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Introduction Separated endodontic instruments may adversely affect the outcome of endodontic treatment. The combination of ultrasonic techniques and dental operating microscopes appears to be effective in the removal of separated instruments compared with more randomized techniques. This study evaluated the roles of root canal curvature and separated instrument length on the time needed to loosen and retrieve the instrument fragments. Methods The retrieval procedures of 128 separated instruments referred to a private endodontic practice for retreatment by general practitioners were evaluated in patients who were monitored for a minimum of 6 months. Preoperative cone-beam computed tomographic images were used to measure separated instrument lengths in relation to the degrees of canal curvatures. Ultrasonic instruments were used in the initial phase to remove the tooth structure and to loosen the fractured instrument. In the second phase, ultrasonic instruments, wire loops, or XP Shapers (FKG Dentaire SA, La Chaux-de-Fonds, Switzerland) were used for fragment removal. The time periods for all procedures were recorded. Statistical analysis was completed applying log-normal regression, structural equation modeling, and linear regression using Stata Version 14.2 software (StataCorp LLC, College Station, TX). Results All separated instruments were successfully retrieved. Using the protocol in this study, 89.8% of the instruments were removed using ultrasonic instruments alone with a mean time of 221 seconds. The instrument removal time was dependent on both the instrument length and the root canal curvature. Additionally, preparation times were proportionately longer with increasing separated instrument lengths when the loop device was required. Conclusions The preparation phase appears to have an important role in the retrieval of separated instruments. Preparation times for both non-loop and loop groups demonstrate that length and curvature are independent predictors of the log-transformed time. Generally, procedure times were extended with increasing file lengths and higher degrees of canal curvature.

Glass ionomer (GI) cements and self-etch (SE) or universal adhesives after etching (ER) adapt variably with dentine. Dentine characteristics vary with depth (deep/shallow), location (central/peripheral), and microscopic site (intertubular/peritubular). To directly compare adhesion to dentine, non-destructive imaging and testing are required. Here, GI, ER, and SE adapted at different dentine depths, locations, and sites were investigated using micro-CT, xenon plasma focused ion beam scanning electron microscopy (Xe PFIB-SEM), and energy dispersive X-ray spectroscopy (EDS). Extracted molars were prepared to deep or shallow slices and treated with the three adhesives. Micro-CT was used to compare changes to air volume gaps, following thermocycling, and statistically analysed using a quantile regression model and Fisher's exact test. The three adhesives performed similarly across dentine depths and locations, yet no change or overall increases and decreases in gaps at all dentine depths and locations were measured. The Xe PFIB-SEM-milled dentine-adhesive interfaces facilitated high-resolution characterization, and element profiling revealed variations across the tooth-material interfaces. Dentine depth and location had no impact on adhesive durability, although microscopic differences were observed. Here we demonstrate how micro-CT and Xe PFIB-SEM can be used to compare variable dental materials without complex multi-stage specimen preparation to minimize artefacts.

Background Headache disorders are highly prevalent worldwide, but not well investigated in adolescents. Few studies have included representative nationwide samples. This study aimed to present the prevalence and burden of recurrent headache in Australian adolescents. Methods The prevalence of recurrent headache, headache characteristics (severity and frequency) and burden on health-related quality of life in Australian children aged 10–17 years were presented, using nationally representative data from the Longitudinal Study of Australian children (LSAC). The LSAC, commencing in 2004, collects data every 2 years from a sample of Australian children of two different age cohorts: B ‘baby’ cohort, aged 0–1 years and K ‘kindergarten’ cohort, aged 4–5 years at the commencement of the study. Face-to-face interviews and self-complete questionnaires have been conducted with the study child and parents of the study child (carer-reported data) at each data collection wave, with seven waves of data available at the time of the current study. Wave 7 of the LSAC was conducted in 2016, with B cohort children aged 12–13 years and K cohort children aged 16–17 years. For the current study, data were accessed for four out of seven waves of available data (Wave 4–7) and presented cross-sectionally for the two cohorts of Australian children, for the included age groups (10–11 years, 12–13 years, 14–15 years and 16–17 years). All available carer-reported questionnaire data pertaining to headache prevalence, severity and frequency, general health and health-related quality of life, for the two cohorts, were included in the study, and presented for male and female adolescents. Carer-reported general health status of the study child and health-related quality of life scores, using the parent proxy-report of the Paediatric Quality of Life Inventory™ 4.0, were compared for male and female adolescents with recurrent headache and compared with a healthy group. Finally, health-related quality of life scores were compared based on headache frequency and severity. Results The LSAC study initially recruited 10,090 Australian children (B cohort n = 5107, K cohort n = 4983), and 64.1% of the initial sample responded at wave 7. Attrition rates across the included waves ranged from 26.3% to 33.8% (wave 6 and 7) for the B cohort, and 16.3% to 38.0% (wave 4–7) for the K cohort. Recurrent headache was more common in females, increasing from 6.6% in 10–11 years old females to 13.2% in 16–17 years old females. The prevalence of headache in males ranged from 4.3% to 6.4% across the age groups. Health-related quality of life scores were lower for all functional domains in adolescents with recurrent headache, for both sexes. Headache frequency, but not severity, was significantly associated with lower health-related quality of life scores, in both males and females. Conclusions Recurrent headache was common among Australian adolescents and increased in prevalence for females, across the age groups. Frequent recurrent headache is burdensome for both male and female adolescents. This study provides information regarding the prevalence and burden of recurrent headache in the adolescent population based on findings from the Longitudinal Study of Australian Children.

