Immersion of debrided diabetic foot ulcer tissue in electrochemically generated pH neutral hypochlorous acid significantly reduces the microbial bioburden: whole-genome sequencing of Staphylococcus aureus, the most prevalent species recovered.

BACKGROUND: Diabetic foot ulcer infections (DFUIs) are the leading cause of lower-limb amputations, mediated predominantly by Staphylococcus aureus. pH-neutral electrochemically generated hypochlorous acid (anolyte) is a non-toxic, microbiocidal agent with significant potential for wound disinfection. AIMS: To investigate both the effectiveness of anolyte for microbial bioburden reduction in debrided ulcer tissues and the population of resident S. aureus. METHODS: Fifty-one debrided tissues from 30 people with type II diabetes were aliquoted by wet weight and immersed in 1- or 10-mL volumes of anolyte (200 parts per million) or saline for 3 min. Microbial loads recovered were determined in colony forming units/g (cfu/g) of tissue following aerobic, anaerobic and staphylococcal-selective culture. Bacterial species were identified and 50 S. aureus isolates from 30 tissues underwent whole-genome sequencing (WGS). FINDINGS: The ulcers were predominantly superficial, lacking signs of infection (39/51, 76.5%). Of the 42/51 saline-treated tissues yielding ≥105 cfu/g, a microbial threshold reported to impede wound-healing, only 4/42 (9.5%) were clinically diagnosed DFUIs. Microbial loads from anolyte-treated tissues were significantly lower than saline-treated tissues using 1 mL (1065-fold, 2.0 log) and 10 mL (8216-fold, 2.1 log) immersion volumes (P<0.0005). S. aureus was the predominant species recovered (44/51, 86.3%) and 50 isolates underwent WGS. All were meticillin susceptible and comprised 12 sequence types (STs), predominantly ST1, ST5 and ST15. Whole-genome multi-locus sequence typing identified three clusters of closely related isolates from 10 patients indicating inter-patient transmission. CONCLUSIONS: Short immersions of debrided ulcer tissue in anolyte significantly reduced microbial bioburden: a potential novel DFUI treatment.

The impact of COVID-19 on access to dental care for people with disabilities: a global survey during the COVID-19 first wave lockdown.

BACKGROUND: It is unclear what immediate impact the COVID-19 pandemic has had on delivery of oral healthcare to people with disabilities worldwide. AIM: To report the international impact of COVID-19 lockdown on oral healthcare provision for people with disabilities before, during and after the first lockdown (March to July 2020). MATERIAL AND METHODS: Cross-sectional online self-administered survey of dentists who treat people with disabilities completed 10th to 31st of July 2020. Responses allowed comparison from before, during and immediately after the first wave lockdowns of the COVID-19 pandemic. Data were analysed using McNemar's test to compare reported practice before to during lockdown, and before to after lockdown. RESULTS: Four-hundred-thirty-six respondents from across global regions reported a significant reduction from before to during and from before to after lockdown regarding: the proportion of dentists treating people with all types of disability (p <0.001) and the number of patients with disabilities seen per week (p<0.0001). The proportion reporting no availability of any pharmacological supports rose from 22% pre-lockdown to 61% during lockdown (p < 0.001) and a persistent 44% after lockdown (p < 0.001). An increase in teledentistry was observed. CONCLUSIONS: During the first COVID-19 lockdown, there was a significant negative impact on the delivery of dental care to people with disabilities. Oral healthcare access was significantly restricted for people with disabilities with access to sedation and general anaesthesia particularly affected. There is now an increased need to ensure that no-one is left behind in new and existing services as they emerge post-pandemic.

Development of a battery of tests to measure attitudes and intended behaviours of dental students towards people with disability or those in marginalised groups.

