Hospitalisations due to pulp and periapical conditions in Australian children from 1998-99 to 2017-18.

OBJECTIVE: To assess the demographic and time trends in hospitalisation rate for Pulp and Periapical Diseases (P&PDs) over 20-years (1998-99 to 2017-18), amongst children and adolescents (under age 19 years) in all states and territories of Australia. P&PDs are considered potentially preventable, with the possibility of them resulting in emergency presentations if timely treatment is not provided. They can result in treatment under general anaesthesia, which is costly. DESIGN: Retrospective analysis of hospitalisation for pulp and periapical diseases. SETTING: Public and private hospitals across Australia. MAIN OUTCOME MEASURES: The number of hospitalisations (measured using the number of separations or cases of hospital admission) for all pulp and periapical diseases by age-group. RESULTS: There were about 40,000 hospitalisations regarding P&PDs over the 20 years among Australian children under 19 years old. The rate of admissions ranged from means of 28.5 to 44.1 per 100,000 population. The number of admissions increased over 20 years for all children, except those younger than 4 years. Children aged 5-9 years had the highest rate of admissions and, more days in hospital per admission than other age groups. Most children only had one-day admissions. CONCLUSION: Pulp and periapical diseases hospitalisation rates have increased over two decades. Additional approaches to improve child dental health in Australia need to be considered.

Size estimation of unerupted canines and premolars using various independent variables: a systematic review.

INTRODUCTION: Prediction of unerupted permanent teeth is an essential part of orthodontic diagnosis and treatment planning. This prediction is done by mixed dentition space analysis based on the estimation of mesiodistal dimensions of unerupted permanent canine and premolars from already erupted permanent teeth. Permanent mandibular incisors are most commonly used for prediction. Recent literature reveals that mandibular incisors are not accurate predictors and other independent variables have been introduced to make a more accurate and precise prediction. The objective of this paper was to evaluate the literature in light of a variety of independent variables and their predictive accuracy. METHODS: Electronic databases such as MEDLINE, PubMed, Scopus, Embase, Web of Science, CINAHL Plus were searched to identify articles published until September 2021. RESULTS: The search resulted in a total of 1098 articles, of which 24 papers met our inclusion criteria and were included in this review. Articles using permanent mandibular incisors only as a predictor were excluded during the eligibility assessment. The results show that various independent variables including mesiodistal and vestibulo-oral dimensions of permanent maxillary and mandibular incisors and molars, molar basal arch length, intermolar distance, maxillary and mandibular arch and gender have been used as predictors to more accurately determine mesiodistal width of unerupted canine and premolars in different populations. CONCLUSION: Ethnic tooth size variations strongly emphasize the need to determine which independent variable gives a more accurate prediction of unerupted permanent teeth to develop a population-specific prediction model. This will play a significant role in managing space problems and developing malocclusions.

Prediction of mesio-distal dimensions of the unerupted permanent canines and premolars using measurements of different groups of erupted teeth: retrospective cross-sectional analysis of digital records in Western Australians.

PURPOSE: Recently, other combinations of teeth are claimed to be better predictors for size estimation of permanent canine and premolars. The present study aimed to determine which combinations of teeth presented an appropriate predictor in Western Australians using digital technology. METHODS: A total of 500 (323 females, 177 males) participants meeting the inclusion criteria were randomly selected from private orthodontic clinics. Mesiodistal dimensions of selected teeth obtained from pre-orthodontic treatment digital records were analyzed using SPSS 20. Fifteen possible combinations of teeth were used to determine the best prediction capability. RESULTS: Different combinations of teeth showed a higher correlation with the sum of permanent canine and premolars. In females, group 13 (Mandibular incisors and maxillary first molars) and in males, group 15 (mandibular incisors, maxillary central incisors, and first molars) and group 14 (mandibular incisors and first molars) showed a higher correlation in maxilla and mandible respectively. Linear regression equations were developed based on the best predictor for each arch and gender. CONCLUSION: Permanent mandibular incisors may not be better predictors when used alone. Newly developed equations, based on different combinations of teeth, more accurately predicted the sum of mesiodistal dimensions of permanent canine and premolars in the Western Australian population.

Platelets modulate cardiac remodeling via the collagen receptor GPVI after acute myocardial infarction.

