hygienists can participate in oral cancer (OC) control., Method: We assessed knowledge of risk factors, diagnostic procedures, and opinions regarding OC education among 651 dental hygienists practicing in North Carolina using a mail survey. We constructed regression models of factors influencing high knowledge levels., Results: Most correctly identified tobacco and alcohol use as OC risk factors, and 52% felt their knowledge of OC was current; however, we identified gaps. Diagnostic knowledge was highest for those who were recent graduates or received continuing education in the last 5 years; 96% were interested in future continuing education., Conclusion: Increased OC education content in dental hygiene curricula and training programs for practicing hygienists is needed to enhance early detection of OC.

This study describes the incidence of oral and pharyngeal cancer (OPC) in North Carolina (NC) from 1990 to 1999. OPC cases 1990-1999 from the NC Central Cancer Registry were included. Variables included date of diagnosis, county of residence, anatomical site, histology, age at diagnosis, sex, race, stage at diagnosis, grade, tumor behavior, and laterality. The overall average annual rate of OPC was 10.6 cases per 100,000 population. OPC incidence was highest for African-American males and for eastern NC; there was no significant trend in the overall annual incidence rate. Squamous cell carcinoma of the lip increased for white females and other oral cancers decreased among all females. With a few specific exceptions, NCCCR rates were similar to SEER rates. North Carolina continues to have substantial OPC incidence and substantial racial disparities persist.

Background: Dentists play a critical role in the early detection of oral and pharyngeal cancer (OPC). The authors administered a survey that assessed the level of knowledge among dentists regarding risk factors and diagnostic concepts., Methods: In 2002, the authors mailed a 38-item, pretested survey to a random sample of 1,115 licensed dentists practicing in North Carolina. Three-level (low, medium, high) composite index scores for knowledge of risk factors and diagnostic concepts were created using previously developed scales. The authors formulated multivariable models for risk factor and diagnostic knowledge indexes., Results: Of the 584 respondents, only 181 (31 percent) had consistent medium-to-high levels of knowledge on both highly correlated indexes. Dentists who had higher risk factor and diagnostic knowledge scores were significantly (P < .05) more likely to have heard of one or more diagnostic aids (odds ratio [OR], 2.7), to have graduated from dental school within the previous 20 years (OR, 1.8) and to have performed biopsies or referred five or more patients with suspicious lesions per year (OR, 1.7 and 1.5, respectively) than were less-knowledgeable respondents., Conclusions: More education is needed in dental schools, postgraduate programs and continuing education programs to enhance dental professionals' knowledge of OPC risk factors and diagnostic concepts. Such programs should include information about adjunctive diagnostic aids., Practice Implications: Greater knowledge of risk factors and diagnostic concepts may result in more frequent patient referrals, biopsy procedures or both, thus aiding in the early diagnosis and treatment of patients with OPC.

Purpose: North Carolina is the 11th most populous state and ranks 14th among all states in the age-adjusted mortality rate for oral and pharyngeal cancer (OPC). This study assessed North Carolina dental Hygienists' knowledge of tobacco and alcohol use as OPC risk factors, assessment practices of tobacco and alcohol use in patient medical histories, and opinions regarding tobacco and alcohol cessation education. Characteristics of dental hygienists who screen for tobacco and alcohol use in medical histories were also analyzed., Methods: A 40-item survey was mailed to a simple random sample of 1,223 dental hygienists from a registry of 4,076 licensed in North Carolina. Data were included from 651 completed surveys, giving an effective response rate of 57%., Results: Most respondents correctly identified tobacco and alcohol use as risk factors for OPC. A majority assessed patients' tobacco and alcohol use. Less than 10% assessed no tobacco factors, while nearly 42% assessed no alcohol factors. A number of background and practice characteristics were found to be positively associated with tobacco and alcohol screening in patient medical histories. A majority agreed or strongly agreed that dental hygienists should be trained to provide tobacco and alcohol cessation education to their patients; however, few felt trained to provide such education., Conclusion: Improvements in knowledge regarding tobacco and alcohol use as OPC risk factors are needed. Future interventions might include educational programs for currently practicing dental hygienists and increased tobacco and alcohol cessation education in the professional entry-level dental hygiene curricula.