Introduction The purpose of this research was to compare mandibular growth rotation relative to the cranial base in different vertical facial patterns on the basis of multiple 2-dimensional (2D) and 3-dimensional (3D) superimposition methods. Methods Cone-beam computed tomography (CBCT) images taken at a mean interval of 54.8 ± 16.8 months were assessed from a sample of 70 growing patients. Three mandibular superimposition methods were compared against Bjork's structural method: (1) a 2D landmark method (2D-M1), (2) a voxel-based 3D method based on a previously reported method (3D-M1), and (3) a voxel-based 3D method incorporating symphyseal structures as references (3D-M2). After superimposition, the relative change in cranial base lines as depicted in sagittal views were measured for true mandibular rotation. Agreement between methods was assessed with Lin's concordance correlation coefficient, Bland-Altman's limits of agreement, and the Bradley-Blackwood test. Results Lin's concordance correlation coefficients ranged between 0.924 for the 2D-M1 method, 0.695 for the 3D-M1 method, and 0.965 for the 3D-M2 method. Bland-Altman limits of agreement were wide for all but the 3D-M2 method. Finally, the Bradley-Blackwood test of equality of means and variances was significant in all except the 3D-M2 method. Conclusions For time intervals between CBCT volume acquisitions >3 years, the use of the 2D-M1 and 3D-M1 methods is not recommended. There was a high concordance between the 3D-M2 method and Bjork's structural method when assessing mandibular growth rotation using relative changes in cranial base lines. The high concordance was displayed across all vertical facial types and for all time differences between first and second CBCT data acquisitions.

The transactional model of stress is a framework describing the process for coping with stressful events as a relationship between the individual person and environment. This study aimed to investigate the associations between personality, learning environment and experiences of mental health for a cohort of Australian dentistry students.Students were invited in 2017 to complete an online questionnaire including the Depression, Anxiety and Stress Scale (DASS-21), The Dundee Ready Education Environment Measure (DREEM) and Cloninger's Temperament and Character Inventory (TCIR-140). Students were followed-up one year later, and generalised estimating equations were used.A total of 219 (response 73.5%) students participated in the study. Two personality profiles of dentistry students were identified. Group 1 were significantly higher in the traits persistence, self-directedness, cooperativeness and reward dependence, whereas Group 2 were significantly higher in harm avoidance. Students with Group 2 personality had a 3.12 (CI:1.72-5.65) increased odds of depression compared to Group 1 students. Compared to students with positive perceptions of the learning environment, students with negative perceptions had increased odds of stress (3.48, CI: 1.85-6.53), depression (2.71, CI: 1.57- 4.65) and anxiety (2.59, CI: 1.56-4.28).Students with personalities high in levels of self-directedness, cooperativeness and persistence and low in harm avoidance, as found in Group 1, demonstrate high levels of general well-being. Positive perceptions of the dentistry learning environment were found to be an important influence on students stress. This study highlighted a number of factors important to student well-being and provides direction for further investigation of interventions aimed at enhancing student well-being.

Periodontal treatment may be a useful adjunct to medical management of diabetes; however, oral health has not been integrated into multidisciplinary diabetes care in Australia. This study aimed to understand the needs of patients and staff at a diabetes clinic to inform a prototype of integrated dental and diabetes care. Quantitative and qualitative data were collected from patients and staff at West Moreton Diabetes Clinic (WMDC) between September-October 2019. Clinical information, survey responses, and dental screening results were analyzed for 41 patients. Semi-structured interviews were held with six patients and a focus group with seven staff. Most patients (83%) had not seen a dentist in the previous year. Of the 37 patients with remaining natural teeth, 84% required periodontal assessment and 46% had multiple carious lesions. Unmet treatment needs and rates of access were similar for private and public dental patients. Staff and patients reported high levels of support for incorporation of dental care at WMDC. Integrating oral health into diabetes management is well supported by patients and staff to address significant unmet dental needs for both public and private dental patients.Incorporating dental screening/services within diabetes clinics mayincrease uptake and improve awareness of its importance in diabetes management.

Student-led interprofessional health clinics offer valuable opportunities for student learning and meeting the health care needs of the community. This case study describes the operation of a new interprofessional student-led community health service over its initial 13-month period of operation. This case study also presents an overview of the service provision, student placement opportunities and focuses on the challenges associated with the service and the impact on future planning. What is known about the topic? Interprofessional student-led clinics offer an opportunity to meet clinical placement demands and interprofessional training needs while also providing a community service. What does this paper add? This case study adds to the limited literature around knowledge of service delivery and challenges in the operation of community-based student-led interprofessional health services; future planning to streamline processes is also addressed. What are the implications? There may be relevance to other university–industry partnerships that intend to explore student-led interprofessional service operations designed to address placement shortages, student training and community needs.

Objectives Test the odds of factors previously associated with lower limb injury (decreased size of the multifidus (MF) and increased size of the quadratus lumborum (QL) muscle) in an independent sample of Australian Rules Football (ARF) players. Design Prospective cohort study. Setting Professional ARF. Participants: Forty-three male ARF players. Main outcome measures Cross-sectional areas (CSAs) of MF and QL muscles measured from pre-season ultrasound images. Playing season injuries were recorded by club personnel. A multivariable logistic regression model was used to evaluate the usefulness of MF and QL muscle size for predicting playing season lower limb injuries. Results Fifteen players (35%) sustained a playing season lower limb injury. The multivariable model indicated that the odds of sustaining a lower limb injury during the season was 2.38 (95% CI: 1.18, 5.00; P = 0.017) times less likely for a one cm2 increase from the mean value in MF muscle CSA at the L5 vertebral level after adjusting for CSA of the QL, age and BMI. The main effect and interaction models positively predicted 75% of players that sustained a lower limb injury during the season (sensitivity 80%, specificity 85%). Conclusion Future studies could examine the efficacy, feasibility and adherence of ‘at risk’ players to a pre-season training program aimed at increasing MF muscle size and monitor playing season injuries.

