Effect of Trainee Level on Surgical Time and Postoperative Complications of Anterior Cruciate Ligament Reconstruction.

PURPOSE: The objective of this study was to investigate the association between trainee level and surgical time and postoperative complications of anterior cruciate ligament reconstruction (ACLR). METHODS: A retrospective chart review of patients who underwent ACLR at an academic orthopaedic ambulatory surgery center collected demographic and clinical information, including the number of trainees present and trainee level. Unadjusted and adjusted regression analyses assessed the association between trainee number and level with surgical time (time from skin incision to closure) and postoperative complications. RESULTS: Of 799 patients in this study operated on by one of five academic sports surgeons, 87% had at least one trainee involved. The average surgical time overall was 93 ± 21 minutes and by trainee level was 99.7 (junior resident), 88.5 (senior residents), 96.6 (fellows), and 95.6 (no trainees). Trainee level was significantly associated with surgical time (P = 0.0008), with increased surgical time in cases involving fellows (0.0011). Fifteen complications (1.9%) were observed within 90 days of surgery. No notable risk factors of postoperative complications were identified. CONCLUSION: Resident trainee level does not have a notable effect on surgical time or postoperative complications for ACLR at an ambulatory surgery center, although cases involving fellows had longer surgical times. Trainee level was not associated with risk of postoperative complications.

A dense ring of the trans-Neptunian object Quaoar outside its Roche limit.

Planetary rings are observed not only around giant planets1, but also around small bodies such as the Centaur Chariklo2 and the dwarf planet Haumea3. Up to now, all known dense rings were located close enough to their parent bodies, being inside the Roche limit, where tidal forces prevent material with reasonable densities from aggregating into a satellite. Here we report observations of an inhomogeneous ring around the trans-Neptunian body (50000) Quaoar. This trans-Neptunian object has an estimated radius4 of 555 km and possesses a roughly 80-km satellite5 (Weywot) that orbits at 24 Quaoar radii6,7. The detected ring orbits at 7.4 radii from the central body, which is well outside Quaoar's classical Roche limit, thus indicating that this limit does not always determine where ring material can survive. Our local collisional simulations show that elastic collisions, based on laboratory experiments8, can maintain a ring far away from the body. Moreover, Quaoar's ring orbits close to the 1/3 spin-orbit resonance9 with Quaoar, a property shared by Chariklo's2,10,11 and Haumea's3 rings, suggesting that this resonance plays a key role in ring confinement for small bodies.

Magnetic Resonance Imaging Assessment of Cartilage Appearance Following Marrow Stimulation of Osteochondritis Dissecans of the Humeral Capitellum.

PURPOSE: Osteochondritis dissecans (OCD) of the capitellum is often treated by marrow stimulation techniques with good long-term outcomes. Magnetic resonance imaging (MRI) can be used to characterize the healing of cartilage repair tissue. However, no formal system exists for assessment of cartilage healing after marrow stimulation in capitellar OCD. The aims of this study were to describe the postoperative MRI appearance of capitellar repair cartilage after debridement and marrow stimulation for capitellar OCD and assess differences between symptomatic and asymptomatic patients. METHODS: This was a retrospective study of patients with capitellar OCD who underwent arthroscopic debridement and marrow stimulation and had a postoperative MRI to assess healing. The classification system developed by Marlovits and colleagues (Magnetic Resonance Observation of Cartilage Repair Tissue) was used to quantitatively profile the cartilage repair tissue in comparison to adjacent "normal" cartilage. Study participants completed an online survey to correlate outcomes with cartilage appearance. RESULTS: Eleven patients who underwent MRI for routine evaluation (asymptomatic), and 18 who underwent MRI for symptoms were identified. Overall, 59% of defects were completely filled, and in 83%, the cartilage surface had ulcerations or fibrillations. The cartilage variables were similar between symptomatic and asymptomatic patients. Capitellar subchondral bone edema was observed on the MRI of every patient who underwent a reoperation and was present in only 62% of those who did not. Clinical scores did not correlate with MRI cartilage findings, but the small sample size limited conclusions regarding clinical outcomes related to postoperative cartilage features seen on MRI. CONCLUSIONS: This detailed assessment of cartilage appearance by MRI after marrow stimulation for capitellar OCD demonstrated that incomplete cartilage fill was common in both symptomatic and asymptomatic patients. Those requiring a second surgery were more likely to demonstrate subchondral bone edema. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Early Improvement in Patient-Reported Outcome Scores After Operative Treatment of Osteochondritis Dissecans of the Humeral Capitellum.