INTRODUCTION: Recommended curricula in Special Care Dentistry (SCD) outline learning objectives that include the domain of attitudes and behaviours, but these are notoriously difficult to measure. The aims of this study were (i) to develop a test battery comprising adapted and new scales to evaluate values, attitudes and intentions of dental students towards people with disability and people in marginalised groups and (ii) to determine reliability (interitem consistency) and validity of the scales within the test battery. MATERIALS AND METHODS: A literature search identified pre-existing measures and models for the assessment of attitudes in healthcare students. Adaptation of three pre-existing scales was undertaken, and a new scale was developed based upon the Theory of Planned Behaviour (TPB) using an elicitation survey. These scales underwent a process of content validation. The three adapted scales and the TPB scale were piloted by 130 students at 5 different professional stages, from 4 different countries. RESULTS: The scales were adjusted to ensure good internal reliability, variance, distribution, and face and content validity. In addition, the different scales showed good divergent validity. DISCUSSION: These results are positive, and the scales now need to be validated in the field. CONCLUSIONS: It is hoped that these tools will be useful to educators in SCD to evaluate the impact of teaching and clinical exposure on their students.

Best clinical practice guidance for local analgesia in paediatric dentistry: an EAPD policy document.

BACKGROUND: The European Academy of Paediatric Dentistry (EAPD) proposes this best-practice guidance to help practitioners to decide when and how to use local analgesia to control pain in children, adolescents, and medically compromised individuals during the delivery of oral health care. METHODS: A search of different databases was conducted using all terms relevant to the subject. Relevant papers were identified after a review of their titles, abstracts or full papers. Three workshops were held during the corresponding EAPD interim seminar in Torino (Italy) in 2017. Several statements were agreed upon and, furthermore, knowledge gaps were identified. RESULTS: An important outcome was that when local analgesia administered appropriately-correct choice of agent(s) and dosage, proper route of administration-it is, firstly, clinically effective for pain-control in treating children and, secondly, it carries a very low risk of morbidity including adverse or side-effects. Furthermore, several gaps in knowledge were identified during the workshop which indicates future research needs. Most importantly it remains unsatisfactory that in several European countries the most frequently used injectable local analgesic agent, articaine, is not approved for usage in children below the age of 4 years. CONCLUSION: When considering the dental demand to treat vulnerable (medically compromised) children and adolescents in a safe, painless, less-invasive and effective way, there seems to be an urgent need to close these gaps in knowledge.

A systematic review of the use of local analgesia in medically compromised children and adolescents.

AIM: To determine if the use of routine techniques and agents for topical and injectable dental local analgesia (LA) are safe for use in medically compromised children and adolescents. METHOD: Medline, Embase and Cochrane Oral Health Group's trials register, were searched electronically, supplemented by hand searching of relevant journals. SELECTION CRITERIA: RCTs, cohort studies, case-control studies, observational studies, case series, case reports, evidence based guidelines reporting on children and adolescents aged 18 years or younger with one/more pre-designated medical condition, being administered topical and/or injectable local analgesic for dental procedures using standard techniques of delivery. Outcomes were presence of adverse events which were attributable directly or indirectly to the underlying medical condition. RESULTS: N = 71 studies were retrieved but only three observational studies, one case series, two case reports and four evidence based guidelines met the criteria for inclusion. A disparate set of medical conditions were reported upon and sparse guidance given in these areas. Thirty-nine review articles and consensus documents provided little or no clinical data to support their recommendations. CONCLUSIONS: There are insufficient high quality data reporting on the use of topical and local analgesia to medically compromised children and adolescents. Apart from a known allergy to local analgesia or one of the agents, there appears to be very few absolute or relative contra-indications to the use of local analgesia in children and adolescents based on medical history. There is an urgent need for high quality studies wherever possible and appropriate, in order to improve and inform the evidence-base in this cohort.

Guidance for the core content of a Curriculum in Special Care Dentistry at the undergraduate level.