The Child Dental Benefits Schedule (CDBS) is an ongoing scheme administered through the Australian Government providing eligible children funding for clinical dental treatment. This study aimed to investigate the access of dental services across children's early childhood and examine whether the CDBS has improved access to dental care. The longitudinal study of Australian children is an ongoing cross-sequential cohort study with a representative sample of Australian children recruited in 2004. Birth (0-1 year) and kindergarten (4-5 years) cohorts were recruited through Medicare enrolment information at baseline and were representative of the Australian child population. Population-weighted longitudinal mixed effects Poisson models with individual identifiers as a random effect were used to assess the effect of Medicare dental schedules on reported dental attendance. Prior to the implementation of the CDBS for both cohorts, the birth cohort reported the lowest attendance rate at age 4-5. The introduction of the CDBS increased the rate of dental attendance for the low household income group by 8% (95% CI: 1%, 15%) after adjusting for confounders. The model provides evidence that dental attendance increased with age and the Indigenous population have 31% (95% CI: 4%, 55%) lower attendance rate after adjustment. The increase in reported access to dental services and favourable visiting patterns in low-income households during the operation of the CDBS provides some evidence that the schedule's primary aims to improve access to care in the child population are being met. Access to healthcare is multifaceted and the underutilisation of the schedule in the population warrants review of the schedule performance using other patient-centred indicators.

To investigate age and site-related changes to human dentin collagen, sound human teeth collected from donors aged 13-29 (young) and 50-74 (aged) years (n = 9/group) were cut to shallow and deep sites. Dentin collagen orientation and fibril bundling was investigated using the Picrosirius Red (PSR) stain observed under cross-polarized light microscopy (Pol), and collagen distribution was investigated using Confocal Laser Scanning Microscopy (CLSM). Collagen types III to I distribution in peritubular dentin (PTD) was revealed using Herovici stain and brightfield microscopy. Image analysis software and linear mixed modelling quantified outcomes. In situ dentin collagen was observed using Xenon Plasma Focussed Ion Beam Scanning Electron Microscopy (Xe PFIB-SEM). The PSR-Pol analysis revealed less coherently aligned and more bundled collagen fibrils in aged dentin (P = 0.005). Deep inner dentin collagen in both groups were less coherently aligned with reduced bundling. Regardless of age, CLSM showed collagen distribution remained stable; and more collagen type III was detectable in PTD located in inner dentin (Young: P = 0.006; Aged: P = 0.008). Observations following Xe PFIB-SEM cross-sectioning showed apatite-like deposits surrounding large intratubular collagen fibers, and evidence of smaller intertubular dentin collagen fibrils in situ. In conclusion, aging changes collagen network architecture, but not distribution or content.

OBJECTIVES Previous studies have identified many demographic, socioeconomic, behavioural and clinical variables associated with subjective parental ratings of child oral health. This study investigated associations between children's lifetime exposure to fluoridated drinking water (LEFW) and dental caries prevalence and parental ratings. METHODS Australia's National Child Oral Health Study 2012-2014 conducted oral epidemiological examinations for 24 664 children aged 5-14 and investigated risk factors for child oral health and disease through questionnaires. Parents also subjectively rated their child's oral health. This cross-sectional study estimated prevalence ratios for associations between LEFW and prevalence of dental caries in the primary and permanent dentitions and parental oral health ratings for 5-8 year old and 9-14 year old children. E-value sensitivity analyses helped assess whether observed effect sizes may have arisen through unmeasured confounding. RESULTS Children aged 5-8 with 0%-10% or 11%-89% LEFW are respectively 1.5 (95% CI 1.2-1.8) and 1.5 (95% CI 1.1-2.0) times more likely than children with 90%-100% LEFW to receive a fair or poor parental oral health rating. Children aged 9-14 with 0%-10% or 11%-89% LEFW are 1.2 (95% CI 1.0-1.4) times more likely than children with 90%-100% LEFW to receive a fair or poor parental oral health rating. Children aged 5-8 with 0%-10% or 11%-89% LEFW are respectively 1.4 (1.3-1.6) and 1.3 (95% CI 1.1-1.4) times more likely than children with 90%-100% LEFW to experience caries in their primary teeth. Children aged 9-14 with 0%-10% or 11%-89% LEFW are respectively 1.4 (95% CI 1.3-1.5) and 1.1 (95% CI 1.0-1.2) times more likely than children with 90%-100% LEFW to experience caries in their permanent teeth. CONCLUSIONS Longer lifetime exposure to fluoridated drinking water is causally associated with a lower childhood dental caries prevalence and more positive parental ratings of child oral health. The associations are stronger for younger children.

Exercise therapy such as motor control training (MCT) has been shown to reduce pain and disability in people with low back pain (LBP). It is unknown which patients are most likely to benefit. This longitudinal cohort study aimed to: (1) retrospectively examine records from a large cohort of patients who received MCT treatment, (2) identify potentially important predictors of response to MCT and (3) test the predictors on an independent (split) sample derived from the original cohort of patients, using one group to identify the predictors and the other to test them. The response of 775 patients with LBP to MCT was classified as ‘improved’ or ‘not improved’ based on self-reported change in pain levels and symptoms. Measures were examined for associations with improvement and entered into a logistic regression model to classify patients as low, medium or high benefits of improvement with MCT. The model was tested on an independent sample. A positive response was seen in patients with: no evidence of scoliosis [OR = 4.0, 95% CI (1.7, 9.6)], LBP without associated groin pain [OR = 2.2, 95% CI (1.0, 5.0)], LBP which was chronic recurrent in nature [OR = 3.1, 95% CI (1.8, 5.3)] and poor results on muscle testing of the multifidus muscle [OR = 2.0, 95% CI (1.1, 3.7)]. Testing on an independent sample confirmed that patients could be classified into benefit groups. This study provides a first step towards assisting clinicians to select patients most likely to respond to MCT. These slides can be retrieved under Electronic Supplementary Material.