Introduction: Platelets play an important role in cardiovascular diseases. After acute myocardial infarction, platelets display enhanced activation and migrate into the infarct zone. Furthermore, platelets trigger acute inflammation and cardiac remodeling leading to alterations in scar formation and cardiac function as observed in thrombocytopenic mice. GPVI is the major collagen receptor in platelets and important for platelet activation and thrombus formation and stability. Antibody induced deletion of GPVI at the platelet surface or treatment of mice with recombinant GPVI-Fc results in reduced inflammation and decreased infarct size in a mouse model of AMI. However, the role of GPVI has not been fully clarified to date. Methods/Results: In this study, we found that GPVI is not involved in the inflammatory response in experimental AMI using GPVI deficient mice that were analyzed in a closed-chest model. However, reduced platelet activation in response to GPVI and PAR4 receptor stimulation resulted in reduced pro-coagulant activity leading to improved cardiac remodeling. In detail, GPVI deficiency in mice led to reduced TGF-ß plasma levels and decreased expression of genes involved in cardiac remodeling such as Col1a1, Col3a1, periostin and Cthrc1 7 days post AMI. Consequently, collagen quality of the scar shifted to more tight and less fine collagen leading to improved scar formation and cardiac function in GPVI deficient mice at 21d post AMI. Conclusion: Taken together, this study identifies GPVI as a major regulator of platelet-induced cardiac remodeling and supports the potential relevance of GPVI as therapeutic target to reduce ischemia reperfusion injury and to improve cardiac healing.

Gall bladder torsion masquerading as appendicitis in a teenage boy.

SUMMARY: This report describes acute gallbladder torsion in a previously healthy 16-year-old male. The patient presented with acute right-sided abdominal pain in keeping with acute appendicitis and was taken for a diagnostic laparoscopy where an intraoperative diagnosis of gallbladder torsion was made. This case highlights a very rare surgical presentation in an uncommon patient profile. It highlights the benefit of diagnostic laparoscopy in a resource-constrained facility.

Innovative methodology to guide planning of dental workforce distribution: a GIS-based study in Nepal.

OBJECTIVES: To build a predictive model based on the distribution pattern of dentists and population in selective districts of Nepal. METHOD: Cross-sectional descriptive study conducted using secondary data from the census report and available dentist data of Nepal. Population data were obtained from the most recently available census. For dentists' data, a literature search was carried out in the databases such as PubMed, Google scholar, One Search and Medline. All data were extracted from the integrated database in the Geographic Information System (GIS), and a predictive model was built. RESULTS: Overall, there was an uneven distribution of dentists in Nepal. When the distribution of dentists was compared with the population clusters, it was found that the slope of the population growth was below or equal to (≤) 20,000 for three provinces (2, 6, and 7), which means that lower numbers of dentists are available with respect to population density in these provinces. The slope was above 50,000 for province 3, and the number of dentists was almost half of the total nationwide. The number of dentists correlated with population clusters. CONCLUSION: There are substantial disparities in the distribution of dentists in Nepal. Dentists were distributed relative to higher population clusters and were unevenly distributed. The Nepal government should make necessary arrangements to address the need for the human workforce in resource-limited settings. The methods used in this study could be applied globally, as the data used are available for most countries.

Oral health education and prevention strategies among remote Aboriginal communities: a qualitative study.

BACKGROUND: The delivery of effective oral health promotion strategies is essential to improving oral health outcomes among remote Aboriginal communities. This study aimed to explore the perceptions and attitudes of Aboriginal Australians living in remote Kimberley communities towards oral health education and disease prevention. METHODS: Semi-structured interviews and yarning circles were carried out following purposive sampling of Aboriginal adults living in the East Kimberley region of Western Australia. RESULTS: A total of 80 community members participated in the yarning process. School-based oral health promotion and community-driven restrictions on the sale of sugary food and drink were seen as positive strategies in improving oral health. Lifestyle changes brought about by modernity, internet availability and fixed community stores were perceived to create new challenges and shift the priorities for those living in remote communities. CONCLUSIONS: Community-based yarning may better inform future oral health strategies in the Kimberley. A neoliberal approach of shifting responsibility onto the individual ignores the complex social inequities faced by Aboriginal people living in remote communities where macro-level determinants such as remoteness, food security and education significantly influence decisions around diet and oral health.