Objectives: To establish incidence rates and risk factors for HIV-associated oral candidiasis (OC), oral hairy leukoplakia (OHL), and any HIV-associated oral diseases (HIV-OD)., Design: This prospective, cumulative case-control study followed 283 initially oral disease-free HIV-1-infected men and women for 2 years. Incidence rate ratios (IRR) and incidence proportions for OC, OHL, and HIV-OD were estimated. Multivariable analyses using Poisson regression determined the most parsimonious best-fitting model explaining the outcomes., Results: Incidence rate (per 1000 person-months) was 9.3 for OC, 6.8 for OHL, and 13.5 for HIV-OD. Incidence of OC was associated with low CD4 count (adjusted IRR = 3.0 (95% CI = 1.7, 5.1)), smoking (IRR = 1.9 (1.0, 3.8)) and combination antiretroviral therapy (IRR = 0.3 (0.1, 0.8)). Incidence of OHL was associated with low CD4 count, conditional upon smoking status. Conclusions Low CD4 count and smoking are important risk factors for HIV-associated OC and OHL. Antiretroviral medications are protective for OC but not for OHL.

Objective: This study assesses knowledge of oral cancer risk factors, clinical signs, and oral cancer examination experience among North Carolina adults., Methods: A statewide random digit dial, computer-assisted telephone interview was conducted in 2002. Data from 1,096 respondents, with a response rate of 62 percent, were poststratified to 2000 census data by sex, race, and age group to produce population-based estimates. Knowledge of one sign of oral cancer, four or more risk factors for oral cancer, and having ever had an oral cancer examination were compared in logistic regression models using normalized weights., Results: Fourteen (95% confidence interval [CI] +/-2) percent of adults had never heard of oral or mouth cancer. Risk factor knowledge was high for 56 percent (95% CI+/-3) and associated in a logistic regression model with younger age, feeling personal factors cause cancer, and nonuse of snuff. One sign of oral cancer (sore/lesion, red or white patch in mouth, and bleeding in the mouth) was correctly identified by 53 percent (95% CI+/-3) with significantly more correct responses from younger people, nonsmokers, and some college education. Only 29 percent (95% CI+/-3) reported ever having had an oral cancer examination when this procedure was described. Most respondents reported exams performed by dentists. In a weighted logistic regression model, older age, being dentate, nonsmokers, alcohol users, and those with some college education were significantly more likely to report having ever had an oral cancer examination., Conclusions: Although there is moderate knowledge of signs and risk factors for oral cancer among North Carolina adults, knowledge deficits remain. Oral cancer examinations need to be increased, particularly among tobacco smokers.

Objective: This prospective observational study examined differences in perceived oral health status, treatment needs, dental care utilization patterns, and barriers to care between HIV-infected non-Hispanic blacks and whites in North Carolina., Methods: 632 adult HIV-infected medical clinic attendees provided information on their oral health status and dental care history during face-to-face interviews with a trained interviewer., Results: Compared to whites, blacks were significantly more likely to be female, older, less educated, have lower income, and have acquired HIV by heterosexual sex or injecting drug use. Although two-thirds of patients reported good oral health, blacks were significantly more likely to have loose teeth, need extractions, and be episodic dental care utilizers. Primary barriers to dental care were cost (30%), fear (19%), and low motivation (13%). Sixty-five percent of patients had unmet dental needs in the last three years. Race, cost, fear, and immune competence were significantly associated with unmet dental need in a multivariable model., Conclusions: Disparities exist within this HIV-infected population in oral symptoms, utilization patterns, and perceived unmet dental need. Targeted interventions that address barriers to care are needed to help establish preventive dental care patterns in this region, especially among blacks.