Tick-borne relapsing fever (TBRF) is a potentially serious spirochetal infection caused by certain species of Borrelia and acquired through the bite of Ornithodoros ticks. In 2017, Austin Public Health, Austin, TX, identified five cases of febrile illness among employees who worked in caves. A cross-sectional serosurvey and interview were conducted for 44 employees at eight organizations that conduct cave-related work. Antibodies against TBRF-causing Borrelia were detected in the serum of five participants, four of whom reported recent illness. Seropositive employees entered significantly more caves (Median 25 [SD: 15] versus Median 4 [SD: 16], p = 0.04) than seronegative employees. Six caves were entered more frequently by seropositive employees posing a potentially high risk. Several of these caves were in public use areas and were opened for tours. Education of area healthcare providers about TBRF and prevention recommendations for cavers and the public are advised.

Borrelia spirochetes are the causative agents of Lyme borreliosis (LB) and relapsing fever (RF). Despite the steady rise in infections and the identification of new species causing human illness over the last decade, isolation of borreliae in culture has become increasingly rare. A modified Barbour-Stoenner-Kelly (BSK) media formulation, BSK-R, was developed for isolation of the emerging RF pathogen, Borrelia miyamotoi. BSK-R is a diluted BSK-II derivative supplemented with Lebovitz’s L-15, mouse and fetal calf serum. Decreasing the concentration of CMRL 1066 and other components was essential for growth of North American B. miyamotoi. Sixteen B. miyamotoi isolates, originating from Ixodes scapularis ticks, rodent and human blood collected in the eastern and upper midwestern United States, were isolated and propagated to densities > 108 spirochetes/mL. Growth of five other RF and ten different LB borreliae readily occurred in BSK-R. Additionally, primary culture recovery of 20 isolates of Borrelia hermsii, Borrelia turicatae, Borrelia burgdorferi and Borrelia mayonii was achieved in BSK-R using whole blood from infected patients. These data indicate this broadly encompassing borreliae media can aid in in vitro culture recovery of RF and LB spirochetes, including the direct isolation of new and emerging human pathogens.

One of the primary changes in the neuromuscular system in response to microgravity is skeletal muscle atrophy, which occurs especially in muscles that maintain posture while being upright on Earth. Reduced size of paraspinal and abdominal muscles has been documented after spaceflight. Exercises are undertaken on the International Space Station (ISS) during and following space flight to remediate these effects. Understanding the adaptations which occur in trunk muscles in response to microgravity could inform the development of specific countermeasures, which may have applications for people with conditions on Earth such as low back pain (LBP).The aim of this study was to examine the changes in muscle size and function of the lumbar multifidus (MF) and anterolateral abdominal muscles (1) in response to exposure to 6 months of microgravity on the ISS and (2) in response to a 15-day reconditioning program on Earth.Prospective longitudinal series.Data were collected from five astronauts who undertook seven long-duration missions on the ISS.For the MF muscle, measures included cross-sectional area (CSA) and linear measures to assess voluntary isometric contractions at vertebral levels L2 to L5. For the abdominal muscles, the thickness of the transversus abdominis (TrA), obliquus internus abdominis (IO) and obliquus externus abdominis (EO) muscles at rest and on contraction were measured.Ultrasound imaging of trunk muscles was conducted at four timepoints (preflight, postflight, mid-reconditioning, and post reconditioning). Data were analyzed using multilevel linear models to estimate the change in muscle parameters of interest across three time periods.Beta-coefficients (estimates of the expected change in the measure across the specified time period, adjusted for the baseline measurement) indicated that the CSA of the MF muscles decreased significantly at all lumbar vertebral levels (except L2) in response to exposure to microgravity (L3=12.6%; L4=6.1%, L5=10.3%; p.001), and CSAs at L3-L5 vertebral levels increased in the reconditioning period (p.001). The thickness of the TrA decreased by 34.1% (p.017), IO decreased by 15.4% (p=.04), and the combination of anterolateral abdominal muscles decreased by 16.2% (p.001) between pre- and postflight assessment and increased (TrA0.008; combined p=.035) during the postreconditioning period. Results showed decreased contraction of the MF muscles at the L2 (from 12.8% to 3.4%; p=.007) and L3 (from 12.2% to 5%; p=.032) vertebral levels following exposure to microgravity which increased (L2, p=.046) after the postreconditioning period. Comparison with preflight measures indicated that there were no residual changes in muscle size and function after the postreconditioning period, apart from CSA of MF at L2, which remained 15.3% larger than preflight values (p.001).In-flight exercise countermeasures mitigated, but did not completely prevent, changes in the size and function of the lumbar MF and anterolateral abdominal muscles. Many of the observed changes in size and control of the MF and abdominal muscles that occurred in response to prolonged exposure to microgravity paralleled those seen in people with LBP or exposed to prolonged bed rest on Earth. Daily individualized postflight reconditioning, which included both motor control training and weight-bearing exercises with an emphasis on retraining strength and endurance to re-establish normal postural alignment with respect to gravity, restored the decreased size and control of the MF (at the L3-L5 vertebral levels) and anterolateral abdominal muscles. Drawing parallels between changes which occur to the neuromuscular system in microgravity and which exercises best recover muscle size and function could help health professionals tailor improved interventions for terrestrial populations. Results suggested that the principles underpinning the exercises developed for astronauts following prolonged exposure to microgravity (emphasizing strength and endurance training to re-establish normal postural alignment and distribution of load with respect to gravity) can also be applied for people with chronic LBP, as the MF and anterolateral abdominal muscles were affected in similar ways in both populations. The results may also inform the development of new astronaut countermeasures targeting the MF and abdominal muscles.

