The association of painful and non-painful morbidities with frailty: a cross sectional analysis of a cohort of community dwelling older people in England.

INTRODUCTION: The association between chronic pain and frailty might indicate that pain is an independent driver of frailty but might alternatively be explained by inclusion within frailty identification tools of morbidities that commonly lead to chronic pain. This research examines the extent to which the association of pain with frailty might be attributed to morbidities. METHODS: A cross-sectional analysis of older people in a UK cohort with or at risk of musculoskeletal problems or frailty (Investigating Musculoskeletal Health and Wellbeing study), used multivariable logistic regression and Z-tests to assess the degrees of associations of pain (McGill Pain Rating Index), and painful and non-painful morbidity counts with frailty (modified FRAIL questionnaire). RESULTS: Data were from 2,185 participants, 56% female, median age 73 (range 60 to 96) years. 430 (20%) participants were classified as frail. In a fully adjusted standardised model, pain (aOR 2.07 (95%CI 1.83 to 2.33) and 'any' morbidity aOR (1.74 (95%CI 1.54 to 1.97) were both significantly associated with frailty. When morbidity was subclassified as painful or non-painful, painful (aOR 1.48 (95%CI 1.30 to 1.68) and non-painful (aOR1.39 (95%CI 1.24 to 1.56)) morbidities each were associated with frailty, as also was pain (aOR 2.07 (95%CI 1.83 to 2.34, p < 0.001). CONCLUSIONS: Pain is associated with frailty, over and above any effect of painful and non-painful morbidities. This forms the justification for future research which focuses on pain management in the identification, prevention, and treatment of frailty.

Changes in Tooth Mobility and Position in an Established Dentition Following Placement of a New Restoration.

The aim of this study is to examine and evaluate physiologic tooth mobility and movement in different groups of patients. Four groups of patients were examined and recordings were taken. Group A1 consisted of 12 undergraduate students under the age of 30, A2 consisted of 11 members of staff over the age of 30 and A3 consisted of 9 patients with periodontal disease between the ages of 40-65 years old. The fourth Group B, 14 patients between 30-70 years old, received single-tooth restorations and recordings were taken immediately after, a month and four months following the cementation of the restoration. Patients in the first 3 groups showed no significant change in tooth mobility and movement between appointments. The fourth group demonstrated a non-statistically significant increase in tooth mobility following the cementation of the restoration due to the force applied on the occlusal surface of the tooth during the cementation process, while tooth movement was not observed beyond that of physiological tooth migration. Regardless of the age or the restorations a patient receives over the years, with careful occlusal consideration, no significant changes in tooth mobility and movement should be observed.

A Passive Noise Attenuation Earplug Designed to Minimise Unwanted Air Turbine Driven High-Speed Dental Drill Noise.

INTRODUCTION: Air turbine dental drill noise contains high-frequency components that are of concern for patients and dental staff. Meanwhile, verbal communication between the dentist and patient is essential. Conventional active noise-cancelling headphones are ineffective for dental drill noise and simply suppress all sound and hinder communication. METHOD: A compact passive earplug device was designed specifically to attenuate broadband high-frequency noise ranges from 5 to 8 kHz employing an array of quarter wavelength (QW) resonators. This device was 3D printed and tested against white noise to enhance the objectivity of analysis, using a calibrated ear and cheek simulator to effectively measure its performance. RESULTS: The results showed that the resonators produced an average reduction of 27 dB across the targeted frequency range. When compared with two proprietary passive earplugs, this developed passive device prototype was able to attenuate an average of 9 dB more across the target frequency range whilst delivering louder speech signals of 14 dB more. The results also show that using an array of resonators exhibits an accumulated effect of individual resonator performance. CONCLUSIONS: This low-cost passive device could have a place in the dental clinic to reduce unwanted drill noise equivalent to the white noise high frequency spectra tested.

Mandibular Distalisation for Tooth Wear in Patients Requiring Mandibular Protrusion for Sleep Apnoea.