Objectives: To determine the relationship of immunosuppression with measures of probing pocket depth (PPD), recession (REC), and clinical attachment level (CAL) in an HIV-infected population from North Carolina (NC), a state in the southeastern United States (USA)., Design: Cross-sectional study of HIV-infected adults (n = 326) treated at the University of North Carolina Hospitals. Clinical medical record review and sociodemographic interview data were collected. Median age of study participants was 37 years (range 19-67). Males comprised 78% and Blacks 60%. Analyses were limited to those who were dentate (n = 316)., Main Outcome Measures: Main outcomes were cases vs non-cases of notable PPD, REC, and CAL. Immunosuppression measured by CD4+ cell count microL was the exposure of interest., Results: Defined cases of PPD (n = 148) were 2.6 (95% CI = 1.3, 5.3) times less likely to occur at CD4+ cells < 200 than non-cases, whereas, cases of REC (n = 94) were 2.8 (95% CI = 1.2, 6.6) times more likely to occur at that level of severe immunosuppression, controlling for confounders., Conclusion: Sub-groups of persons with HIV experience a high burden of periodontitis where notable severity and extent of PPD, CAL, and REC were clearly evident at different stages of immunosuppression.

Objective: The purpose of this study was to determine temporal trends in the prevalence of oral manifestations of human immunodeficiency virus (HIV)., Study Design: Five hundred seventy HIV-infected adults recruited consecutively were examined by using established presumptive clinical criteria for HIV-associated oral lesions. Prevalence of oral lesions before the widespread use of HIV protease inhibitors (February 1995 through August 1996, 8% of the early sample, n = 271) was compared with lesion prevalence in a more recent period of greater protease inhibitor use (December 1996 through February 1999, 42% of the late sample, n = 299)., Results: Overall prevalence of oral lesions significantly decreased from early to late periods, 47.6% to 37.5%, respectively (P =.01), with some variation by lesion type. Prevalence of hairy leukoplakia (25. 8% to 11.4%; P <.01) and necrotizing periodontal diseases (4.8% to 1. 7%; P =.03) decreased, whereas HIV salivary gland disease increased (1.8% to 5.0%; P =.04). Changes in prevalence of oral candidiasis (20.3% to 16.7%), aphthous ulcers (3.7% to 3.0%), oral warts (2.2% to 4.0%), herpes simplex virus lesions (1.8% to 2.0%), and Kaposi's sarcoma (1.1% to 0.3%) were not statistically significant (P >.20 for all comparisons)., Conclusion: The pattern of oral opportunistic infections is changing in the era of protease inhibitor use.

Objectives: This study estimates factors associated with the prevalence of HIV-associated periodontal diseases (HIV-P) and the severity and extent of periodontitis in HIV-infected adults from North Carolina (NC)., Methods: Data are derived from a cross-sectional study of HIV-infected adults (total n = 326, dentate n = 316) treated at the University of North Carolina Hospitals. Outcomes were a diagnosis of HIV-P and measures of probing pocket depth (PPD), recession (REC), and clinical attachment level (CAL). Immunosuppression was measured by peripheral blood CD4+ cells/mm3., Results: In addition to persons with HIV (non-AIDS), this study included 10 percent of the AIDS cases in North Carolina. Median age was 37 years (range = 19-67); 78 percent were male and 60 percent were black. Sixty-two percent of persons had a probing pocket depth > or = 5 mm; 46% had recession > or = 3 mm, and 66 percent had attachment level > or = 5 mm in one or more sites. Cases of HIV-P (n = 15) were rare. Persons taking HIV-antiretroviral medication were one-fifth (OR = 0.20; 95% CI = 0.07, 0.63) as likely to have HIV-P as those not taking those medications, controlling for CD4+ cell counts., Conclusions: HIV-infected persons in this study group from North Carolina exhibited severe and extensive measures of adult periodontitis. A small proportion experienced a severe form of HIV-P, which was attenuated by antiretroviral therapy.