Rattus rattus was first reported from the West Nile Region of Uganda in 1961, an event that preceded the appearance of the first documented human plague outbreak in 1970. We investigated how invasive R. rattus and native small mammal populations, as well as their fleas, have changed in recent decades. Over an 18-month period, a total of 2,959 small mammals were captured, sampled, and examined for fleas, resulting in the identification of 20 small mammal taxa that were hosts to 5,109 fleas (nine species). Over three-fourths (75.8%) of captured mammals belonged to four taxa: R. rattus, which predominated inside huts, and Arvicanthis niloticus, Mastomys sp., and Crocidura sp., which were more common outside huts. These mammals were hosts for 85.8% of fleas collected, including the efficient plague vectors Xenopsylla cheopis and X. brasiliensis, as well as likely enzootic vectors, Dinopsyllus lypusus and Ctenophthalmus bacopus. Flea loads on small mammals were higher in certain environments in villages with a recent history of plague compared to those that lacked such a history. The significance of these results is discussed in relation to historical data, the initial spread of plague in the WNR and the continuing threat posed by the disease.

Introduction Since the introduction of the digital dental assessment systems, there has been a shift towards this trend as it appears to provide a more accurate, reliable, time efficient, and reproducible assessment. The Planmeca Emerald scanner coupled with Romexis Compare software allows students and staff to objectively assess individual crown preparations, receive numerical values of key dimensions, and subsequently undergo comparison with ideal crown preparation dimensions. Objectives To measure the inter‐ and intra‐rater reliability using the intra‐oral scanner and Romexis Compare for prosthodontic crown preparations, and to evaluate the possible implementation of this software as a grading and self‐assessment tool in a preclinical setting. Methods The Planmeca scanner and Romexis Compare were used to compare the difference between 30 experimental preparations (n = 15 anterior teeth, n = 15 posterior teeth) with their respective unprepared typodont teeth. Three student examiners (W., K., V.) independently scanned the typodont teeth in pre‐formed standardized and non‐standardized putty jigs. Each preparation was measured from facial, lingual, incisal/occlusal, and margin surfaces. A second trial was completed after 2 weeks to assess intra‐rater reliability. The data were tabulated, graphed, and analyzed using SPSS and GraphPad Prism. Results The results of the study show greater consistencies in inter‐operator measurements for anterior teeth. Some variations, however, were found in posterior teeth measurements between the operators. The results of the intra‐rater measurements appear to be relatively consistent. Conclusion With some limitations, Romexis Compare can be used as a reliable and repeatable method for objective and consistent evaluation of student prosthodontic preparations in a preclinical setting.

Plague is a highly virulent fleaborne zoonosis that occurs throughout many parts of the world; most suspected human cases are reported from resource-poor settings in sub-Saharan Africa. During 2008–2016, a combination of active surveillance and laboratory testing in the plague-endemic West Nile region of Uganda yielded 255 suspected human plague cases; approximately one third were laboratory confirmed by bacterial culture or serology. Although the mortality rate was 7% among suspected cases, it was 26% among persons with laboratory-confirmed plague. Reports of an unusual number of dead rats in a patient’s village around the time of illness onset was significantly associated with laboratory confirmation of plague. This descriptive summary of human plague in Uganda highlights the episodic nature of the disease, as well as the potential that, even in endemic areas, illnesses of other etiologies might be being mistaken for plague.

Background: Dental students are required to demonstrate competency by pre-clinical simulated practice before performing invasive clinical procedures on patients. The Moog Simodont® Dental Trainer provides a virtual reality-based dental simulation environment for training students. Aim: This cross-sectional questionnaire-based study compared students’ perception of the pre-clinical paediatric dentistry training gained in Simodont® and conventional simulation environment. Design: The dental students who completed pulpotomies and stainless steel crowns (SSCs) training in Simodont® and conventional pre-clinical simulation laboratory were invited to complete a questionnaire on their experience in both environments. The percentages for the distribution of responses to statements about training modality were tabulated, and intra-participant comparisons were used to measure student preference for either Simodont® or conventional simulation training. Results: One hundred students completed the survey. Fifty-one per cent of students agreed that using Simodont® assisted their learning, and 56% felt Simodont® training facilitated their understanding of paediatric dentistry tasks. Generally, participants felt more comfortable with simulation training than Simodont® for both practical exercises. Eighty-eight per cent of the participants disagreed that Simodont® should replace conventional simulation. Conclusions: The study suggests that Simodont® could be used as an adjunct in training dental students for pre-clinical paediatric dentistry restorative exercises.

During the Ebola virus outbreak of 2013-2016, the Viral Special Pathogens Branch field laboratory in Sierra Leone tested approximately 26 000 specimens between August 2014 and October 2015. Analysis of the B2M endogenous control Ct values showed its utility in monitoring specimen quality, comparing results with different specimen types, and interpretation of results. For live patients, blood is the most sensitive specimen type and oral swabs have little diagnostic utility. However, swabs are highly sensitive for diagnostic testing of corpses.

A novel species within the Borrelia burgdorferi sensu lato complex, provisionally named Borrelia mayonii , was recently found to be associated with Lyme borreliosis in the Upper Midwest of the United States. Moreover, B. mayonii was detected from host-seeking Ixodes scapularis , the primary vector of B. burgdorferi sensu stricto in the eastern United States. We therefore conducted a study to confirm the experimental vector competence of I. scapularis for B. mayonii (strain MN14-1420), using colony ticks originating from adults collected in Connecticut and CD-1 white mice. Larvae fed on mice 10 weeks after needle-inoculation with B. mayonii acquired spirochetes and maintained infection through the nymphal stage at an average rate of 12.9%. In a transmission experiment, 40% of naive mice exposed to a single infected nymph developed viable infections, as compared with 87% of mice fed upon by 2–3 infected nymphs. Transmission of B. mayonii by one or more feeding infected nymphs was uncommon up to 48 h after attachment (one of six mice developed viable infection) but occurred frequently when nymphs were allowed to remain attached for 72–96 h or feed to completion (11 of 16 mice developed viable infection). Mice infected via tick bite maintained viable infection with B. mayonii , as determined by ear biopsy culture, for at least 28 weeks. Our results demonstrate that I. scapularis is capable of serving as a vector of B. mayonii . This finding, together with data showing that field-collected I. scapularis are infected with B. mayonii , indicate that I. scapularis likely is a primary vector to humans of this recently recognized Lyme borreliosis spirochete.