Given the rapidly changing demography of populations worldwide, dental professionals of the future need to be able to meet the challenge posed by the evolving landscape in health care needs. Leading institutions are now embedding teaching and learning in special care dentistry (SCD) within their curricula, to provide students with the knowledge, skills and attitudes to meet the oral health needs of vulnerable groups within their communities. The International Association for Disability and Oral Health (iADH) has initiated the development of undergraduate curriculum guidance in SCD through a consensus process. The curriculum in SCD is defined in statements of learning outcomes with many of the skills being transferable across the undergraduate course. This curriculum includes examples of teaching and assessment, designed to enhance critical thinking in relation to SCD and to promote positive attitudes towards disability and diversity. The learning outcomes are designed to be readily adapted to conform to the generic profiles and competencies, already identified in undergraduate frameworks by global educational associations, as well as meeting the requirements of professional regulatory bodies worldwide. Suggestions for teaching and learning are not intended to be prescriptive; rather, they act as a signpost to possible routes to student learning. Ideally, this will require that students have a sufficiently diverse patient case mix during their undergraduate studies, to achieve the required levels of confidence and competence by the time they graduate. Clinical care competencies in SCD emphasise the need for learners to broaden their theoretical knowledge and understanding through practical experience in providing care for people with special health care needs. It is crucial to the development of equitable dental services for all members of a community, that these learning outcomes are embedded into evolving curricula but most importantly, that they are evaluated and refined in a dynamic way with shared learning for all teachers.

Vaginal birth after caesarean section: a cohort study investigating factors associated with its uptake and success.

OBJECTIVES: To investigate the demographic and obstetric factors associated with the uptake and success rate of vaginal birth after caesarean section (VBAC). DESIGN: Cohort study using data from Hospital Episode Statistics. SETTING: English National Health Service. POPULATION: Women whose first birth resulted in a live singleton delivery by caesarean section between 1 April 2004 and 31 March 2011, and who had a second birth before 31 March 2012. METHODS: Logistic regression to estimate adjusted odds ratios (OR). MAIN OUTCOME MEASURES: Attempted and successful VBAC. RESULTS: Among the 143,970 women in the cohort, 75,086 (52.2%) attempted a VBAC for their second birth. Younger women, those of non-white ethnicity and those living in a more deprived area had higher rates of attempted VBAC. Overall, 47,602 women (63.4%) who attempted a VBAC had a successful vaginal birth. Younger women and women of white ethnicity had higher success rates. Black women had a particularly low success rate (OR, 0.54; 95% confidence interval [CI], 0.50-0.57). Women who had an emergency caesarean section in their first birth also had a lower VBAC success rate, particularly those with a history of failed induction of labour (OR, 0.59; 95% CI, 0.53-0.67). CONCLUSION: In this national cohort, just over one-half of women with a primary caesarean section who were eligible for a trial of labour attempted a VBAC for their second birth. Of these, almost two-thirds successfully achieved a vaginal delivery.

Guidance on the core content of an undergraduate curriculum in special care dentistry.

This paper has been previously published in the Journal of Disability and Oral Health and provides guidance on the core content of an undergraduate curriculum in special care dentistry by featuring three abstracts, published over the last year in the European Journal of Dental Education, on the context and methodological approach to the curriculum process.

The value of education in special care dentistry as a means of reducing inequalities in oral health.

People with disability are subject to inequality in oral health both in terms of prevalence of disease and unmet healthcare needs. Over 18% of the global population is living with moderate to severe functional problems related to disability, and a large proportion of these persons will require Special Care Dentistry at some point in their lifetime. It is estimated that 90% of people requiring Special Care Dentistry should be able to access treatment in a local, primary care setting. Provision of such primary care is only possible through the education and training of dentists. The literature suggests that it is vital for the dental team to develop the necessary skills and gain experience treating people with special needs in order to ensure access to the provision of oral health care. Education in Special Care Dentistry worldwide might be improved by the development of a recognised academic and clinical discipline and by providing international curricula guidelines based on the International Classification of Functioning, Disability and Health (ICF, WHO). This article aims to discuss the role and value of promoting and harmonising education in Special Care Dentistry as a means of reducing inequalities in oral health.

New reports of Australian cutaneous leishmaniasis in Northern Australian macropods.

Cutaneous leishmaniasis caused by various species of Leishmania is a significant zoonotic disease in many parts of the world. We describe the first cases of Australian cutaneous leishmaniasis in eight northern wallaroos, one black wallaroo and two agile wallabies from the Northern Territory of Australia. Diagnosis was made through a combination of gross appearance of lesions, cytology, histology, direct culture, serology and a species-specific real-time PCR. The causative organism was found to be the same unique species of Leishmania previously identified in red kangaroos. These clinical findings provide further evidence for the continuous transmission of the Australian Leishmania species and its presence highlights the importance of continued monitoring and research into the life-cycle of this parasite.