Objectives: Examine variations in oral manifestations of HIV by gender, race, risk behaviors, substance use and immune status in a previously unstudied population in the southeast region of the USA., Design: Cross-sectional analytic study., Setting: Academic medical center, North Carolina, USA., Subjects: First 238 HIV-infected adults (76% male; 59% Black) enrolled in an ongoing longitudinal study., Methods: Oral examination, medical chart review, sociodemographic and behavioral interview. Descriptive, bivariate, and multivariable analyses., Outcomes: Presence of oral manifestations of HIV., Results: 50% had recent CD4 counts < 200 cells microliters-1, 48% had one or more oral lesion. Specific lesion prevalence: hairy leukoplakia (OHL) 26.5%; candidiasis (OC) 20%; HIV-associated periodontal diseases (HIV-PD) 8.8%; aphthae 4.2%; papillomas 2.5%; herpes simplex 2.1%; HIV salivary gland disease 2.1%; Kaposi's sarcoma (KS) 1.7%; other 1.3%. In bivariate analyses, OHL was associated with being male, White, having a CD4 < 200, and men who have sex with men (MSM); OC was associated with CD4 < 200 and current smoking; HIV-PD was associated with consumption of more than seven alcohol-containing drinks per week; KS was associated with being male and MSM. Significant variables in multivariable analysis for presence of any oral lesion were White, CD4 < 200, and more than seven drinks/week; for OHL were male and CD4 < 200; and for OC were White, CD4 < 200, current smoking, and not MSM., Conclusions: MSM were at increased risk for KS and OHL, not OC, while smokers were at increased risk of OC. OC, OHL, and any oral lesion were associated with immune suppression. OHL was more likely in males independent of CD4 count.

Burkitt's lymphoma is a malignancy of B-lymphocyte origin that was initially described in African children with jaw tumors. These tumors often spread to involve abdominal viscera and other sites, have rapid growth kinetics, and are principally responsive to chemotherapy. Prolonged survival is predicted by site and extent of tumor, with bone marrow and central nervous system involvement being indicators of a poor prognosis. The dental practitioner plays an important role in diagnosis of jaw lesions and treatment throughout the course of the disease. An examination of 17 cases of Burkitt's lymphoma diagnosed at The North Carolina Memorial Hospital, University of North Carolina at Chapel Hill, North Carolina, over a 10-year period is undertaken and an illustrative case study is presented to demonstrate the challenge of caring for the patient with Burkitt's lymphoma.

Golden-winged Warblers (Vermivora chrysoptera, Parulidae) are declining migrant songbirds that breed in the Great Lakes and Appalachian regions of North America. Within their breeding range, Golden-winged Warblers are found in early successional habitats adjacent to mature hardwood forest, and previous work has found that Golden-winged Warbler habitat preferences are scale-dependent. Golden-winged Warbler Working Group management recommendations were written to apply to large regions of the breeding range, but there may be localized differences in both habitat availability and preferences. Rapid declines at the southernmost extent of their breeding range in Western North Carolina necessitate investigation into landscape characteristics governing distribution in this subregion. Furthermore, with the increase in availability of community science data from platforms such as eBird, it would be valuable to know if community science data produces similar distribution models as systemic sampling data. In this study, we described patterns of Golden-winged Warbler presence in Western North Carolina by examining habitat variables at multiple spatial scales using data from standardized Audubon North Carolina (NC) playback surveys and community science data from eBird. We compared model performance and predictions between Audubon NC and eBird models and found that Golden-winged Warbler presence is associated with sites which, at a local scale (150m), have less mature forest, more young forest, more herb/shrub cover, and more road cover, and at a landscape scale (2500m), have less herb/shrub cover. Golden-winged Warbler presence is also associated with higher elevations and smaller slopes. eBird and Audubon models had similar variable importance values, response curves, and overall performance. Based on variable importance values, elevation, mature forest at the local scale, and road cover at the local scale are the primary variables driving the difference between Golden-winged Warbler breeding sites and random background sites in Western North Carolina. Additionally, our results validate the use of eBird data, since they produce species distribution modeling results that are similar to results obtained from more standardized survey methods. [ABSTRACT FROM AUTHOR]