Dento-maxillofacial Radiology (DMFR) is comprised of the smallest cohort of specialists in Australia. A survey was undertaken to assess awareness of DMFR; radiology reporting and referring protocols; as well as dental practitioners' satisfaction with their radiology reporting arrangements. An original online survey created using Checkbox†, was sent to dental practitioners. The survey was promoted on Australian-based dental Facebook forums and emailed to targeted members via Australian professional dental associations. A total of 399 responses were received, with over 80% of respondents aware of DMFR as a specialty. Approximately 40% of practitioners were self-reporting their imaging. There was correlation between increased satisfaction with external reporting and utilization of DMFR services; and decreased satisfaction with medical radiology services. More than 90% of general dentists and greater than 85% of dental specialists prefer DMFR reports to medical radiology reports. Approximately 80% of practitioners believed their satisfaction would change positively if they had access to a DMFR report. The research indicates a high degree of self-reporting or non-reporting by dental practitioners. There is low satisfaction with external reporting performed by Medical Radiologists primarily due to a lack of dental knowledge or detail; and a preference for DMF Radiology reports.

Objectives: The literature describing the oral health of people with Multiple Sclerosis (MS) is scant and the findings equivocal. The aim of this study was to describe the oral health and oral self-care behaviours of people living with MS and compare it to the Australian population. Methods: Participants enrolled with the Australian MS Longitudinal Study (AMSLS) were invited to participate in the survey using an online or paper-based questionnaire. Data were collected on level of disability, oral health, oral self-care and factors influencing attendance for oral health care. Results: Completed questionnaires were received for 1523 respondents. Over one-fifth (n = 320; 22%) rated their oral health as fair or poor, and more than half (n = 840; 57%) reported toothache in the last 12 months. These proportions were higher than those for the general Australian adult population (oral health prevalence ratio (PR) = 1.25 [1.12, 1.40]; toothache PR = 3.63 [3.39, 3.88]), and this is despite comparable or better self-maintenance habits and dental attendance reported by respondents. People with MS reported high rates of mouth dryness (68.4%), teeth sensitivity (64.7%), change of taste (40.5%) and orofacial pain (39.0%); fewer than 10% experienced none of these. There was a lower prevalence of self-reported need for treatment (extraction or filling) than in the Australian adult population (15.8% vs 32.9%). Conclusions: People with MS have a greater oral health burden, demonstrated by their poorer self-reported oral health than the Australian adult population. Furthermore, they experience high rates of toothache, mouth dryness, teeth sensitivity, change of taste and orofacial pain. These findings are contrary to their self-reported good oral self-care and dental attendance habits and suggest some of the oral health impacts are due to MS rather than dental behaviours.

Borrelia miyamotoi , a relapsing fever group spirochete, is an emerging tick-borne pathogen. It has been identified in ixodid ticks across the Northern Hemisphere, including the West Coast of the United States. We describe the chromosome and large linear plasmid sequence of a B. miyamotoi isolate cultured from a California field-collected Ixodes pacificus tick.

Sports related concussion (SRC) is a risk for players involved in high impact, collision sports. A history of SRC is a risk factor for future concussions, but the mechanisms underlying this are unknown. Despite evidence that most visible signs and symptoms associated with sports concussion resolve within 7-10 days, it has been proposed that subclinical loss of neuromuscular control and impaired motor functioning may persist and be associated with further injury. Alternatively, indicators of poor sensorimotor performance could be independent risk factors. This study investigated if a history of SRC and/or pre-season sensorimotor performance predicted season head/neck injuries. Methods: 190 male rugby league, rugby union and Australian Football League players participated. Pre-season assessments included self-report of SRC within the previous 12 months and a suite of measures of sensorimotor function (balance, vestibular function, cervical proprioception and trunk muscle function). Head/neck injury data were collected in the playing season. Results: Forty-seven players (25%) reported a history of SRC. A history of concussion was related to changes in size and contraction of trunk muscles. Twenty-two (11.6%) players sustained a head/neck injury during the playing season, of which, 14 (63.6%) players had a previous history of SRC. Predictors of in-season head/neck injuries included history of SRC, trunk muscle function and cervical proprioceptive errors. Five risk factors were identified and players with three or more of these had 14 times greater risk of sustaining a season neck/head injury (sensitivity of 75% and specificity of 82.5%) than players with 2 or fewer risk factors. Conclusion: The modifiable risk factors identified could be used to screen football players in the pre-season and guide development of exercise programs aimed at injury reduction.

Borrelia miyamotoi sensu lato relapsing fever group spirochetes are emerging as causative agents of human illness ( Borrelia miyamotoi disease) in the United States. Host-seeking Ixodes scapularis ticks are naturally infected with these spirochetes in the eastern United States and experimentally capable of transmitting B. miyamotoi . However, the duration of time required from tick attachment to spirochete transmission has yet to be determined. We therefore conducted a study to assess spirochete transmission by single transovarially infected I. scapularis nymphs to outbred white mice at three time points post-attachment (24, 48, and 72 h) and for a complete feed ( > 72–96 h). Based on detection of B. miyamotoi DNA from the blood of mice fed on by an infected nymph, the probability of spirochete transmission increased from 10% by 24 h of attachment (evidence of infection in 3/30 mice) to 31% by 48 h (11/35 mice), 63% by 72 h (22/35 mice), and 73% for a complete feed (22/30 mice). We conclude that (i) single I. scapularis nymphs effectively transmit B. miyamotoi relapsing fever group spirochetes while feeding, (ii) transmission can occur within the first 24 h of nymphal attachment, and (iii) the probability of transmission increases with the duration of nymphal attachment.