PURPOSE: Outcome measures that lack sensitivity for the detection of clinical changes early after surgery for capitellar osteochondritis dissecans (OCD) make it difficult to determine the optimal treatment for these defects. We sought to evaluate the early responsiveness of patient-reported outcomes measurement information system (PROMIS) scores in a cohort of patients operatively treated for capitellar OCD. METHODS: Four PROMIS questionnaires (mobility, upper extremity [UE], pain interference, and peer relations) were electronically administered to patients treated for capitellar OCD at a single tertiary academic medical center between January 1, 2015, and July 1, 2018. The questionnaires were administered at the initial preoperative outpatient clinic visit as well as at the 2-week, 6-week, and final return-to-play (RTP) visits. RESULTS: Twenty-nine patients (31 elbows, mean age 12.9 years) with available preoperative and postoperative PROMIS data were included. The mean final follow-up period was 26 weeks. Compared with that before surgery, there was a significant improvement in the mobility, pain interference, and UE scores at 6 weeks following surgery. The scores improved most significantly by 6 weeks, reached a relative plateau, and remained significantly improved through the RTP visit thereafter. Patients with preoperative, intra-articular loose bodies scored significantly better than those without them during the 6-week and RTP visits. Patients with lesions >1 cm2, compared with those with lesions ≤1 cm2, demonstrated greater improvement in the UE scores during the RTP visit. CONCLUSIONS: In patients undergoing operative treatment for capitellar OCD, a significant improvement in the PROMIS domains of mobility, pain interference, and UE can be expected early in the postoperative period, with majority of patients reaching their greatest improvement in scores by 6 weeks following surgery. CLINICAL RELEVANCE: This is important information for preoperative counseling. In addition, this information is helpful in confirming that PROMIS scores are responsive in the detection of changes in outcomes during the early postoperative period in this population.

Magnetic Resonance Imaging in Osteochondritis Dissecans of the Humeral Capitellum: Preoperative Assessment of Lesion Size and Lateral Wall Integrity.

PURPOSE: Magnetic resonance imaging (MRI) is a helpful tool in the evaluation of osteochondritis dissecans (OCD) of the humeral capitellum. The relationship between MRI appearance and clinically relevant intraoperative findings is incompletely understood. The goal of this study was to evaluate capitellar OCD lesions via preoperative MRI and to determine its accuracy in predicting lesion characteristics including lesion size and capitellar lateral wall integrity. METHODS: Patients surgically treated for capitellar OCD between January 2010 and June 2018 were reviewed. Preoperative MRI images were assessed by a musculoskeletal radiologist with documentation of lesion size, location, violation of the lateral wall, and stage, in accordance with previously established criteria. These data were compared with intraoperative findings. Involvement of the lateral wall of the capitellum was defined using 2 methods: (1) subchondral edema or articular cartilage disruption in the lateral third of the capitellum (lateral third method) or (2) disruption of the proximal-distal subchondral line along the lateral border of the capitellum descending vertically before the subchondral bone turns horizontally to form the radiocapitellar articulation (capitellar lateral wall sign method). Diagnostic test characteristics were compared for both methods. RESULTS: We reviewed the preoperative MRIs of 33 elbows with capitellar OCD and found no significant difference in mean lesion size between preoperative MRI (1.12 cm2) and intraoperative measurement (1.08 cm2). For detection of lateral wall integrity, preoperative MRI evaluation using the capitellar lateral wall sign method had an accuracy of 93%, sensitivity of 80%, specificity of 96%, positive predictive value of 80%, and negative predictive value of 96%. CONCLUSIONS: Preoperative MRI is a valid predictor of lesion size. The capitellar lateral wall sign method is highly accurate in the identification of lateral wall involvement, which may influence preoperative planning. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

A 3-Dimensional Quantitative Analysis of Volume Loss Following Submental Cryolipolysis.

