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Objectives: To review the effectiveness of antiseptic oral sprays on oral health. Methods and materials: Three electronic databases (PubMed, Cochrane Library and Web of Science) were systematically searched to identify relevant studies. Only randomized controlled trials (RCTs) comparing the effect of oral sprays to placebo/control spray or mouthrinse on dental plaque and gingival inflammation were included. Results: Among a total of 996 papers, 20 effective studies fulfilled the selection criteria, and 8 studies were suitable for inclusion in meta‐analyses. A meta‐analysis of three studies using a 0.2% chlorhexidine (CHX) spray intervention, without prophylaxis at baseline, showed reductions in Plaque Index (PI) (Silness and Löe) and Gingival Index (GI) (Silness and Löe) scores of 0.74 (95% CI: −1.03 to −0.45) and 0.22 (95% CI: −0.38 to −0.06), respectively. Five studies provided a prophylaxis for subjects before study initiation. Three of these five studies used 0.2% CHX spray. A meta‐analysis demonstrated an increase of 0.18 (95% CI: −0.01 to 0.37) in PI (Silness and Löe) scores. Two RCTs compared 0.12% and 0.2% CHX spray, and a meta‐analysis showed increases of 1.71 (95% CI: 1.27 to 2.14) and 1.58 (95% CI: 1.23 to 1.93), respectively, in PI (Quigley and Hein) scores. Of the RCTs not amenable to meta‐analysis, eight studies reported significant improvements in PI and GI scores. Conclusions: Available evidence suggests that oral sprays are an acceptable delivery method for antiseptic agents. Further high‐quality studies are warranted to determine the effectiveness of alternative chemotherapeutic agents delivered via oral sprays on oral health. [ABSTRACT FROM AUTHOR]

Investigating the oral care delivered by nursing staff in acute hospital setting is having a remarkable shortage within the current literature. This was provoked due to lack of previous performed investigation in the acute hospital setting besides inconsistent existence of a standardized and comprehensive oral care knowledge, attitude and practice (KAP) instrumentation. Therefore, the purpose of this study is to assess the oral care KAP level for inpatients among nursing staff; to identify possible barriers to the provision of oral care; and to identify training preferences to improve the oral care of inpatients, in acute hospital settings in Hong Kong; and to provide standardized comprehensive KAP based assessment tool that would benefit and guide other future studies. In this study, a cross-sectional survey was conducted after a 55-item self-administered structured questionnaire was developed. A modified KAP tool was developed. The tool includes 4 domains: oral care knowledge, attitude, practice, and experience. Nursing staff was recruited from July 2018 to April 2019 via convenience sampling. Either online or printed questionnaires were completed. Proportions of nursing staff with good KAP, as defined by having 60% of the total score in the respective domain, were estimated with 95% confidence intervals (CI). Analysis of covariance was used to compare the mean scores of KAP among different independent variables and identify the factors associated with good KAP. 404 nursing staff were recruited. Approximately 29.5%, 33.7% and 14.9% of the respondents had good oral care knowledge, attitude and practice, respectively, and 53.2% of the respondents had unpleasant oral care experience. Better oral care practice was associated with higher levels of oral care knowledge (β = 0.1) and oral care attitude (β = 0.3). To conclude: nursing staff in acute hospital settings reported low levels of oral care KAP with variations between the RN, EN and HCA. This study adds to the literature the association between oral care unpleasant experiences and the oral care practice, as well as oral care knowledge and attitude which also in turns associated with practice. The developed standardised tool could be applied for future studies. Recommendations on the future research, training and practices were made., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Tsui et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The body of evidence regarding self-management programs (SMPs) for adult chronic non-cancer pain (CNCP) is steadily growing, and regular updates are needed for effective decision-making., Objectives: To systematically identify, critically appraise, and summarize the findings from randomized controlled trials (RCTs) of SMPs for CNCP., Methods: We searched relevant databases from 2009 to August 2021 and included English-language RCT publications of SMPs compared with usual care for CNCP among adults (18+ years old). The primary outcome was health-related quality of life (HR-QoL). We conducted meta-analysis using an inverse variance, random-effects model and calculated the standardized mean difference (SMD) and associated 95% confidence interval (CI) and statistical heterogeneity using the I 2 statistic., Results: From 8538 citations, we included 28 RCTs with varying patient populations, standards for SMPs, and usual care. No RCTs were classified as having a low risk of bias. There was no evidence of a significant improvement in overall HR-QoL, irrespective of pain type, immediately post-intervention (SMD 0.01, 95%CI - 0.21 to 0.24; I 2 57%; 11 RCTs; 979 participants), 1 - 4 months post-intervention (SMD 0.02, 95%CI - 0.16 to 0.20; I 2 48.7%; 12 RCTs; 1160 participants), and 6 - 12 months post-intervention (SMD 0.07, 95%CI - 0.06 to 0.21; I 2 26.1%; 9 RCTs; 1404 participants). Similar findings were made for physical and mental HR-QoL, and for specific QoL assessment scales (e.g., SF-36)., Conclusions: There is a lack of evidence that SMPs are efficacious for CNCP compared with usual care. Standardization of SMPs for CNCP and better planned/conducted RCTs are needed to confirm these conclusions.