Borrelia miyamotoi , of the relapsing-fever spirochete group, is an emerging tick-borne pathogen causing human illness in the northern hemisphere. Here, we present the chromosome, eight extrachromosomal linear plasmids, and a draft sequence for five circular and one linear plasmid of a Borrelia miyamotoi strain isolated from an Ixodes sp. tick from Connecticut, USA.

Serological assays and a two-tiered test algorithm are recommended for laboratory confirmation of Lyme disease. In the United States, the sensitivity of two-tiered testing using commercially available serology-based assays is dependent on the stage of infection and ranges from 30% in the early localized disease stage to near 100% in late-stage disease. Other variables, including subjectivity in reading Western blots, compliance with two-tiered recommendations, use of different first- and second-tier test combinations, and use of different test samples, all contribute to variation in two-tiered test performance. The availability and use of sample sets from well-characterized Lyme disease patients and controls are needed to better assess the performance of existing tests and for development of improved assays. To address this need, the Centers for Disease Control and Prevention and the National Institutes of Health prospectively collected sera from patients at all stages of Lyme disease, as well as healthy donors and patients with look-alike diseases. Patients and healthy controls were recruited using strict inclusion and exclusion criteria. Samples from all included patients were retrospectively characterized by two-tiered testing. The results from two-tiered testing corroborated the need for novel and improved diagnostics, particularly for laboratory diagnosis of earlier stages of infection. Furthermore, the two-tiered results provide a baseline with samples from well-characterized patients that can be used in comparing the sensitivity and specificity of novel diagnostics. Panels of sera and accompanying clinical and laboratory testing results are now available to Lyme disease serological test users and researchers developing novel tests.

The US Food and Drug Administration recently approved ciprofloxacin for treatment of plague (Yersina pestis infection) based on animal studies. Published evidence of efficacy in humans is sparse. We report 5 cases of culture-confirmed human plague treated successfully with oral ciprofloxacin, including 1 case of pneumonic plague.

The recommended laboratory diagnostic approach for Lyme disease is a standard two-tiered testing (STTT) algorithm where the first tier is typically an enzyme immunoassay (EIA) that if positive or equivocal is reflexed to Western immunoblotting as the second tier. bioMérieux manufactures one of the most commonly used first-tier EIAs in the United States, the combined IgM/IgG Vidas test (LYT). Recently, bioMérieux launched its dissociated first-tier tests, the Vidas Lyme IgM II (LYM) and IgG II (LYG) EIAs, which use purified recombinant test antigens and a different algorithm than STTT. The dissociated LYM/LYG EIAs were evaluated against the combined LYT EIA using samples from 471 well-characterized Lyme patients and controls. Statistical analyses were conducted to assess the performance of these EIAs as first-tier tests and when used in two-tiered algorithms, including a modified two-tiered testing (MTTT) approach where the second-tier test was a C6 EIA. Similar sensitivities and specificities were obtained for the two testing strategies (LYT versus LYM/LYG) when used as first-tier tests (sensitivity, 83 to 85%; specificity, 85 to 88%) with an observed agreement of 80%. Sensitivities of 68 to 69% and 76 to 77% and specificities of 97% and 98 to 99% resulted when the two EIA strategies were followed by Western immunoblotting and when used in an MTTT, respectively. The MTTT approach resulted in significantly higher sensitivities than did STTT. Overall, the LYM/LYG EIAs performed equivalently to the LYT EIA in test-to-test comparisons or as first-tier assays in STTT or MTTT with few exceptions.

The sequences of the complete linear chromosome and 7 linear plasmids of the relapsing fever spirochete Borrelia turicatae are presented in this report. The 925,547 bp of chromosome and 380,211 bp of plasmid sequence were predicted to contain a total of 1,131 open reading frames, with an average G+C content of 29.7%.

It is established thatYersinia pestis, the causative agent of bubonic plague, recently evolved from enteropathogenicYersinia pseudotuberculosisby undergoing chromosomal degeneration while acquiring two unique plasmids that facilitate tissue invasion (pPCP) and dissemination by fleabite (pMT). Thereafter, plague bacilli spread from central Asia to sylvatic foci throughout the world. These epidemic isolates exhibit a broad host range including man as opposed to enzootic (pestoides) variants that remain in ancient reservoirs where infection is limited to muroid rodents. Cells ofY. pseudotuberculosisare known to express glucose-6-phosphate dehydrogenase (Zwf) and aspartase (AspA); these activities are not detectable in epidemicY. pestisdue to missense mutations (substitution of proline for serine at amino position 155 of Zwf and leucine for valine at position 363 of AspA). In this study, functional Zwf was found in pestoides strains E, F and G but not seven other enzootic isolates; enzymic activity was associated with retention of serine at amino acid position 155. Essentially, full AspA activity occurred in pestoides isolates where valine (pestoides A, B, C and D) or serine (pestoides E, F, G and I) occupied position 363. Reduced activity occurred in strains Angola and A16, which contained phenylalanine at this position. Thekcatbut notKmof purified AspA from strain Angola was significantly reduced. In this context,aspAof the recently described attenuated enzootic microtus biovar encodes active valine at position 363, further indicating that functional AspA is a biomarker for avirulence ofY. pestisin man.