BACKGROUND: Cryolipolysis is a proven and effective means of fat reduction; however, there are no standardized means of measuring volume reduction. OBJECTIVES: We aim to assess the volume loss using a 3-dimensional (3D) analysis following submental cryolipolysis. METHODS: A retrospective cohort study between April 2016 and August 2018 was performed. Thirty-five patients underwent a single 45-minute cycle of cryolipolysis to the submental region using the CoolSculpting System. A 3-fold analysis was performed employing an independent observer assessment of 2-dimensional photographs and 3D volumetric analysis utilizing the Vectra XT system, and patient satisfaction was measured with the FACE-Q questionnaire. RESULTS: Our results suggested the mean (standard deviation) pretreatment volume (n = 35) was 104.12 cm3 (28.78). The 6-week mean posttreatment volume (n = 26) was 81.55 cm3 (21.29). The mean volume reduction found at 6 weeks posttreatment showed a reduction of 22.46 cm3 (19.10) (95% CI 14.74 to 30.17, P < 0.0001). The 12-week mean posttreatment volume (n = 24) was 82.24 cm3 (23.97). The 12-week posttreatment demonstrated a reduction of 22.30 cm3 (14.04) (95% CI 16.37 to 28.23, P < 0.0001). The mean percentage correct for each reviewer correctly identifying the pretreatment and posttreatment photograph was 76.33% (7.14). Patient satisfaction showed a mean FACE-Q score of 54.10 (20.41). CONCLUSIONS: The study further affirms that submental cryolipolysis is an efficacious and safe, noninvasive method for reducing submental adiposity resulting in notable patient satisfaction rates. Furthermore, results suggest that patients can have a volume loss of about 20% on average, allowing them to be more confident and comfortable with their appearance.

Reducing Indigenous Oral Health Inequalities: A Review from 5 Nations.

Indigenous populations around the world experience a disproportionate burden in terms of oral diseases and conditions. These inequalities are likely due to a complex web of social determinants that includes poverty, historical consequences of colonialism, social exclusion, government policies of assimilation, cultural annihilation, and racism in all its forms (societal, institutional). Despite documented oral health disparities, prevention interventions have been scarce in Indigenous communities. This review describes oral health interventions and their outcomes conducted for Indigenous populations of the United States, Canada, Brazil, Australia, and New Zealand. The review includes research published since 2006 that are available in English in electronic databases, including MEDLINE. A total of 13 studies were included from the United States, Canada, Brazil, and Australia. The studies reviewed provide a wide range of initiatives, including interventions for prevention and treatment of dental disease, as well as interventions that improve oral health knowledge, behaviors, and other psychosocial factors. Overall, 6 studies resulted in improved oral health in the study participants, including improvements in periodontal health, caries reduction, and oral health literacy. Preferred intervention methodologies included community-based research approaches, culturally tailored strategies, and use of community workers to deliver the initiative. Although these studies were conducted with discrete Indigenous populations, investigators reported similar challenges in research implementation. Recommendations for future work in reducing oral health disparities include addressing social determinants of health in various Indigenous populations, training future generations of dental providers in cultural competency, and making Indigenous communities true partners in research.

Renal tubular resistance is the primary driver for loop diuretic resistance in acute heart failure.

BACKGROUND: Loop diuretic resistance is a common barrier to effective decongestion in acute heart failure (AHF), and is associated with poor outcome. Specific mechanisms underlying diuretic resistance are currently unknown in contemporary AHF patients. We therefore aimed to determine the relative importance of defects in diuretic delivery vs. renal tubular response in determining diuretic response (DR) in AHF. METHODS AND RESULTS: Fifty AHF patients treated with intravenous bumetanide underwent a 6-h timed urine collection for sodium and bumetanide clearance. Whole-kidney DR was defined as sodium excreted per doubling of administered loop diuretic and represents the sum of defects in drug delivery and renal tubular response. Tubular DR, defined as sodium excreted per doubling of renally cleared (urinary) loop diuretic, captures resistance specifically in the renal tubule. Median administered bumetanide dose was 3.0 (2.0-4.0) mg with 52 (33-77)% of the drug excreted into the urine. Significant between-patient variability was present as the administered dose only explained 39% of variability in the quantity of bumetanide in urine. Cumulatively, factors related to drug delivery such as renal bumetanide clearance, administered dose, and urea clearance explained 28% of the variance in whole-kidney DR. However, resistance at the level of the renal tubule (tubular DR) explained 71% of the variability in whole-kidney DR. CONCLUSION: Defects at the level of the renal tubule are substantially more important than reduced diuretic delivery in determining diuretic resistance in patients with AHF.

Hypochloremia and Diuretic Resistance in Heart Failure: Mechanistic Insights.