Management of dental emergencies amongst Australian general medical practitioners - A case-vignette study.

BACKGROUND: In Australia, because of inequity in dental service accessibility and affordability, patients can see general medical practitioners (GPs) for acute dental conditions. METHODS: This cross-sectional study consisted of surveys distributed to the board registered GPs practising in Australia. The main outcome measures included statistical analysis of GPs managing different dental emergency scenarios and their confidence and expectations in managing dental emergencies. RESULTS: A total of 425 GPs participated in the study. The sample primarily consisted of GPs practising in metropolitan clinics (n = 315). Most participants reported that they would refer to the dentist for mobilized tooth (n = 402). There was a negative correlation between GPs with 5-29 years of experience and traumatized tooth management (P < 0.05). GPs aged between 40 and 49 years were more inclined to treat patients with mobilized teeth [Multivariate (MV): 0.42(0.09-0.74)]. However, GPs with 0-5 years of experience were less likely to manage patients with dental abscess [MV: -0.52(-0.80 to -0.24)]. CONCLUSION: Most GPs referred dental emergencies to dentists. GP management of dental emergencies were predominantly palliative. Therefore, opportunities for collaborative practice models amongst GPs and dentists may be needed to bridge the gap in the regional and remote locations.

Current practices of Western Australian general dentists regarding management of patients on anticoagulant/antiplatelet therapy.

PURPOSE: Currently, there are little to no published studies outlining general dentists' knowledge in the management of patients on anticoagulant/antiplatelet therapies in Australia. The aim of this study was to investigate the current practices of Western Australian (WA) general dentists with regards to dental management of patients taking anticoagulants/antiplatelets. MATERIALS AND METHODS: WA dentists were invited to undertake a survey to investigate their knowledge on the management of patients taking anticoagulant/antiplatelet. The questionnaire provided to WA general dentists consisted of pre-extraction advice on patients (direct oral anticoagulants [DOACs], antiplatelets, warfarin, dual antiplatelets and antiplatelet/anticoagulant). Results were analysed using descriptive statistics as well as chi-square tests. RESULTS: Of the 89 participants, 40.5% had <5 years of general dental experience. Most WA general dentists (64%-71%) responded with 'no change' when performing extractions on patients on DOACs, antiplatelet therapy, warfarin, dual antiplatelets and antiplatelets/anticoagulants (P = 0.00). Furthermore, dentists with 6-10 years of experience were more likely to cease antiplatelet for 24 h before extractions (P < 0.05). Dentists who extracted 10-30 teeth per month were likely to stop antiplatelets and DOACs for more than 48 h compared to other groups (P < 0.05). CONCLUSION: Most WA dentists would not cease anticoagulant/antiplatelet therapy when undergoing dental extractions.

Hot-phonon effects in photo-excited wide-bandgap semiconductors.

Carrier and lattice relaxation after optical excitation is simulated for the prototypical wide-bandgap semiconductors CuI and ZnO. Transient temperature dynamics of electrons, holes as well as longitudinal-optic (LO), transverse-optic (TO) and acoustic phonons are distinguished. Carrier-LO-phonon interaction constitutes the dominant energy-loss channel as expected for polar semiconductors and hot-phonon effects are observed for strong optical excitation. Our results support the findings of recent time-resolved optical spectroscopy experiments.

Incidental findings detected on cone beam computed tomography in an older population for pre-implant assessment.

OBJECTIVES: The aim of this retrospective study was to record incidental findings in CBCT scans taken in an older population for pre-implant assessment, and to examine whether these findings would influence the intended dental implant placement. METHODS: 300 consecutive CBCT scans over the age of 40 years was carried out. The incidental findings were grouped into regions as follows: dentoalveolar structures, maxilla and mandible, paranasal sinuses, temporomandibular joint (TMJ), naso/oral-pharyngeal airway, cervical spine and neurovascular canals. The incidental findings are further categories into their significance towards the intended treatment plan. RESULT: Incidental findings were noted on all of the scans. 555 incidental findings (1.85 findings/scan) were identified. The highest number of incidental findings was in the sinuses (34%), followed by dentoalveolar structures (31%), nasal/oral-pharyngeal airway (12%), maxilla and mandible (10%), TMJ (6%), cervical spine (4%) and neurovascular canals (3%). A total of 37% of findings required follow-up. In 12% of cases detection of the incidental findings lead to amendment or abortion of the intended implant treatment plan. CONCLUSION: Incidental findings within and beyond the region of interest are common in CBCT scans. The numbers of incidental findings per scan in an older population is higher than in a younger population.