Objective: To compare the effectiveness of chlorine dioxide, chlorhexidine and placebo sprays in improving oral hygiene among institutionalised elders., Background: Available evidence suggests that oral sprays may be an effective alternative delivery method for plaque control; however, few studies have evaluated antimicrobial agents other than chlorhexidine., Materials and Methods: A total of 228 elders across 11 nursing homes in Hong Kong were recruited into the clinical trial. Participants were randomly allocated into one of the following groups: 0.1% pH-balanced chlorine dioxide spray, 0.2% chlorhexidine spray or sterile water spray (placebo control), once daily. Dental plaque, gingival bleeding and other clinical oral health outcomes were assessed at baseline, 3 and 6 months. Participant acceptability of the interventions was assessed at the end of the clinical trial., Results: Review assessments were conducted for 135 elders at 6 months. Significantly greater reductions in plaque index scores were observed with the chlorhexidine spray (0.4) and chlorine dioxide spray (0.3) than the placebo spray (0.1). While significant reductions in gingival bleeding scores were observed within the chlorhexidine (7.4), chlorine dioxide (7.5) and placebo (5.3) sprays after 6 months, change scores were not significantly different between groups. Significantly greater increases in the levels of staining were observed in the chlorhexidine spray group (-0.1) than the chlorine dioxide (0.0) and placebo spray (0.0) groups., Conclusion: Antimicrobial sprays were shown to be effective among institutionalised elders. Chlorine dioxide spray showed equivalent effects on dental plaque and gingival bleeding relative to the chlorhexidine spray over a 6-month period., (© 2021 Gerodontology Association. John Wiley & Sons Ltd.)

Background: While systematic reviews (SR) generally suggest that vaccination is an effective way to prevent influenza infection, it is not clear if these conclusions are based on high quality SR methods. As such, we systematically identified, critically appraised, and summarised the characteristics and adherence to methodological standards in SRs with meta-analysis of efficacy/effectiveness of influenza vaccines., Methods: We searched MEDLINE, Embase, Scopus, CINAHL, Global Health, and CDSR for English-language SR publications up to July 11, 2022. We summarised the characteristics, adherence to methodological standards and SR quality (AMSTAR 2)., Results: From 11,193 retrieved citations, we included 48 publications (47 SRs). Seventy-five percent were of a critically low quality, 19% of a low quality, 2% of a moderate quality, and 4% of a high quality. Thirteen percent were industry-funded, about 13% co-authored by industry employee(s), and 4% commissioned by an organisation or authority. Only 45% percent reported protocol registration, 6% reported collaboration with a knowledge synthesis librarian/information specialist, and 60% utilised a reporting checklist (e.g. PRISMA)., Conclusions and Relevance: SRs with meta-analysis of efficacy/effectiveness of influenza vaccines are mostly of critically low quality and even the more recent reviews did not follow current best SR practices. These findings are significant in view of the controversies that surround influenza vaccines, and the use of SRs in informed decision-making. However, the findings do not justify curtailment or cessation of influenza vaccine use as vaccines continue to offer substantial net public health benefit.HighlightsWe systematically identified, critically appraised, and summarised the characteristics and adherence to methodological standards in 47 systematic reviews with meta-analysis of efficacy/effectiveness of influenza vaccines.13% of the reviews were industry-funded.About 13% of the reviews were co-authored by industry employee(s).4% of the reviews were commissioned by an organisation/authority.45% of the reviews reported protocol registration.6% of the reviews reported collaborating with a knowledge synthesis librarian/information specialist to prepare the search strategy.60% of the reviews reported using the PRISMA (or similar) checklist.75% of the reviews were judged to be of critically low quality; 19% of low quality; 2% of moderate quality; 4% of high quality.

Background: Influenza antiviral drugs remain controversial and it is not clear if conclusions on their efficacy/effectiveness are based on high quality systematic reviews (SRs). We systematically identified, critically appraised, and summarized the characteristics and adherence to methodological standards in SRs with meta-analysis of efficacy/effectiveness of influenza antiviral drugs for prevention and/or treatment of influenza., Methods: We searched MEDLINE, Embase, Scopus, CINAHL, Global Health, and CDSR for English-language SR publications up to July 2020. We summarized the characteristics, adherence to methodological standards and SR quality (AMSTAR 2)., Results: From a total 3,898 citations after removal of duplicates from all identified citations, we included 24 SRs. Seventy-five percent ( n  = 18) were of a critically low quality, 8% ( n  = 2) of a low quality, 17% ( n  = 4) of a moderate quality, and none were of a high quality. Seventeen percent ( n  = 4) were industry-funded, 4% ( n  = 1) coauthored by industry employee(s), and 33% ( n  = 8) commissioned by an organization or authority. Only 33% percent ( n  = 8) reported protocol registration, 4% ( n  = 1) reported collaboration with a knowledge synthesis librarian/information specialist, and 17% ( n  = 4) utilized a systematic review reporting checklist., Conclusions: The evidence suggests that SRs of efficacy/effectiveness of influenza antiviral drugs are mostly of critically low quality and do not follow current best SR practices. These findings are significant in view of the important role of SRs in decision-making and the controversies that surround the use of the influenza antiviral drugs. However, the findings should not be interpreted to mean curtailment/cessation of use of antiviral drugs for influenza.