BACKGROUND: Recent epidemiological studies have implicated chloride, rather than sodium, as the driver of poor survival previously attributed to hyponatremia in heart failure. Accumulating basic science evidence has identified chloride as a critical factor in renal salt sensing. Our goal was to probe the physiology bridging this basic and epidemiological literature. METHODS AND RESULTS: Two heart failure cohorts were included: (1) observational: patients receiving loop diuretics at the Yale Transitional Care Center (N=162) and (2) interventional pilot: stable outpatients receiving ≥80 mg furosemide equivalents were studied before and after 3 days of 115 mmol/d supplemental lysine chloride (N=10). At the Yale Transitional Care Center, 31.5% of patients had hypochloremia (chloride ≤96 mmol/L). Plasma renin concentration correlated with serum chloride (r=-0.46; P<0.001) with no incremental contribution from serum sodium (P=0.49). Hypochloremic versus nonhypochloremic patients exhibited renal wasting of chloride (P=0.04) and of chloride relative to sodium (P=0.01), despite better renal free water excretion (urine osmolality 343±101 mOsm/kg versus 475±136; P<0.001). Hypochloremia was associated with poor diuretic response (odds ratio, 7.3; 95% confidence interval, 3.3-16.1; P<0.001). In the interventional pilot, lysine chloride supplementation was associated with an increase in serum chloride levels of 2.2±2.3 mmol/L, and the majority of participants experienced findings such as hemoconcentration, weight loss, reduction in amino terminal, pro B-type natriuretic peptide, increased plasma renin activity, and increased blood urea nitrogen to creatinine ratio. CONCLUSIONS: Hypochloremia is associated with neurohormonal activation and diuretic resistance with chloride depletion as a candidate mechanism. Sodium-free chloride supplementation was associated with increases in serum chloride and changes in several cardiorenal parameters. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02031354.

Reduced Cardiac Index Is Not the Dominant Driver of Renal Dysfunction in Heart Failure.

BACKGROUND: It is widely believed that a reduced cardiac index (CI) is a significant contributor to renal dysfunction in patients with heart failure (HF). However, recent data have challenged this paradigm. OBJECTIVES: This study sought to determine the relationship between CI and renal function in a multicenter population of HF patients undergoing pulmonary artery catheterization (PAC). METHODS: Patients undergoing PAC in either the randomized or registry portions of the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) trial were included (n = 575). We evaluated associations between CI and renal function across multiple subgroups and assessed for nonlinear, threshold, and longitudinal relationships. RESULTS: There was a weak but significant inverse correlation between CI and estimated glomerular filtration rate (eGFR), such that higher CI was paradoxically associated with worse eGFR (r = -0.12; p = 0.02). CI was not associated with blood urea nitrogen (BUN) or the BUN to creatinine ratio. Similarly, no associations were observed between CI and better renal function across multiple subgroups defined by indications for PAC or hemodynamic, laboratory, or demographic parameters. A nonlinear or threshold effect could not be identified. In patients with serial assessments of renal function and CI, we were unable to find within-subject associations between change in CI and eGFR using linear mixed modeling. Neither CI nor change in CI was lower in patients developing worsening renal function (p ≥ 0.28). CONCLUSIONS: These results reinforce evidence that reduced CI is not the primary driver for renal dysfunction in patients hospitalized for HF, irrespective of the degree of CI impairment or patient subgroup analyzed.

Are Stage of Change constructs relevant for subjective oral health in a vulnerable population?

UNLABELLED: Stage of Change constructs may be proxy markers of psychosocial health which, in turn, are related to oral health. OBJECTIVE: To determine if Stage of Change constructs were associated with subjective oral health in a population at heightened risk of dental disease. METHODS: Stage of Change constructs were developed from a validated 18-item scale and categorised into 'Pre-contemplative', 'Contemplative' and 'Active'. A convenience sample of 446 Australian non-Aboriginal women pregnant by an Aboriginal male (age range 14-43 years) provided data to evaluate the outcome variables (self-rated oral health and oral health impairment), the Stage of Change constructs and socio-demographic, behavioural and access-related factors. Factors significant at the p < 0.05 level in bivariate analysis were entered into prevalence regression models. RESULTS: Approximately 54% of participants had fair/poor self-rated oral health and 34% had oral health impairment. Around 12% were 'Pre-contemplative', 46% 'Contemplative' and 42% 'Active'. Being either 'pre-contemplative' or 'contemplative' was associated with poor self-rated oral health after adjusting for socio-demographic factors. 'Pre-contemplative' ceased being significant after adjusting for dentate status and dental behaviour. 'Pre-contemplative' remained significant when adjusting for dental cost, but not 'Contemplative'. The Stages of Change constructs ceased being associated with self-rated oral health after adjusting for all confounders. Only 'Contemplative' (reference: 'Active') was a risk indicator in the null model for oral health impairment which persisted after adding dentate status, dental behaviour and dental cost variables, but not socio-demographics. When adjusting for all confounders, 'Contemplative' was not a risk indicator for oral health impairment. CONCLUSIONS: Both the 'Pre-contemplative' and 'Contemplative' Stage of Change constructs were associated with poor self-rated oral health and oral health impairment after adjusting for some, but not all, covariates. When considered as a proxy marker of psychosocial health, Stage of Change constructs may have some relevance for subjective oral health.