Improving Iraqi school dental services: A GIS-based study of service location optimisation.

BACKGROUND: The United Nations (UN) estimated the population of Iraq in 2005 at almost 29 million, of which nearly 14 million were children aged 0-14 years. Iraq is aiming to improve child oral health, and subsequent child general health, through school dental services, offered by primary health care centres. OBJECTIVE: To develop and test a GIS-based planning approach for the Hillah district of Iraq as a model for the rest of the country. All data were gathered from open sources. SETTING: The city has 98 neighbourhoods, with a total child population of 368 274, occupying 161 Sq. km2, with 14 fixed primary health care dental clinics. DESIGN: Accessibility zones were created using GIS, based on the ability of dentists to make their way to schools. OUTCOME MEASURES: A total of 23 307 of 0-4 year-olds (14%) and 74 384 (45%) of 0-15 year-olds lived outside the accessibility zones. RESULT: Areas where services are not available to the child population were identified, whether or not they attended primary schools. CONCLUSION: Reforming the existing dental health services in Iraq can be achieved by careful planning and appropriate utilisation of health resources.

The distribution of dentists in Australia Socio-economic profile as an indicator of access to services.

OBJECTIVES: Analyse the dentist to population ratio relative to socio-economic profile to identify areas of workforce shortages and inform the policy direction of workforce recruitment strategies and public dental service planning. METHODS: The suburb, state and postcode of dentists listed on the public access register of the Australian Health Practitioner Regulation Agency were geocoded by latitude and longitude and added to a map of Australia built on Australian Bureau of Statistics (ABS) Statistical Area 2 (SA2) census districts. Population data detailing the relative socio-economic disadvantage of each Statistical Area 1 (SA1) within each SA2 was superimposed on the map and used to calculate the number of dentists per 100 000 population relative to level of socio-economic disadvantage as defined by the ABS Socio-Economic Index for Areas, (SEIFA) Index of Relative Socio-economic Disadvantage (IRSD). The results were reported according to state and territory, and the Accessibility and Remoteness Index of Australia (ARIA+). RESULTS: The dentist to population ratio was lower in areas of disadvantage within major cities. All regions outside major cities had population cohorts with dentist to population ratios below the 65 dentists per 100 000 benchmark, conservatively estimated to be the minimum required for reasonable access to services. CONCLUSION: There is an inequity in the distribution of dentists relative to the socio-economic profile and geographic location of the Australian population. Shortages of dentists persist across many IRSD deciles in regional and rural areas. Within major cities there are fewer dentists per capita in the lower socio-economic districts.

An audit of thyroid function testing in acutely ill patients at a South African academic hospital.

Background: Non-thyroidal illness syndrome (NTIS) can be defined as the presence of abnormal thyroid function in the absence of primary thyroid dysfunction and is associated with acute illness. Thyroid function testing is generally not advised in the critically ill patient. Thyroid-stimulating hormone (TSH) measurement is the preferred screening test for thyroid disease, but results may be misleading and variable in the setting of critical illness. Objectives: To describe the pattern of requests for TSH testing in patients admitted to the emergency department and intensive care units at Tygerberg Hospital, Cape Town, South Africa. Methods: A retrospective, descriptive (observational) study was conducted over a 6-month period to determine the number of requests for TSH testing received for patients admitted to the emergency department and intensive care units. Results: A total of 1 139 requests for TSH testing were received from the emergency department and intensive care units, of which 166 were excluded. Of the 973 requests evaluated, 14% yielded abnormal results. The majority (79.4%) of the abnormal TSH results were most likely attributed to NTIS. Follow-up TSH results after 6 - 8 weeks were available in only 18% of cases with abnormal TSH levels at initial presentation. Conclusion: We found that TSH testing was often requested in critically ill patients, but that most results were either normal or indicative of NTIS. Follow-up testing of abnormal TSH results was rarely performed. We recommend continued education of junior clinicians regarding thyroid function testing in critically ill patients. Contributions of the study: This study describes the requesting pattern for TSH tests in patients admitted to the emergency department and intensive care unit at Tygerberg Hospital, South Africa. The findings emphasise the importance of prudent thyroid function testing in critically ill patients and follow-up in suspected cases of non-thyroidal illness syndrome.