Introduction: Healing time for neuropathic planter foot ulcers (NPFUs) in persons with diabetes may be reduced through use of non-removable fiberglass total contact casting (F-TCC) compared with removable cast walkers (RCWs), although the evidence base is still growing., Research Design and Methods: We conducted a rapid review and systematically searched for, and critically assessed, randomized controlled trials (RCTs) that compared the efficacy of F-TCC versus RCW, focusing on the time to ulcer healing in adult persons (18+ years) with NPFUs and type 1 or type 2 diabetes. We meta-analysed the mean differences and associated 95% CIs using an inverse variance, random-effects model. We also conducted a trial sequential analysis (TSA) to assess if the available evidence is up to the required information size for a robust conclusion. We assessed and quantified statistical heterogeneity between the included studies using the I 2 statistic., Results: Out of 102 retrieved citations, five RCTs met the eligibility criteria. Participants' inclusion in relation to stage of ulcer was highly variable as was peripheral neuropathy complicating comparisons. F-TCC appeared to present a shorter ulcer healing time (-5.42 days, 95% CI -9.66 days to -1.17 days; I 2 9.9%; 5 RCTs; 169 participants) compared with RCW. This finding was supported by the TSA., Conclusions: There is limited evidence from RCTs to suggest that F-TCC has a shorter ulcer healing time compared with RCW among adults with diabetic NPFUs. Properly designed and conducted RCTs are still required for a stronger evidence base., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The effectiveness of T cell-mediated rejection (TCMR) therapy for achieving histological remission remains undefined in patients on modern immunosuppression. We systematically identified, critically appraised, and summarized the incidence and histological outcomes after TCMR treatment in patients on tacrolimus (Tac) and mycophenolic acid (MPA). English-language publications were searched in MEDLINE (Ovid), Embase (Ovid), Cochrane Central (Ovid), CINAHL (EBSCO), and Clinicaltrials.gov (NLM) up to January 2021. Study quality was assessed with the National Institutes of Health Study Quality Tool. We pooled results using an inverse variance, random-effects model and report the binomial proportions with associated 95% confidence intervals (95% CI). Statistical heterogeneity was explored using the I 2  statistic. From 2875 screened citations, we included 12 studies (1255 participants). Fifty-eight percent were good/high quality while the rest were moderate quality. Thirty-nine percent of patients (95% CI 0.26-0.53, I 2 77%) had persistent ≥Banff Borderline TCMR 2-9 months after anti-rejection therapy. Pulse steroids and augmented maintenance immunosuppression were mainstays of therapy, but considerable practice heterogeneity was present. A high proportion of biopsy-proven rejection exists after treatment emphasizing the importance of histology to characterize remission. Anti-rejection therapy is foundational to transplant management but well-designed clinical trials in patients on Tac/MPA immunosuppression are lacking to define the optimal therapeutic approach., (© 2021 The Authors. American Journal of Transplantation published by Wiley Periodicals LLC on behalf of The American Society of Transplantation and the American Society of Transplant Surgeons.)