A qualitative study of the meaning of oral health and self-care for 40 Dunedin residents living on lower incomes.

BACKGROUND AND OBJECTIVES: This project extends studies of oral health cultures for lower income families by identifying the participants' meaning of oral health self-care, barriers to its attainment, and suggestions for its improvement. METHODS: Forty open-ended interviews were conducted with Dunedin residents purposively selected from a variety of ages, backgrounds and ethnicities. Transcribed interviews were analysed thematically. RESULTS: Five key themes emerged: (1) oral health understandings for self and wider family groups; (2) the complexity of understanding cost in relation to oral self-care; (3) oral self-care tools and daily oral health routines; (4) relationships with oral health workers and the meaning of good and bad care provision; and (5) the State's involvement in oral health. CONCLUSIONS: Participants valued good oral health and were knowledgeable about it, but cost was the primary barrier to care.

Preliminary findings from the Oranga Niho dental student outplacement project.

OBJECTIVES: To examine stakeholder perspectives of the Bachelor of Dental Surgery 2012-2013 clinical outplacement programme with Maori Oral Health Providers (MOHPs) and inform the programme's ongoing development. DESIGN: A mixed methods kaupapa Maori action research project. SETTING: Six North Island MOHPs and the University of Otago Faculty of Dentistry. PARTICIPANTS AND METHODS: Online questionnaires were used to conduct a pre- and post-outplacement survey of dental students and a twice-yearly survey of all MOHP-based clinical supervisors. Paper questionnaires were used to survey adult clients and caregivers of child clients that the students treated. Data were analysed descriptively and thematically. MAIN OUTCOME MEASURES: 68 (61%) of the 112 eligible students completed the pre- and post-outplacement questionnaires; 31 clinical supervisor questionnaire responses were received representing all six MOHPs; and 426 client and 130 caregiver questionnaire responses were received from five MOHPs. RESULTS: 79% of students felt well prepared for outplacement and 75% indicated that they would consider working for a MOHP in future. Of the clinical supervisors, 93% indicated that the students were adequately prepared for outplacement, and 68%, that they would recommend one or more students for employment. However, 58% associated the outplacements with decreased productivity. More than 97% of adult clients and caregivers of child clients were pleased with the care that the students provided. CONCLUSION: Recommendations for strengthening the outplacement programme included: increasing communication between the Faculty, MOHPs and students; addressing the financial cost of the programme to the MOHPs; and providing more support for clinical supervisors.

Implications of the implementation of the revised dose limit to the lens of the eye: the view of IRPA professionals.

In April 2011, the International Commission on Radiological Protection issued a statement on reduction of the equivalent dose limits for the lens of the eye, and strongly recommended its consideration in the revision of the International Atomic Energy Agency's International Basic Safety Standards on Radiation Protection. The reduced dose limit was incorporated in the final version of the Basic Safety Standards. As significant concern was expressed by radiation protection professionals worldwide, the International Radiation Protection Association (IRPA) established a task group to assess the impact of implementation of the revised dose limit for the lens of the eye for occupational exposure. IRPA Associate Societies (ASs) were asked for their views using a questionnaire addressing three topics: implications for dosimetry, implications for methods of protection, and wider implications. The responses received indicate various methods of approach and express different points of view, reflecting nuances of particular ASs or specific professional groups. Topic experts nominated by ASs were selected to assist with collation of responses, and a report was produced by the task group. Conclusions were drawn on the three issues, including potential cost implications. A number of recommendations were drawn from the responses received including: the request for more understanding about the relationship between exposure of the lens of the eye and cataract formation, and further guidance to assist implementation; the importance of economic and social considerations when introducing the limits into national regulations; the need to propose or define procedures related to employment of people with existing or pre-cataract conditions; and the practical aspects relating to dosimetry and protective equipment.

The high cost of spasticity in multiple sclerosis to individuals and society.