Background: Decreased access to preventive care services has been proposed as a mechanism for the association between low socioeconomic status (SES) and advanced stage at diagnosis in patients with head and neck squamous cell carcinoma (HNSCC). Methods: Retrospective analysis of patients diagnosed with HNSCC in North Carolina between 2002 and 2006. Results: A total of 1108 patients with HNSCC were included in the study. In the multivariable analysis, use of annual routine dental services (OR 0.7, 95% CI 0.5‐0.9) and colonoscopy in the past 10 years (OR 0.7, 95% CI 0.5‐0.9) were associated with lower odds of advanced T stage at diagnosis. Having no insurance (OR 1.8, 95% CI 1.1‐2.9), an income <$20 000 (OR 1.6 95% CI 1.03‐2.6), and >10 pack‐years tobacco use (OR 1.5, 95% CI 1.04‐2.2) were associated with advanced T stage at diagnosis. Conclusion: Use of preventive care services and SES independently predict stage at diagnosis in HNSCC. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to determine active periodontal disease status in HIV and to determine the impact of periodontal disease resolution on HIV status. Methods In this longitudinal cohort study, 73 HIV-positive subjects received comprehensive dental care. AAP, CDC/ AAP, and BGI case definitions determined periodontal classification. Likelihood and frequency of moderate/severe periodontal disease were assessed based on demographic variables. The influence of periodontal intervention was assessed at baseline, 12, and 24 months. IL-6 was measured in a subset of subjects. Results Of the periodontal classifications, BGI demonstrated the highest percentage category improvement with the intervention (>50%). Moderate/severe periodontitis was positively associated with HIV regardless of race, smoking status, gender, income level, and age, and was associated with increased IL-6. At baseline, the majority of subjects had severe periodontal disease regardless of ART status. Subjects with suppressed viral load at baseline demonstrated a significant improvement in BGI classification ( P = 0.026), increased CD4 counts ( P = 0.027), and decreased IL-6 levels ( P = 0.03). Conclusions Periodontal inflammation was prevalent regardless of ART status. In virologically suppressed subjects, the intervention decreased periodontitis with a concomitant IL-6 decrease and CD4 increase. These findings suggest a relationship between periodontal inflammation, oral microbial translocation, and HIV status. [ABSTRACT FROM AUTHOR]

Although associations between periodontal and systemic health have been well established, there is little evidence regarding dental hygienists' knowledge of the oral-systemic connection. The purpose of this study was to determine the knowledge levels of North Carolina dental hygienists regarding oral-systemic connections and their attitudes and confidence about incorporating this knowledge into clinical practice. A survey was developed, pilot tested, revised, and mailed to 1,665 licensed dental hygienists in North Carolina. After three mailings, the response rate was 62 percent, with 52 percent (N=859) meeting the inclusion criteria. The majority (>80 percent) of the respondents correctly identified risk factors for diabetes and cardiovascular disease (CVD), but were less knowledgeable about risk factors for osteoporosis and adverse pregnancy outcomes. Most knew that there is strong evidence linking periodontal disease with CVD (77 percent) and diabetes (70 percent). The majority felt that dental hygienists should be trained to identify risk factors for oral-systemic disease (94 percent) and to actively manage patients with systemic disease (78 percent). Eighty-eight percent felt that dental and medical professionals should be taught to practice collaboratively. These dental hygienists had a high level of knowledge in some areas of oral-systemic disease but could improve their confidence levels and knowledge through expanded content in their educational programs and continuing education. Interprofessional education and collaboration would also assist in integration of knowledge into clinical practice. [ABSTRACT FROM AUTHOR]