BACKGROUND: Pathological tooth wear is an increasing concern and may require intervention and occlusal rehabilitation. Often the treatment includes distalisaton of the mandible to restore the dentition in centric relation. Obstructive sleep apnoea (OSA) is another condition treated my mandibular repositioning but in this case by an advancement appliance. The authors have a concern that there could be a group of patients with both conditions where distalisation for their tooth wear management would be contrary to their OSA treatment. This paper aims to look at this potential risk. METHODS: A literature search was carried out using the following keywords (OSA or sleep apnoea or apnea or snoring or AHI or Epworth score) and for tooth surface loss (TSL or distalisation or centric relation or tooth wear or full mouth rehabilitation). RESULTS: No studies were identified which considered the effect of mandibular distalisation on OSA. CONCLUSION: There is a theoretical risk that dental treatment involving distalisation may adversely affect patients at risk of OSA or worsening their condition due to the modification of airway patency. Further study is recommended.

Analysis of Posterior Zirconia Crowns with Vertical Margin Preparations.

BACKGROUND: The interest in vertical crown preparation is growing and several variations are presented in the dental literature but limited clinical outcome data exists for teeth prepared for a vertical finish line. AIM: To audit clinical outcomes for 73 teeth after vertical preparation for knife-edge zirconia crowns. METHOD: Seventy-three teeth had knife-edge zirconia crowns placed after vertical finish line preparation. The outcomes for these teeth were analysed from a retrospective audit of clinical records. RESULTS: The mean follow-up time was 21 months (SD: 10 months; range: 6-40). One tooth had to be extracted due to fracture at cervical level. One crown had to be re-made after margin fracture during try-in. No subsequent endodontic treatment was needed for any of the prepared teeth. No change in alveolar bone height was noted on radiographic follow-up. The mean bleeding score for the crowned teeth was higher than the mean bleeding score for a control tooth, but this was not statistically significant. CONCLUSION: This retrospective evaluation has shown favourable outcomes for 72 teeth after vertical preparation for knife-edge crowns. Longer follow-up is needed but the present results show that the technique is a viable procedure with potential advantages.

Discovery of inhibition of Burkholderia cenocepacia, Pseudomonas aeruginosa and Stenotrophomonas maltophilia by the Brown Rot Basidiomycete Fungus, Postia placenta.

Antimicrobial resistance (AMR) has now emerged as a major global public health problem. Certain bacterial pathogens, particularly Gram negative organisms associated with patients with cystic fibrosis (CF), have become resistant to several classes of antibiotics resulting in pan-resistance, which creates a clinical treatment dilemma. This study wished to explore the production of antibacterial extracellular metabolites from plant pathogenic fungi. Fungal Culture Extracts (FCEs) were prepared from 10 fungi (Armillaria gallica, Clitocybe nebularis, Fusarium coeruleum, Fusarium oxysporum, Fusarium poae, Hymenoscyphus fraxineus, Nectria fuckeliana, Phytophthora infestans, Phytophthora ramorum, Postia placenta), which were tested for activity against the CF pathogens, Pseudomonas aeruginosa (PA) (n=8), Burkholderia cenocepacia (n=2) and Stenotrophomonas maltophilia (n=2). In addition, FCE were assessed for their ability to alter antibiotic susceptibility in PA (n=8), with six antipseudomonal antibiotics (ceftazidime, ciprofloxacin, colistin, meropenem, piperacillin/tazobactam, tobramycin). None of the FCEs showed inhibitory activity to the 12 bacterial isolates tested, with the exception of the FCE from Postia placenta, which showed inhibition against all 12 bacteria. An antagonistic interaction was observed, where a statistically significant decrease in mean zone sizes was noted with Armillaria gallica (p=0.03) and Phytophthora infestans (p=0.03) FCEs and their interaction with the fluoroquinolone antibiotic, ciprofloxacin. Given the increase in clinical morbidity and mortality associated with chronic lung infections with Pseudomonas aeruginosa, Burkholderia cenocepacia and Stenotrophomonas maltophilia, coupled with the difficulty in treating such chronic infection due to overwhelming antimicrobial resistance, any novel substance showing inhibition of these organisms merits further investigation as a potential future antimicrobial agent, with potential clinical therapeutic application.

Fighting antimicrobial resistance (AMR): Chinese herbal medicine as a source of novel antimicrobials - an update.