The impact of COVID-19 on routine patient care from a laboratory perspective.

BACKGROUND: Globally, few studies have examined the effect of the COVID-19 pandemic on routine patient care and follow-up. OBJECTIVES: To evaluate the effect of the COVID-19 response on biochemical test requests received from outpatient departments (OPDs) and peripheral clinics serviced by the National Health Laboratory Service Chemical Pathology Laboratory at Tygerberg Hospital, Cape Town, South Africa (SA). Request volumes were used as a measure of the routine care of patients, as clinical information was not readily available. METHODS: A retrospective audit was conducted. The numbers of requests received from OPDs and peripheral clinics for creatinine, glycated haemoglobin (HbA1c), lipid profiles, thyroid-stimulating hormone (TSH), free thyroxine, free tri-iodothyronine (fT3), serum and urine protein electrophoresis, serum free light chains and neonatal total serum bilirubin were obtained from 1 March to 30 June for 2017, 2018, 2019 and 2020. RESULTS: The biggest impact was seen on lipids, creatinine, HbA1c, TSH and fT3. The percentage reduction between 1 March and 30 June 2019 and between 1 March and 30 June 2020 was 59% for lipids, 64% for creatinine and HbA1c, 80% for TSH and 81% for fT3. There was a noteworthy decrease in overall analyte testing from March to April 2020, coinciding with initiation of level 5 lockdown. Although an increase in testing was observed during June 2020, the number of requests was still lower than in June 2019. CONCLUSIONS: This study, focusing on the short-term consequences of the SA response to the COVID-19 pandemic, found that routine follow-up of patients with communicable and non-communicable diseases was affected. Future studies are necessary to evaluate the long-term consequences of the pandemic for these patient groups.

The distribution of allied dental practitioners in australia: socio-economics and rurality as a driver of better health service accessibility.

OBJECTIVES: Analysis of the distribution of allied dental practitioners relative to the socio-economic profile of the population, to develop a baseline of employment demographics at a time of proposed deregulation of practicing restrictions. METHODS: A database of allied dental practitioners (ADP - oral health therapists, dental therapists and dental hygienists) was compiled from the public access register of the Australian Health Practitioner Regulation Agency. The principal practice locations limited to suburb and postcode were geocoded by latitude and longitude and superimposed on a map of the Australian landmass using QGIS software. Using Australian Bureau of Statistics data, the number of ADPs for each Statistical Area 2 (SA2) was counted and apportioned according to proportion of the population within each SA2 for each quintile of the Index of Relative Socio-economic Disadvantage (IRSD). The results were reported according to oral health therapists, dental therapists and dental hygienists per 100 000 population for each IRSD quintile, by state and territory, and the Australian Regional Index for Areas (ARIA+). RESULTS: The ADP to population ratio was not consistent for each professional class between states and territories, IRSD quintiles and (ARIA+) regional areas. Across major cities, South Australia was the state with the highest ratio of oral health therapists (10.6-12.9) and dental hygienists (14.6-24.5) for all IRSD quintiles. Western Australia had the highest ratio of dental therapists (9.3-16.0), CONCLUSION: There is no consistent pattern of distribution of ADPs relative to the socio-economic profile of the population across states and territories, and regional (ARIA+) areas of Australia.

Identifying solar access effects on visitors' behavior in outdoor resting areas in a subtropical location: a case study in Japan Square in Curitiba, Brazil.

Changes in microclimate due to urban morphology tend to directly affect outdoor thermal comfort, thereby influencing people's behavior. In order to investigate that, this study analyzed preferences for specific resting areas within an urban square surrounded by high-rise buildings in a subtropical location. In order to understand behavioral adaptations as regards sunlight availability (direct or reflected) or shaded situations (partly, fully) in resting areas, the analysis was conducted according to an observational method during the four seasons of 2016. Two high-definition cameras with time-lapse function were positioned at vantage points facing distinct benches, shooting at intervals of 1.5 min between scenes. Altogether, 86,561 scenes were analyzed. As a thermal comfort parameter, the outdoor thermal comfort index 'PET' (physiological equivalent temperature) was used, by post-processing meteorological data from the local meteorological station. The availability of situations (sun-lit, shaded-partly or fully, reflected sunlight) in each frame and per bench and the preference of visitors for such areas were considered in the analysis. During winter, there was a prevalence of shaded situations, mostly due to adjacent buildings. In summer, the most common condition was partly shaded by trees. The choice for a given resting condition was found to be closely related to PET index values and thermal comfort/stress classes and less so to seasonal changes.