Objectives: To summarise the current evidence regarding interventions for accurate and timely cancer diagnosis among symptomatic individuals., Design: A scoping review following the Joanna Briggs Institute's methodological framework for the conduct of scoping reviews and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist., Data Sources: MEDLINE (Ovid), CINAHL (EBSCOhost) and PsycINFO (Ovid) bibliographic databases, and websites of relevant organisations. Published and unpublished literature (grey literature) of any study type in the English language were searched for from January 2017 to January 2021., Eligibility and Criteria: Study participants were individuals of any age presenting at clinics with symptoms indicative of cancer. Interventions included practice guidelines, care pathways or other initiatives focused on achieving predefined benchmarks or targets for wait times, streamlined or rapid cancer diagnostic services, multidisciplinary teams and patient navigation strategies. Outcomes included accuracy and timeliness of cancer diagnosis., Data Extraction and Synthesis: We summarised findings graphically and descriptively., Results: From 21 298 retrieved citations, 88 unique published articles and 16 unique unpublished documents (on 18 study reports), met the eligibility for inclusion. About half of the published literature and 83% of the unpublished literature were from the UK. Most of the studies were on interventions in patients with lung cancer. Rapid referral pathways and technology for supporting and streamlining the cancer diagnosis process were the most studied interventions. Interventions were mostly complex and organisation-specific. Common themes among the studies that concluded intervention was effective were multidisciplinary collaboration and the use of a nurse navigator., Conclusions: Multidisciplinary cooperation and involvement of a nurse navigator may be unique features to consider when designing, delivering and evaluating interventions focused on improving accurate and timely cancer diagnosis among symptomatic individuals. Future research should examine the effectiveness of the interventions identified through this review., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: This study examined student access to online resources of a faculty's learning management system (LMS). Issues relating to current e-learning resources usage were identified and formed the basis for recommendations to help assist stakeholders in teaching, learning and research., Methods: Learning analytics from four cohorts of undergraduate dental students were extracted from the database of a LMS spanning between 2012 and 2016. Individual datasets were combined into one master file, re-categorised, filtered and analysed based on cohort, year of study, course and nature of online resource., Results: A total of 157,293 access events were documented. The proportion of administrative to learning data varied across cohorts, with oldest cohort having the highest ratio (82:18) in their final year and most recent cohort having a ratio of 33:67 in their 4th year demonstrating a higher proportion to learning. Seven Learning domains were identified in the access data: access to problem-based learning resources was the highest and next was fixed prosthodontics videos. The prosthodontics discipline had the highest access across the curriculum while some others had very limited or even no learning access events., Conclusion: A number of limitations have been identified with the analytics and learning resources in this LMS and engagement with learning resource provision. More detailed data capture of access use and unique identifiers to resources as well as keyword tagging of the resources are required to allow accurate mapping and support of students learning. Moreover, motivation or nudging of students behaviour to more actively engage with learning content needs exploration., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: This study examined relationships of students' access of e-learning (learning analytics) for a healthcare psychomotor skills course, approaches to learning (R-SPQ-2F psychometric) and academic achievement (summative examination results). An understanding of the relationships may help in supporting students learning., Methods: Two consecutive cohorts of 5th year dental students were asked to complete the R-SPQ-2F questionnaire and permission to access data of online videos and associated quizzes and two summative written examination results were examined. The summative assessments were an OSCA and a written-paper question both in prosthodontics. Multiple linear regression and correlation analysis were performed., Results: Students (n=98) performed a total of 10470 video access events and 7714 attempts in online quizzes. Deep learning approach was the strongest predictor variable (β=0.270; P=.004) on written-paper question result. While video and quiz access were moderately correlated (r=0.600; P<.001) to each other, video access was not a significant predictor to either of the examination results. Quiz access was negatively associated with academic achievement for the written-paper question results (β=-0.349; P<.001)., Conclusions: Only deep approach to learning appeared to be relevant for the written-paper question examination grades. Conversely, the number of video and quiz access did not relate to either examination results. This suggests e-learning access and examinations do not appear to relate under the conditions explored. Other attributes of learning management access may need to be explored to determine if access to learning management systems may be useful in offering remedial support to students., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Seasonal influenza vaccination (SIV) rates remain suboptimal in many populations, even in those with universal SIV., Objective: To summarize the evidence on interventions on health care providers (physicians/nurses/pharmacists) to increase SIV rates., Methods: We systematically searched/selected full-text English publications from January 2000 to July 2019 (PROSPERO-CRD42019147199). Our outcome was the difference in SIV rates between patients in intervention and non-intervention groups. We calculated pooled difference using an inverse variance, random-effects model., Results: We included 39 studies from 8370 retrieved citations. Compared with no intervention, team-based training/education of physicians significantly increased SIV rates in adult patients: 20.1% [7.5-32.7%; I2 = 0%; two randomized controlled trials (RCTs)] and 13.4% [8.6-18.1%; I2 = 0%; two non-randomized intervention studies (NRS)]. A smaller increase was observed in paediatric patients: 7% (0.1-14%; I2 = 0%; two NRS), and in adult patients with team-based training/education of physicians and nurses together: 0.9% (0.2-1.5%; I2 = 30.6%; four NRS). One-off provision of guidelines/information to physicians, and to both physicians and nurses, increased SIV rates in adult patients: 23.8% (15.7-31.8%; I2 = 45.8%; three NRS) and paediatric patients: 24% (8.1-39.9%; I2 = 0%; two NRS), respectively. Use of reminders (prompts) by physicians and nurses slightly increased SIV rates in paediatric patients: 2.3% (0.5-4.2%; I2 = 0%; two RCTs). A larger increase was observed in adult patients: 18.5% (14.8-22.1%; I2 = 0%; two NRS). Evidence from both RCTs and NRS showed significant increases in SIV rates with varied combinations of interventions., Conclusions: Limited evidence suggests various forms of physicians' and nurses' education and use of reminders may be effective for increasing SIV rates among patients., (© The Author(s) 2021. Published by Oxford University Press.)