Antimicrobial resistance (AMR) has now emerged as a global public health crisis, requiring the discovery of new and novel antimicrobial compounds, that may be precursors of future therapeutic antibiotics. Chinese Herbal Medicine (CHM) comes with a rich pedigree of holistic and empirical usage in Asia for the last 5000 years. Extracts of Anemarrhena asphodeloides Bunge, Angelica sinensis (Oliv.) Diels, Dianthus superbus L. Forsythiae fructus (Lian Qiao), Lonicerae flos (Jin Yin Hua), Naemorhedi cornu, Platycladus orientalis Franco, Polygonum aviculare, Polygonum cuspidatum, Poria cocos (Schw.), Rehmannia glutinosa (Gaertn.) DC, Rheum palmatum, Salvia miltiorrhiza Bunge, Scutellaria barbata, Scutellariae radix (Huang Qin) and Ursi fel (Xiong Dan) have shown to have antimicrobial properties against clinically significant Gram-negative and Gram-positive bacterial pathogens, as well as the mycobacteria (TB and non-tuberculous mycobacteria). Evidence is now beginning to emerge through systematic reviews of the outcomes of clinical studies employing CHM to treat infections. Of the 106 Cochrane systematic reviews on CHM, 16 (ca 15%) reviews examine CHM in the context of treating a specific infection disease or state. This update examines direct antimicrobial effect of CHM on bacterial pathogens, as well as synergistic effects of combining CHM with conventional antibiotics.

The Role of Suboptimal Concentrations of Nebulized Tobramycin in Driving Antimicrobial Resistance in Pseudomonas aeruginosa Isolates in Cystic Fibrosis.

BACKGROUND: Antimicrobial resistance in Pseudomonas aeruginosa may be driven by exposure to suboptimal concentrations of tobramycin antibiotic delivered by less efficient nebulizers. METHODS: P. aeruginosa isolates (no. = 114; 32 first + 82 chronic) were challenged in vitro employing extrapolated peak and trough concentrations of tobramycin inhalation solution (TIS), corresponding to 3 nebulizers: Pari LC Plus, Sidestream12NEB400, and MistyNeb2035G. Bacterial persistence and antibiotic susceptibility to tobramycin was determined following 4 TIS cycles: (i) 28 d ON, (ii) 28 d ON + 28 d OFF, (iii) 2 × 28 d ON, and (iv) 28 d ON + 28 d ON + 28 d OFF. RESULTS: All first isolates were eradicated at peak and trough concentrations except for the trough concentration corresponding to Sidestream 12NEB400 (bactericidal activity 87%). For chronic isolates, peak concentrations eradicated 88%, 90%, and 92%, and trough concentrations eradicated 43%, 62%, and 85%, with the Sidestream12NEB400, MistyNeb2035G, and Pari LC Plus nebulizers, respectively. A statistically significant increase in antibiotic resistance with sensitive, intermediate, and resistant P. aeruginosa was noted following cycles (i) through (iv) at trough concentrations with the Sidestream 12NEB400 and MistyNeb2035G nebulizers. There was a significant reduction in tobramycin resistance following a 28-d OFF cycle, and no difference was noted following 1 × 28 d ON versus 2 × 28 d ON cycles. CONCLUSIONS: Our results indicate that suboptimal concentrations of tobramycin drove increased antibiotic resistance, emulating standard cycles of ON/OFF inhaled therapy. This was evident at extrapolated tobramycin concentrations at trough levels corresponding to less efficient nebulizers by initially allowing for the survival of intermediate and resistant organisms, because nebulizer performance did not achieve critical antibiotic concentrations sufficient to eradicate the organism, and by allowing the development of resistance in those cells that were able to survive the initial tobramycin challenge. Transferred to clinical practice, for people with cystic fibrosis on TIS treatment, it is important that clinicians employ an efficient nebulizer that helps mitigate an upward drift in antibiotic resistance, thereby protecting the clinical value of TIS within treatment for cystic fibrosis.

Fungal vaccines.