Access to special care dentistry, part 8. Special care dentistry services: seamless care for people in their middle years - part 2.

This article about special care dentistry in the middle years considers people who have Down's syndrome and cerebral palsy and those who have cardiac and respiratory disease. The increased life expectancy of people with Down's syndrome, currently 50-60 years, is reflected in the changing population profile and needs of these individuals. The preventive and dental treatment of most people with Down's syndrome and cerebral palsy can be met in general dental practice. However, those people with profound disability, anxiety or learning disability may require either a shared approach to care or referral for specialist care. Cardiac and respiratory disease occur commonly in the general population both in middle and older age groups and the dental team will meet increasing numbers of people with these conditions. The procedures and drugs used in dentistry can aggravate heart disease and it is important that the dental team are aware of the common cardiac conditions and their management, as well as how to best manage the oral care of this group. Also, they have a role to play in the provision of oral health advice, smoking cessation and dietary advice. This is particularly important as poor oral hygiene has been linked to respiratory pathogen colonisation and dental plaque may act as a reservoir for aspiration pneumonia in susceptible individuals.

Access to special care dentistry, part 9. Special care dentistry services for older people.

This article looks at three common neurological conditions associated with later years: stroke, Parkinson's disease and dementia. All of them impact on oral health, access to dental services and delivery of dental care, and treatment goals need to be adapted to take into account patients' changing needs, medical status, pattern of recovery or the stage of dementia that they have reached. The article concludes by considering the topic of elder abuse. The dental team may have a role both in identifying abuse and ensuring appropriate action is taken.

Access to special care dentistry, part 6. Special care dentistry services for young people.

This article brings together some of the 'hidden disabilities' common amongst adolescents and young adults. Many of these conditions carry a social stigma and some are associated with secretive behaviour and even denial. The article will describe the features, management and oral implications of five eating disorders (Prader-Willi syndrome, anorexia nervosa, bulimia nervosa, binge eating disorder and pica) and three types of mental health problems (schizophrenia, obsessive-compulsive disorder and bipolar disorder). Without the input of the dental profession, and in the main the primary dental care service, all these conditions can have a detrimental effect on the dentition at a relatively early stage in life. Mental health problems are more common in adolescents and young adults than most people realise and this article will also consider the impact on oral health and delivery of dental care to young people who have experienced childhood sexual abuse.

Access to special care dentistry, part 7. Special care dentistry services: seamless care for people in their middle years--part 1.

Children and older people have been relatively well served by specialist dental care. Despite increasing disability amongst people in their middle years, there have been no or few dedicated dental teams with responsibility for provision of their oral care. This article explores the ethos and practicality of seamless care across the age groups and the primary/secondary care interface, with a focus on embedding oral health into general healthcare plans through the multidisciplinary team approach. The article explores four conditions--rheumatoid arthritis, Huntingdon's disease, multiple sclerosis and diabetes. It considers the features of each condition and how they can impact on both oral health and the delivery of dental services. It also considers the elements of care that contribute to a holistic and seamless approach to oral care services.

Access to special care dentistry, part 5. Safety.

This article considers the delivery of efficient and effective dental services for patients whose disability and/or medical condition may not be obvious and which consequently can present a hidden challenge in the dental setting. Knowing that the patient has a particular condition, what its features are and how it impacts on dental treatment and oral health, and modifying treatment accordingly can minimise the risk of complications. The taking of a careful medical history that asks the right questions in a manner that encourages disclosure is key to highlighting hidden hazards and this article offers guidance for treating those patients who have epilepsy, latex sensitivity, acquired or inherited bleeding disorders and patients taking oral or intravenous bisphosphonates.

Access to special care dentistry, part 4. Education.