The Distribution of Dental Health Specialist Locations in Sri Lanka.

AIM: To investigate the distribution of dental health specialist locations staffed by Oral and Maxillo-Facial Surgeons (OMF), Restorative dentists, and Orthodontists in Sri Lanka in relation to population distribution and socio-economic status. METHODS: Specialist dental locations were mapped using GIS (Geographic Information System) and overlayed with census population data and socio-economic quintiles. RESULTS: Overall, there was an uneven geographic distribution of the total 55 specialist dental locations and 74 attributed specialist work force within the country. Access to specialist care is remarkably high in Western and Central provinces, compared to the Northern, Eastern and North Central provinces. When the geographic distribution was compared to population socio-economics, it was found that in Sri Lanka only 22.3%, 44.4%, and 25.4% of the most disadvantaged lived within 20 kms from an Orthodontic, OMF and Restorative clinic respectively, compared to 66.3%, 82.8% and 44.7% of the least disadvantaged. CONCLUSION: The findings of this study can contribute to the decision-making process when determining future locations of dental specialist clinics and identifying subgroups in the population who are geographically and socio-economically isolated from accessing care.

Socioeconomic determinants as risk factors for squamous cell carcinoma of the head and neck: a case-control study in Iran.

Our aim was to assess the association between different components of sociodemographic status and the risk of developing squamous cell carcinoma (SCC) of the head and neck after we had adjusted for the influence of the known behavioural risk factors of smoking and drinking alcohol. We selected 146 patients with histopathologically-confirmed SCC of the head and neck, and matched them for age and sex with 266 healthy controls for this case-control study. Personal details, occupation, socioeconomic status, smoking, and alcohol consumption were recorded. The association of sociodemographic variables with oral cancer was evaluated both separately and with a composite socioeconomic index. Chi squared tests, adjusted odds ratios (OR), and 95% CI were computed using logistic regression to estimate the effect. There was a significant difference between the two groups in the composite socioeconomic index (p<0.001). The group with "low" socioeconomic status had the highest risk of oral cancer (OR=3.89, 95% CI 1.28 to 11.82). Better-educated people with higher incomes had a lower risk of SCC of the head and neck after we had controlled for behavioural risk factors. However, marital and employment status and place of residence were not significantly associated with risk. Our findings confirm that some socioeconomic determinants were associated with the development of oral cancer in this study group.

Impact of ledipasvir/sofosbuvir on the work productivity of genotype 1 chronic hepatitis C patients in Asia.

Chronic, untreated hepatitis C virus (HCV) infection is associated with a poor clinical prognosis and a detrimental impact on patients' lives, including on work productivity. To estimate the value of productivity losses due to genotype 1 (GT1) HCV infection in Hong Kong, Singapore, South Korea and Taiwan and to estimate the potential productivity gains associated with treating patients with ledipasvir/sofosbuvir (LDV/SOF) therapy, an economic model was developed with a time horizon of 1 year. Hepatitis C virus patients entered the model at 12 weeks post-treatment, having achieved or not achieved sustained virological response (SVR). Absenteeism and presenteeism rates were taken from a pooled analysis of data from the ION 1-3 studies. These rates were converted into hours of lost productivity, multiplied by the average wage and applied to the total employed, adult GT1 population in each country. Results were compared assuming no treatment, and assuming all patients were treated with LDV/SOF. Total productivity losses due to untreated HCV were: $11.3 million, $17.1 m, $146.0 m and $349.1 m in Hong Kong, Singapore, South Korea and Taiwan. LDV/SOF treatment resulted in economic gains of $4.5 m, $6.8 m, $58.7 m and $138 m, respectively. These gains were due to reduced presenteeism. The results were sensitive to changes in the prevalence of HCV and the average wage. In conclusion, productivity losses due to untreated HCV infection represent a substantial economic burden. By instituting universal HCV treatment with LDV/SOF (or other therapies with high SVR rates), productivity gains can be achieved.