Cancer patients are among high-risk individuals for whom seasonal influenza vaccine (SIV) is recommended, but rates of vaccination in this subpopulation remain suboptimal; even in jurisdictions with universal influenza vaccination programs. We sought to summarize the evidence to better understand the determinants of SIV uptake (vaccine receipt) among cancer patients. We searched MEDLINE, Embase, and CINAHL from 2000 to February 12, 2020, focusing on articles on the determinants of seasonal influenza vaccination among cancer patients, published in English. Study selection was conducted independently by 2 reviewers. One reviewer extracted data from the included studies and another reviewer checked the extracted data for errors. Outcomes were sociodemographic and health-related factors. We pooled adjusted results from studies using the inverse variance, random-effects method, and reported the odds ratios (OR) and their 95% confidence intervals (CI). Out of 2664 citations, 10 studies (mostly from USA and South Korea) met our eligibility criteria. Overall, being older (OR 2.23, 95% CI 1.46-3.38; I 2 92.3%, [6 studies]), a nonsmoker (1.43, 1.32-1.51; I 2 0%, [4 studies]), having a chronic illness (1.18, 1.07-1.29; I 2 15.7%, [5 studies]), having had a medical check-up in the past year (1.75, 1.65-1.86; I 2 0%, [2 studies]), and having health insurance (1.39, 1.13-1.72; I 2 21.8%, [3 studies]) were associated with increased SIV uptake. Compared with being African-American, being Caucasian was also associated with increased SIV uptake (1.79, 1.47-2.13; I 2 10.7%, [3 studies]). Limited evidence suggests seasonal influenza vaccination among cancer patients may be determined by some sociodemographic and health-related factors., Competing Interests: Conflicts of Interest S.M.M. has received unrestricted research grants from GlaxoSmithKline, Merck, Sanofi Pasteur, Pfizer and Roche-Assurex for unrelated studies, and fees as an advisory board member for Sanofi Pasteur. The other authors declare that they have no conflict of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background/objectives: Despite influenza vaccination programs in various jurisdictions, seasonal influenza vaccine (SIV) uptake remains suboptimal among older people (≥65years old), an important subpopulation for influenza vaccination. We sought to summarize determinants of SIV uptake (any vaccine receipt) and vaccination adherence (receipt of vaccine in two or more seasons in sequence) among older people., Methods: We searched for population-based studies conducted in community-dwelling older people (irrespective of their health status) from 2000-2019. Two reviewers independently selected publications for inclusion. One reviewer extracted data from the included studies; a second checked the extracted data for errors. Disagreements were resolved by discussion and consensus, or a third reviewer. We were interested in the determinants of SIV uptake and vaccination adherence. Where appropriate, we pooled adjusted results using the inverse variance, random-effects method and reported the odds ratios (OR) and their 95% confidence intervals (CI)., Results: Out of 11,570 citations screened, we included 34 cross-sectional studies. The following were associated with increased SIV uptake: being older (OR 1.52, 95%CI 1.38-1.67 [21 studies]), white (1.30, 1.14-1.49 [10 studies]), married (1.23, 1.17-1.28 [9 studies]), non-smoker (1.28, 1.11-1.47 [7 studies]), of a higher social class (1.20, 1.06-1.36 [2 studies]), having a higher education (1.12, 1.04-1.21 [14 studies]), having a higher household income (1.11, 1.05-1.18 [8 studies]), having a chronic illness (1.53, 1.44-1.63 [16 studies]), having poor self-assessed health (1.23, 1.02-1.40 [9 studies]), having a family doctor (2.94, 1.79-4.76 [2 studies]), and having health insurance (1.58, 1.13-2.21 [6 studies]). The influence of these factors varied across geographical regions. Being older (1.26, 1.11-1.44 [2 studies]) was also associated with increased vaccination adherence., Conclusions: Several factors may determine SIV uptake and vaccination adherence among older people. More studies are needed to provide a stronger evidence base for planning more effective influenza vaccination programs., Competing Interests: AC and ET are employees of Sanofi Pasteur. SMM has received unrestricted research grants from GlaxoSmithKline, Merck, Sanofi Pasteur, Pfizer and Roche-Assurex for unrelated studies, and fees as an advisory board member for Sanofi Pasteur. This study was also partially funded through a research grant from Sanofi Pasteur USA for a related, and already published, study. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products to declare.