Invasive fungal disease continues to be a cause of significant life-threatening morbidity and mortality in humans, particularly in those with a diminished immune system, such as with haematological malignancies. The mainstay of treating such life-threatening fungal infection has been antifungal drugs, including azoles, echinocandins and macrocyclic polyenes. However, like antibiotic resistance, antifungal resistance is beginning to emerge, potentially jeopardizing the effectiveness of these molecules in the treatment of fungal disease. One strategy to avoid this is the development of fungal vaccines. However, the inability to provoke a sufficient immune response in the most vulnerable immunocompromised groups has hindered translation from bench to bedside. This review will assess the latest available data and will investigate potential Aspergillus antigens and feasible vaccine techniques, particularly for vaccination of high-risk groups, including immunocompromised and immunosuppressed populations.

The Central Aspects of Pain in the Knee (CAP-Knee) questionnaire; a mixed-methods study of a self-report instrument for assessing central mechanisms in people with knee pain.

OBJECTIVES: Pain is the prevailing symptom of knee osteoarthritis. Central sensitisation creates discordance between pain and joint pathology. We previously reported a Central Pain Mechanisms trait derived from eight discrete characteristics: Neuropathic-like pain, Fatigue, Cognitive-impact, Catastrophising, Anxiety, Sleep disturbance, Depression, and Pain distribution. We here validate and show that an 8-item questionnaire, Central Aspects of Pain in the Knee (CAP-Knee) is associated both with sensory- and affective- components of knee pain severity. METHODS: Participants with knee pain were recruited from the Investigating Musculoskeletal Health and Wellbeing study in the East Midlands, UK. CAP-Knee items were refined following cognitive interviews. Psychometric properties were assessed in 250 participants using Rasch-, and factor-analysis, and Cronbach's alpha. Intra-class correlation coefficients tested repeatability. Associations between CAP-Knee and McGill Pain questionnaire pain severity scores were assessed using linear regression. RESULTS: CAP-Knee targeted the knee pain sample well. Cognitive interviews indicated that participants interpreted CAP-Knee items in diverse ways, which aligned to their intended meanings. Fit to the Rasch model was optimised by rescoring each item, producing a summated score from 0 to 16. Internal consistency was acceptable (Cronbach's alpha = 0.74) and test-retest reliability was excellent (ICC2,1 = 0.91). Each CAP-Knee item contributed uniquely to one discrete 'Central Mechanisms trait' factor. High CAP-Knee scores associated with worse overall knee pain intensity, and with each of sensory- and affective- McGill Pain Questionnaire scores. CONCLUSION: CAP-Knee is a simple and valid self-report questionnaire, which measures a single 'Central Mechanisms' trait, and may help identify and target centrally-acting treatments aiming to reduce the burden of knee pain.

The virtual CF clinic: Implications for sputum microbiology.

The COVID19 pandemic has shifted the paradigm of how outpatient clinics are delivered within CF care, resulting in a significant reduction of patient visits to CF centres. One consequence of this has been a reduction in the number of sputa/cough swabs that patients submit for routine analysis. This report examines why it is important to maintain optimal sputum microbiology and explores (i). the microbiological efficiency of postal submission of sputum specimens from the community and (ii) the regulatory conditions that must be met through postal submission of respiratory specimens. Virtual clinics have now been established within CF care and it is incumbent on each speciality within the CF MDT to explore ways to nurture and support their individual contribution to the success of the virtual clinic. Within microbiology, adopting innovative approaches to sputum collection in the community and transportation via postal services will allow for continued microbiological vigilance thereby supporting patient safety.

A simple preservation method for the storage of Aspergillus fumigatus and Scedosporium apiospermum filamentous fungi isolated from the sputum of patients with cystic fibrosis (CF).

A novel method is described for the laboratory storage of the filamentous fungi, Aspergillus fumigatus and Scedosporium apiospermum. These fungi were isolated directly from the sputum of patients with cystic fibrosis (CF) on previously described Medium B+ fungal selective agar. Medium B+ plates containing heavy growths of filamentous fungi were air dried to completeness and the resulting dehydrated agar containing fungi were hermetically sealed within A4 plastic lamination sheets using a domestic paper laminator. Fungi were successfully recovered and recultured post lamination. This method is simple, inexpensive, versatile and widely adaptable and requires minimum preparation/handling/processing, thereby encouraging the routine archiving of fungal isolates. Laminated fungal sheets may be catalogued and stored safely and securely in fireproof lockable filing cabinets in laboratories, thereby saving valuable bench- or freezer space.