Many groups of patients with disabilities have a higher risk of oral disease due to compromised oral hygiene as a consequence of their impairment, oral manifestations of their particular condition and/or the side effects of drug regimes, notably xerostomia and sugar in medicines. This article looks at education related to oral health and its management for both patients and carers. It will encourage a tailored routine for oral hygiene, taking account of the best time of day for the person concerned, the facilities available to them, appropriate preventive measures and the support and adaptations required to minimise the effect their impairment has on managing their oral hygiene. Additionally, it considers educational issues for the dental team related to some elements of managing oral health of people with disability, the dental team's responsibility in educating other health professionals and the availability of undergraduate and postgraduate education in special care dentistry.

Access to special care dentistry, part 2. Communication.

This article considers what communication is, its elements, what helps and what hinders it, and why it matters. It also considers managing people with communication differences and when communication is affected in special care dentistry (SCD). The article focuses on patients with hearing and visual impairments and considers how communication is affected and what techniques can be used to improve the situation. It offers recommendations for communicating with patients with neurological impairments typically seen after stroke, such as aphasia and dysarthria, with tips for the listener including the use of communication aids where appropriate. Finally it will consider communicating with patients who have autistic spectrum conditions and discuss how effective techniques and a tailored approach to their specific needs and anxieties can increase the likelihood of a successful dental visit.

Access to special care dentistry, part 3. Consent and capacity.

This article considers what is meant by informed consent and the implications of the Mental Capacity Act in obtaining consent from vulnerable adults. It explores a number of conditions which impact on this task, namely dyslexia, literacy problems and learning disability. The focus on encouraging and facilitating autonomy and the use of the appropriate level of language in the consent giving process ensures that consent is valid. The use of appropriate methods to facilitate communication with individuals in order to be able to assess capacity and ensure that any treatment options that are chosen on their behalf are in their best interests are outlined. The use of physical intervention in special care dentistry in order to provide dental care safely for both the patient and the dental team is also considered.

Access to special care dentistry, part 1. Access.

This first article in the series will define special care dentistry, who requires it and why? It considers recent legislation and its impact on the primary care practitioner, including reasonable adjustments to the way in which dental care is delivered. It offers practical tips to encourage access to the dental practice and transfer to the dental chair and advice on techniques to aid access to the oral cavity for patients with a range of impairments.

The role of telementoring and telerobotic assistance in the provision of laparoscopic colorectal surgery in rural areas.

PURPOSE: The aim of this study was to assess whether telementoring and telerobotic assistance would improve the range and quality of laparoscopic colorectal surgery being performed by community surgeons. METHODS: We present a series of 18 patients who underwent telementored or telerobotically assisted laparoscopic colorectal surgery in two community hospitals between December 2002 and December 2003. Four community surgeons with no formal advanced laparoscopic fellowship were remotely mentored and assisted by an expert surgeon from a tertiary care center. Telementoring was achieved with real-time two-way audio-video communications over bandwidths of 384 kbps-1.2 mbps and included one redo ileocolic resection, two right hemicolectomies, two sigmoid resections, three low anterior resections, one subtotal colectomy, one reversal of a Hartmann operation, and one abdominoperineal resection. A Zeus TS microjoint system (Computer Motion Inc, Santa Barbara CA) was used to provide telepresence for the telerobotically assisted laparoscopic procedures, which included three right hemicolectomies, three sigmoid resections, and one low anterior resection. RESULTS: There were no major intraoperative complications. There were two minor intraoperative complications involving serosal tears of the colon from the robotic graspers. In the telementored cases, there were two postoperative complications requiring reoperation (intra-abdominal bleeding and small bowel obstruction). Two telementored procedures were converted because of the mentee's inability to find the appropriate planes of dissection. One telerobotically assisted procedure was completed laparoscopically by the local surgeon with aid of telementoring because of inadequate robotic arm position. The median length of hospital stay for this series was 4 days. The surgeons considered telementoring useful in all cases (median score 4 out of 5). The use of remote telerobotic assistance was also considered a significant enabling tool. CONCLUSIONS: Telementoring and remote telerobotic assistance are excellent tools for supporting community surgeons and providing patients better access to advanced surgical care.