Introduction: Candida albicans possesses the ability to switch rapidly between yeast to hyphal forms. Hyphal formation is a remarkable pathogenic characteristic, which allows C. albicans to invade into host cells., Objectives: This study was to investigate the role of the C. albicans SAP9 gene in hyphal formation and invasion ability., Methods: The morphology of fungal cells in the hyphal-inducing liquid media (YPD+10% fetal bovine serum) was observed by the microscopy. And the morphology of the colony on solid agar plates of YPD+10% fetal bovine serum was photographed by the digital camera. The mRNA expressions of hypha-associated genes in serum medium were also analyzed by real time PCR. Then for the interaction between C. albicans and oral epithelial cells, endocytosis essay, invasion essay and damage assay were performed to compare the differences between the sap9Δ/Δ mutant strain and wild type strain., Results: Compared with the wild type strain, the sap9Δ/Δ mutant strain exhibited a deficient yeast-to-hyphal morphological transition under serum hyphal-inducing conditions. Furthermore, the SAP9 knockout strain revealed a significant down-regulation of the expression of EFG1 (~40%), which is a transcription factor gene that mediates hyphae formation in C. albicans. Compared with the wild type strain, a 70% reduction in the endocytosis of the sap9Δ/Δ mutant strain by host cells was observed, as well as a 25% attenuation of active penetration and a 40% attenuation of host cell damage (P <0.05)., Conclusions: Our data strongly suggests that C. albicans Sap9 is a potential hyphal-associated factor that responds to serum hyphal-inducing stimuli via a cAMP-protein kinase A pathway mediated by EFG1, and contributes to the process of invasion of Candida into the epithelial cells, leading to host cell damage., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objectives: This study was to assess the effectiveness of a conventional oral hygiene care programme (COHCP) and an advanced oral hygiene care programme (AOHCP) on prevalence and viable counts of oral opportunistic pathogens among patients undergoing stroke rehabilitation., Methods: A total of 94 patients were randomized to two groups. Subjects were block randomized to either (a) COHCP: manual toothbrushing with oral hygiene instruction (OHI); or (b) AOHCP: powered toothbrushing, mouthrinsing with chlorhexidine and OHI. Prevalence and viable counts of oral opportunistic pathogens including yeasts, aerobic and facultative anaerobic gram-negative bacilli, Staphylococcus aureus, were assessed at baseline, the end of 3 and 6 months., Results: No significant difference was observed in the prevalence of oral opportunistic pathogens within each group over the clinical trial period. A significant decrease in the viable counts of S. aureus was found over the clinical trial period within AOHCP group (p < 0.05), while the viable counts of yeasts and anaerobic gram-negative bacillus (AGNB) remained stable within each group. Regression analysis failed to detect an association between intervention and the prevalence/viable counts of oral opportunistic pathogens., Conclusions: Neither oral healthcare programme significantly affects AGNB, yeast or S. aureus over the study period in terms of prevalence and viable counts., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. All rights reserved.)

Purpose: Problem-based learning (PBL) students report uncertainty on the depth and breadth of learning required, and this is a significant stressor and challenge. Student-generated MCQ questions were trialled and evaluated as a way to support depth and breadth of learning., Methods: Students set MCQs relating to specified learning issues, and an analysis and evaluation of setting and answering the MCQs were performed. The Revised Study Process Questionnaire (R-SPQ-2F) and final written examination scores were correlated to question setting and answering. Students were asked to rate the impact of the MCQs on their learning in PBL., Results: A total of 147 questions were created and 2373 answered. Students reported challenges with setting questions, although these made them think more deeply and helped their learning and affirming their learning progress. MCQs authored indicated significant associations with Understanding, and examination scores were associated with MCQs authored. Students reported a moderate response to how the MCQs supported their depth and breadth of learning., Conclusions: While MCQ setting was perceived as a useful learning exercise, students engaged to different levels and experienced challenges. Students were uncertain whether the MCQs helped clarify the depth and breadth of learning in PBL, as they were not clear whether the questions set by their peers were relevant to the required learning outcomes., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objective: To evaluate the presence of oral opportunistic pathogens among stroke survivors, both before and after oral health care interventions., Methods: A multicenter randomized clinical trial was conducted on hospitalized stroke survivors. Those in the control group were given standard care of oral hygiene (a manual toothbrush and toothpaste), whereas those in the test group were given intense care of oral hygiene (a powered toothbrush and 1% chlorhexidine oral gel). Oral clinical assessments were carried out, and microbiological samples were collected, using concentrated oral rinse samples at 3 time points: baseline, 3 months, and 6 months., Results: The prevalence of oral yeast was significantly reduced in the test group at 6 months (P < .05), but no significant difference was observed over time. A significant reduction was observed in the prevalence of Staphylococcus aureus (P < .01) and aerobic and facultative gram-negative bacilli over time (P < .05), but there were no significant differences noted between groups at 6 months. Candida albicans and Klebsiella pneumoniae were the prominent pathogens determined throughout the trial. Kluyvera strains have also been isolated from this cohort., Conclusion: Oral hygiene intervention using a powered tooth brush and 1% chlorhexidine oral gel was effective in reducing the prevalence of oral opportunistic pathogens., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: This study aimed to examine "intention to" and "performance of" oral hygiene care to stroke patients using the Theory of Planned Behavior., Materials and Methods: A large scale survey of 13 centers in Malaysia was conducted involving 806 nurses in relation to oral hygiene care intentions and practices. In addition, information on personal and environmental factors was collected., Results: The response rate was 95.6% (778/806). The domains of the Theory of Planned Behavior were significantly associated with general intention to perform oral hygiene care: attitudes (β = 0.21, p < 0.001), subjective norms (β = 0.38, p < 0.001), perceived behavior control (β = 0.04, p < 0.001); after controlling for personal and environmental factors. Approximately two-thirds (63.4%, 493) reported the performance of some form of oral hygiene care for patients. This behavior was associated with general intention scores (OR =1.13, 95%CI =1.05-1.22, p <0.01), controlling for other factors. Knowledge scores, training, access to oral hygiene guidelines and kits, as well as working ward type were identified as key factors associated with intention and practice of oral hygiene care., Conclusion: The Theory of Planned Behavior provides understanding of "intention to" and "performance of" oral hygiene care to stroke patients. Several provider and environmental factors were also associated with intentions and practices. This has implications for understanding and improving the implementation of oral hygiene care in stroke rehabilitation. Implications for Rehabilitation Oral hygiene care is crucial for stroke patients as it can prevent oral health problems and potentially life threatening events (such as aspiration pneumonia). Despite oral hygiene care being relative simple to perform, it is often neglected during stroke rehabilitation. A large-scale national survey was conducted to understand "intentions to" and "performance of" oral hygiene care to stroke patients using the Theory of Planned Behavior social cognition model. These study findings may have implications and use in promoting oral hygiene care to stroke patients:i) by understanding the pathways and influences to perform oral hygiene care.ii) to conduct health promotion and health education based on behavioral models such as Theory of Planned Behavior.