BACKGROUND: Spasticity is an extremely common, distressing and disabling symptom of multiple sclerosis. Limited data suggest the associated health care costs correlate with increasing severity and place a high economic burden on individuals, health care systems and society. OBJECTIVE: The aim of this study was to quantify the impact of multiple sclerosis spasticity on health care resources and the associated costs at different levels of severity in people with multiple sclerosis in the United Kingdom. METHODS: An online survey was carried out to understand the resources used in the management of spasticity in multiple sclerosis. The questionnaire asked health care specialists to estimate their involvement and the resource use associated with different levels of spasticity, and the survey outputs were used to derive the resource costs. RESULTS: The level and cost of care substantially increased with the degree of spasticity. Key factors contributing to high annual costs per patient were home care, hospital admissions and high-cost items, such as hospital beds. CONCLUSIONS: Based on the survey results, it can be assumed that managing spasticity early and effectively could result in substantial cost savings, in addition to the improvements in health-related quality of life.

Implications in dosimetry of the implementation of the revised dose limit to the lens of the eye.

In 2012, International Radiation Protection Association (IRPA) established a Task Group to provide an assessment of the impact of the implementation of the ICRP-revised dose limit for the lens of the eye for occupational exposure. Associated Societies (ASs) of IRPA were asked to provide views and comments on the basis of a questionnaire addressing three principal topics: (i) implications for dosimetry, (ii) implications for methods of protection and (iii) wider implications of implementing the revised limits. A summary of the collated responses regarding dosimetry is presented and discussed. There is large agreement on the most critical aspects and difficulties in setting up an appropriate monitoring programme for the lens of the eyes. The recent international standards and technical documents provide guidance for some of the concerns but other challenges remain in terms of awareness, acceptance and practicalities.

Experience of racism and tooth brushing among pregnant Aboriginal Australians: exploring psychosocial mediators.

OBJECTIVES: Despite burgeoning evidence regarding the pathways by which experiences of racism influence health outcomes, little attention has been paid to the relationship between racism and oral health-related behaviours in particular. We hypothesised that self-reported racism was associated with tooth brushing, and that this association was mediated by perceived stress and sense of control and moderated by social support. METHODS: Data from 365 pregnant Aboriginal Australian women were used to evaluate tooth brushing behaviour, sociodemographic factors, psychosocial factors, general health, risk behaviours and racism exposure. Bivariate associations were explored and hierarchical logistic regression models estimated odds ratios (OR) and 95% confidence intervals (CI) for tooth brushing. Perceived stress and sense of control were examined as mediators of the association between self-reported racism and tooth brushing using binary mediation with bootstrapping. RESULTS: High levels of self-reported racism persisted as a risk indicator for tooth brushing (OR 0.51, 95%CI 0.27,0.98) after controlling for significant covariates. Perceived stress mediated the relationship between self-reported racism and tooth brushing: the direct effect of racism on tooth brushing was attenuated, and the indirect effect on tooth brushing was significant (beta coefficient -0.09; bias-corrected 95%CI -0.166,-0.028; 48.1% of effect mediated). Sense of control was insignificant as a mediator of the relationship between racism and tooth brushing. CONCLUSIONS: High levels of self-reported racism were associated with non-optimal tooth brushing behaviours, and perceived stress mediated this association among this sample of pregnant Aboriginal women.. Limitations and implications are discussed.

Neuropsychologic outcomes in patients treated for complex maxillofacial trauma.

Complex fractures of the craniofacial skeleton are caused most commonly, in Australia, by motor vehicle accidents, falls, and interpersonal violence. Significant force is required to fracture the facial skeleton, and the long-term effect these forces have on higher brain function is unclear. The study aim was to assess long-term neuropsychologic changes associated with complex fractures of the facial skeleton. Patients managed for complex fractures of the facial skeleton by the Australian Craniofacial Unit, South Australia, between 2002 and 2011, with at least 1-year follow-up, were assessed using the European Brain Injury Questionnaire. This questionnaire has previously published control data to which results were compared. Of the 2077 patients treated for facial fractures, 46 were identified as having complex fractures of the facial skeleton. Of the 46 patients, 13 were able to be contacted and assessed using the European Brain Injury Questionnaire. Changes in personality and ability to socialize and undertake executive function were noted in approximately 30% of the patients. In addition, approximately 50% of the patients' family members reported significant changes in the patients' life after the accident, yet this was only recognized by approximately 30% of the patients. This study shows that, despite the "crumple zone" of the facial skeleton providing some level of protection to the brain, patients having complex fractures of the facial skeleton have long-term neuropsychologic changes that affect both their own and their family's quality of life.