Acute febrile illness (AFI) is associated with substantial morbidity and mortality worldwide, yet an etiologic agent is often not identified. Convalescent-phase serology is impractical, blood culture is slow, and many pathogens are fastidious or impossible to cultivate. We developed a real-time PCR-based TaqMan array card (TAC) that can test six to eight samples within 2.5 h from sample to results and can simultaneously detect 26 AFI-associated organisms, including 15 viruses (chikungunya, Crimean-Congo hemorrhagic fever [CCHF] virus, dengue, Ebola virus, Bundibugyo virus, Sudan virus, hantaviruses [Hantaan and Seoul], hepatitis E, Marburg, Nipah virus, o'nyong-nyong virus, Rift Valley fever virus, West Nile virus, and yellow fever virus), 8 bacteria ( Bartonella spp., Brucella spp., Coxiella burnetii , Leptospira spp., Rickettsia spp., Salmonella enterica and Salmonella enterica serovar Typhi, and Yersinia pestis ), and 3 protozoa ( Leishmania spp., Plasmodium spp., and Trypanosoma brucei ). Two extrinsic controls (phocine herpesvirus 1 and bacteriophage MS2) were included to ensure extraction and amplification efficiency. Analytical validation was performed on spiked specimens for linearity, intra-assay precision, interassay precision, limit of detection, and specificity. The performance of the card on clinical specimens was evaluated with 1,050 blood samples by comparison to the individual real-time PCR assays, and the TAC exhibited an overall 88% (278/315; 95% confidence interval [CI], 84% to 92%) sensitivity and a 99% (5,261/5,326, 98% to 99%) specificity. This TaqMan array card can be used in field settings as a rapid screen for outbreak investigation or for the surveillance of pathogens, including Ebola virus.

In a case cluster, pneumonic plague transmission was compatible with respiratory droplet rather than aerosol transmission., The public and clinicians have long-held beliefs that pneumonic plague is highly contagious; inappropriate alarm and panic have occurred during outbreaks. We investigated communicability in a naturally occurring pneumonic plague cluster. We defined a probable pneumonic plague case as an acute-onset respiratory illness with bloody sputum during December 2004 in Kango Subcounty, Uganda. A definite case was a probable case with laboratory evidence of Yersinia pestis infection. The cluster (1 definite and 3 probable cases) consisted of 2 concurrent index patient–caregiver pairs. Direct fluorescent antibody microscopy and polymerase chain reaction testing on the only surviving patient's sputum verified plague infection. Both index patients transmitted pneumonic plague to only 1 caregiver each, despite 23 additional untreated close contacts (attack rate 8%). Person-to-person transmission was compatible with transmission by respiratory droplets, rather than aerosols, and only a few close contacts, all within droplet range, became ill.

This quantitative research study assesses the organizational characteristics, market factors, and performance of not-for-profit hospitals in the United States. These results have managerial implications related to hospital efficiency, organizational performance, and the role of not-for-profit hospitals within local communities. The study has policy implications on access to clinical services within local communities, the availability of charity care, and the long-term viability of the not-for-profit health care industry due to potential bankruptcy and closure. This study clearly demonstrates that not-for-profit hospital managers are faced with declining profitability and are challenged to reduce hospital-operating expenses while meeting their charitable mission. Additionally, the greater size and increased clinical complexity of not-for-profit hospitals are increasing organizational overhead. In many cases, the increased clinical complexity is a commitment to the organizational mission of providing a full range of services to the community. From a policy perspective, the study suggests that not-for-profit hospitals have aging facilities and reduced cash flow due to lower profit margins. As a result, many not-for-profit hospitals face potential bankruptcy and closure. This study clearly documents a threat to the provision of charity care in local communities and the long-term viability of the not-for-profit health care industry in the United States.

Pregnancy-associated plasma protein-A (PAPP-A) has been identified as the insulin-like growth factor (IGF)-dependent IGF-binding protein-4 (IGFBP-4) protease produced by human fibroblasts. Recently, we found that serum proteases induced during human pregnancy cleaved IGFBP-4 in both an IGF-II-dependent and an IGF-II-independent fashion. This study sought to determine whether PAPP-A is the predominant IGFBP-4 protease in human pregnancy serum (PS) and to assess the in vitro role of serum PAPP-A. Immunoprecipitation with PAPP-A antibody effectively depleted PAPP-A from the PS and completely abolished both IGF-II-dependent and IGF-II-independent IGFBP-4 proteolytic activity in PS. Direct addition of PAPP-A antibody to PS completely blocked IGFBP-4 proteolysis and partially blocked IGFBP-5 proteolysis, but had no effect on IGFBP-3 proteolysis. To evaluate the role of serum PAPP-A, we tested whether PAPP-A in PS modulated the inhibitory activity of IGFBP-4 on IGF-II-induced cell proliferation in human osteosarcoma MG63 cells. The wild-type IGFBP-4 (WTBP-4; 200 ng/mL) failed to inhibit proliferation of the cells treated with PS (0.1% or 0.3%) alone or in combination with IGF-II (40 ng/mL), whereas the inhibitory effect of WTBP-4 was observed in the cells treated with nonpregnancy serum alone or in combination with IGF-II (P < 0.05). In contrast to WTBP-4, a protease-resistant IGFBP-4 was able to inhibit proliferation of the cells treated with PS alone or in combination with IGF-II (P < 0.05). In the presence of PAPP-A neutralizing antibody, the inhibitory effect of WTBP-4 on proliferation of the cells treated with IGF-II and PS was restored. In summary, these data demonstrate 1) that PAPP-A represents the predominant IGFBP-4 protease in PS; 2) that PAPP-A may in part contribute to IGFBP-5, but not IGFBP-3, proteolytic activity in PS; and 3) that PAPP-A enhances the bioactivity of IGFs in vitro by degrading IGFBP-4.