Maintaining good oral hygiene is important following stroke. This study aimed to evaluate the effectiveness of two oral health promotion (OHP) programmes to reduce dental plaque levels following stroke. A multi-centre randomised clinical control trial was conducted among patients hospitalised following stroke in Malaysia. Patients were randomly allocated to two OHP groups: (i) control group who received the conventional method for plaque control-daily manual tooth brushing with a standardised commercial toothpaste, (ii) test group-who received an intense method for plaque control-daily powered tooth brushing with 1% Chlorhexidine gel. Oral health assessments were performed at baseline, at 3 months and 6 months post-intervention. Within- and between-group changes in dental plaque were assessed over time. Regression analyses were conducted on dental plaque levels at 6 months controlling for OHP group, medical, dental and socio-demographic status. The retention rate was 62.7% (54 of 86 subjects). Significant within-group changes of dental plaque levels were evident among the test group (P < .001) and the control group (P < .001). No significant between-group changes of dental plaque levels were apparent (P > .05). Regression analyses identified that baseline plaque levels (adjusted ß = 0.79, P < .001) and baseline functional dependency level (adjusted ß = -0.34, P < .05) were associated with dental plaques levels at the end of the trial (6 months). Both, "Conventional" and "Intense" oral health promotion programmes may successfully reduce dental plaque during stroke rehabilitation and are of comparable effectiveness. Baseline dental plaque levels and functional dependency level were key factors associated with dental plaque levels at follow-up at 6 months., (© 2017 John Wiley & Sons Ltd.)

This study was to evaluate the effectiveness of oral hygiene care in improving oral health- and health-related quality of life (OHRQoL and HRQoL) among patients receiving outpatient stroke rehabilitation. Subjects were randomized to: (1) a conventional oral hygiene care programme (COHCP) comprising a manual toothbrush, and oral hygiene instruction, or (2) an advanced oral hygiene care programme (AOHCP) comprising a powered toothbrush, 0.2% chlorhexidine mouthrinse, and oral hygiene instruction. The interventional period lasted for 3 months, followed by a 3-month observational period. HRQoL was assessed by SF-12, and OHRQoL was assessed by Oral Health Impact Profile-14 (OHIP-14), General Oral Health Assessment Index (GOHAI), and Oral Health Transitional Scale (OHTS). Participants in AOHCP group had significantly better OHRQoL at the end of clinical trial as assessed by OHTS (p < 0.01), and at the end of observational study as assessed by GOHAI (p < 0.05) than those in the COHCP. Participants in the AOHCP group had significantly better HRQoL as assessed by physical component summary score (PCS) the end of both 3 and 6 months (both p < 0.05). This study provided the evidence that the AOHCP was more effective than the COHCP within stroke rehabilitation in improving subjective health.

During a stroke, the mouth tends to become an unhealthy place and may give rise to various life-threatening conditions. To this end, there have been repeated calls to incorporate oral hygiene guidelines and practices for hospitalized stroke patients to prevent aspiration pneumonia and improve patients' oral health. The objective of the study was to determine health care providers' practices of oral health care among patients hospitalized after an occurrence of stroke and to determine health care providers' background and work environment effect on these practices. A cross-sectional study was conducted among stroke care providers in 13 public hospitals in Malaysia. The questionnaires distributed were self-administered, where nursing staff provided details of their oral health care practices for stroke patients. Information on the background of health care providers and work environment was also collected. Overall, a total of 780 responses from the registered nurses were obtained. Almost half of the respondents (48.1%) reported that they recommended toothbrushing twice or more per day to stroke patients. Two-thirds (64.7%) reported that they performed daily mouthwashing on their patient, while less than half (38.8%) reported daily oral hygiene assistance. Result of the analysis revealed that oral hygiene practices were significantly associated with having working wards ( P < 0.05), level of qualification ( P < 0.05), having oral health care guidelines ( P < 0.001), specific resources ( P < 0.05), and attending previous training in oral care ( P < 0.001). Provision of oral hygiene practices for hospitalized stroke patients is important. A lack of oral health care guidelines, support from dental professionals, specific resources, training, and assistance in daily oral care for patients is evident and detrimental to oral hygiene practices. The current findings have significant implications for new initiatives to support health care providers, particularly the registered nurses performing oral health care for hospitalized stroke patients. Knowledge Transfer Statement: This study may provide a basis of information for improving the delivery of oral health care to stroke patients. Enhancement in the training and improvement in the existing guidelines and resources is pivotal for the provision of better oral health care for the potential benefits to these patients, including their improved quality of life and disease prevention.

Objectives: The objectives of this study were to evaluate and compare the effectiveness of an advanced oral hygiene care programme (AOHCP) and a conventional oral hygiene care programme (COHCP) in improving oral hygiene, and reducing gingival bleeding among patients with stroke during outpatient rehabilitation., Methods: Subjects were randomized to receive (i) the COHCP comprising a manual toothbrush, toothpaste, and oral hygiene instruction, or (ii) the AOHCP comprising a powered toothbrush, 0.2% chlorhexidine mouthrinse, toothpaste, and oral hygiene instruction. Dental plaque, gingival bleeding, and other clinical oral health outcomes were assessed at baseline, the end of the clinical trial, and the end of observation period. Development of infectious complications was also monitored., Results: Participants of both programmes had a significant reduction in the percentages of sites with moderate to abundant dental plaque (p<0.001) and with gingival bleeding (p<0.05). Those in the AOHCP had significantly less plaque and gingival bleeding than those in the COHCP controlling for other factors at the end of the clinical trial period (both p<0.001) and the observational period (plaque: p<0.05, gingival bleeding: p<0.01)., Conclusions: Although both oral hygiene care programmes were effective in terms of plaque and gingival bleeding control, the AOHCP was more effective than the COHCP in reducing dental plaque and gingival bleeding., Clinical Significance: This study highlighted the value of oral hygiene programmes within stroke outpatient rehabilitation and provides evidence to advocate for the inclusion of oral hygiene care programmes within stroke outpatient rehabilitation for patients with normal cognitive abilities., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

The objective of this study was to evaluate the effect of the bacterial endotoxin LPS on Candida biofilm formation in vitro. The effect of the LPS of Pseudomonas aeruginosa, Klebsiella pneumoniae, Serratia marcescens and Salmonella typhimurium on six different species of Candida, comprising Candida albicans ATCC 90028, Candida glabrata ATCC 90030, Candida krusei ATCC 6258, Candida tropicalis ATCC 13803, Candida parapsilosis ATCC 22019 and Candida dubliniensis MYA 646, was studied using a standard biofilm assay. The metabolic activity of in vitro Candida biofilms treated with LPS at 90 min, 24 h and 48 h was quantified by XTT reduction assay. Viable biofilm-forming cells were qualitatively analysed using confocal laser scanning microscopy (CLSM), while scanning electron microscopy (SEM) was employed to visualize the biofilm structure. Initially, adhesion of C. albicans was significantly stimulated by Pseudomonas and Klebsiella LPS. A significant inhibition of Candida adhesion was noted for the following combinations: C. glabrata with Pseudomonas LPS, C. tropicalis with Serratia LPS, and C. glabrata, C. parapsilosis or C. dubliniensis with Salmonella LPS (P<0.05). After 24 h of incubation, a significant stimulation of initial colonization was noted for the following combinations: C. albicans/C. glabrata with Klebsiella LPS, C. glabrata/C. tropicalis/C. krusei with Salmonella LPS. In contrast, a significant inhibition of biofilm formation was observed in C. glabrata/C. dubliniensis/C. krusei with Pseudomonas LPS, C. krusei with Serratia LPS, C. dubliniensis with Klebsiella LPS and C. parapsilosis/C. dubliniensis /C. krusei with Salmonella LPS (P<0.05). On further incubation for 48 h, a significant enhancement of biofilm maturation was noted for the following combinations: C. glabrata/C. tropicalis with Serratia LPS, C. dubliniensis with Klebsiella LPS and C. glabrata with Salmonella LPS, and a significant retardation was noted for C. parapsilosis/C. dubliniensis/C. krusei with Pseudomonas LPS, C. tropicalis with Serratia LPS, C. glabrata/C. parapsilosis/C. dubliniensis with Klebsiella LPS and C. dubliniensis with Salmonella LPS (P<0.05). These findings were confirmed by SEM and CLSM analyses. In general, the inhibition of the biofilm development of LPS-treated Candida spp. was accompanied by a scanty architecture with a reduced numbers of cells compared with the profuse and densely colonized control biofilms. These data are indicative that bacterial LPSs modulate in vitro Candida biofilm formation in a species-specific and time-dependent manner. The clinical and the biological relevance of these findings have yet to be explored.