Innovations that Address Socioeconomic, Cultural, and Geographic Barriers to Preventive Oral Health Care

This report focuses on nine oral health innovations that integrate service delivery and workforce models in order to reduce or eliminate socioeconomic, geographic, and cultural barriers to care. Two additional reports in this series describe the remaining programs that provide care in non-dental settings and care to young children. Although the programs are diverse in their approaches as well as in the specific characteristics of the communities they serve, a common factor among them is the implementation of multiple strategies to increase the number of children from low-income families who access preventive care, and also to engage families and communities in investing in and prioritizing oral health. For low-income children and their families, the barriers that must be addressed to increase access to preventive oral health care are numerous. For example, even children covered by public insurance programs face a shortage of dentists that accept Medicaid and who specialize in pediatric dentistry.(Guay, 2004).The effects of poverty intersect with other barriers such as living in remote geographic areas and community-wide history of poor access to dental care in populations such as recent immigrants . Overcoming these barriers requires creative strategies that address transportation barriers; establish welcoming environments for oral health care; and are linguistically and culturally relevant. Each of these nine programs is based on such strategies, including:-Expanding the dental workforce through training new types of providers or adding new providers to their workforce to increase reach and community presence;-Implementing new strategies to increase the cost-effectiveness of care so that more oral health care services are available and accessible;-Providing training and technical assistance that increase opportunities for and competence in delivering oral health education and care to children;-Developing creative service delivery models that address transportation and cultural barriers as well as the fear and stigma associated with dental care that may arise in communities with historically poor access.The findings from the EAs of these programs are synthesized to highlight diverse and innovative strategies for overcoming barriers to access that have potential for rigorous evaluation that could emerge as best practices. If proven effective, these innovative program elements could then be disseminated and replicated to increase access for populations in need of preventive oral health care

Dental Professionals in Non-Dental Settings

This report focuses on nine oral health innovations seeking to increase access to preventive oral health care in nondental settings. Two additional reports in this series describe the remaining programs that provide care in dental settings and care to young children. The nine innovations described here integrate service delivery and workforce models in order to reduce or eliminate socioeconomic, geographic, and cultural barriers to care. Although the programs are diverse in their approaches as well as in the specific characteristics of the communities they serve, a common factor among them is the implementation of multiple strategies to increase the number of children from low-income families who access preventive care, and also to engage families and communities in investing in and prioritizing oral health. For low-income children and their families, the barriers that must be addressed to increase access to preventive oral health care are numerous. For example, even children covered by public insurance programs face a shortage of dentists that accept Medicaid and who specialize in pediatric dentistry. The effects of poverty intersect with other barriers such as living in remote geographic areas and having a community-wide history of poor access to dental care in populations such as recent immigrants. Overcoming these barriers requires creative strategies that address transportation barriers, establish welcoming environments for oral health care, and are linguistically and culturally relevant. Each of these nine programs is based on such strategies, including:-Expanding the dental workforce through training new types of providers or adding new providers to the workforce toincrease reach and community presence;-Implementing new strategies to increase the cost-effectiveness of care so that more oral health care services are available and accessible;-Providing training and technical assistance that increase opportunities for and competence in delivering oral health education and care to children;-Offering oral health care services in existing, familiar community venues such as schools, Head Start programs and senior centers;-Developing creative service delivery models that address transportation and cultural barriers as well as the fear and stigma associated with dental care that may arise in communities with historically poor access.The findings from the EAs of these programs are synthesized to highlight diverse and innovative strategies for overcoming barriers to access. These strategies have potential for rigorous evaluation and could emerge as best practices. If proven effective, these innovative program elements could then be disseminated and replicated to increase access for populations in need of preventive oral health care

Librarian Participation in Chart Rounds: Final Results of Two Surveys Measuring the Effectiveness of Librarians Working with Family Medicine Residents in a Clinical Setting

OBJECTIVE: To measure the impact of librarian participation at multi-disciplinary chart rounds at three central Massachusetts health centers affiliated with the University of Massachusetts Medical School Worcester Family Medicine residency program. BACKGROUND: Chart rounds, led by Department of Family Medicine and Community Health faculty preceptors, are held daily at each residency practice site. Family Medicine residents present cases based on patients seen that day. New guidelines for chart rounds were developed by residency leadership in 2007 through a grant from AAMC Regional Medicine-Public Health Education Centers. Based on these guidelines, librarians, behavioral health specialists and pharmacists are invited to participate. METHODS: In early 2010, residents (n=32) were invited to complete an IRB-approved Likert-scale (1=strongly disagree to 5=strongly agree) survey asking them to evaluate their satisfaction with chart rounds. The survey included three questions focusing on the effectiveness of library participation. Based on the findings of this first survey, initiatives were undertaken to increase librarian impact. These initiatives specifically reached out to PGY1 residents who had scored library participation lower that PGY2 and PGY3 residents. In 2012, a second survey was distributed (n=24) using the same questions. This poster will present results from both surveys specific to librarian involvement. Both sets of results were analyzed using SPSS 17.0. RESULTS: Results were tabulated for the 2010 survey and the 2012 survey, and were then cross-tabulated to identify changes. The three librarian-related questions posed were -- librarians during rounds: A) changed their [residents] short-term and/or long-term treatment plans; B) helped them locate useful information more efficiently than in the past; and C) helped increase their understanding of identifying and utilizing best-evidence information resources in their practice. Although the sample size was small, following the implementation of the initiatives aimed specifically at first year residents, statistically-significant increases were seen in 2012 survey responses in the first two questions. DISCUSSION: Librarians from the Lamar Soutter Library at UMass Medical School have been participating in chart rounds for many years; at some centers, even before the formal guidelines were developed in 2007. Through these two surveys, the librarian cohort now have quantitative data demonstrating their effectiveness in these clinical settings

Being there, there and there: using research methodology to evaluate the effectiveness of librarians embedded in chart rounds within a multi-center Family Medicine residency program

OBJECTIVE: To measure the impact, analyze results and suggest enhancements of librarian participation at multi-disciplinary chart rounds at three central Massachusetts health centers affiliated with the U Mass Medical School Worcester Family Medicine residency program. METHODS: Chart rounds, led by Department of Family Medicine and Community Health faculty preceptors, are held daily at each residency practice site. Family Medicine residents present cases based on patients seen that day. New guidelines for chart rounds were developed by residency leadership in 2007. Based on these guidelines, librarians, behavioral health specialists and pharmacists are invited to participate. In early 2010, residents (n=32) were invited to complete an IRB-approved survey asking them to evaluate their satisfaction with chart rounds. The survey consisted of ten questions, three of which focused on the effectiveness of library participation. Other questions sought feedback on the value of chart rounds as an educational tool as well as questions about the participation of other specialists. This paper reports results from this survey specific to librarian involvement, analyzed using SPSS 17.0. RESULTS: Survey results were crosstabulated by practice site and by post-graduate year (PGY) across all sites. Of greatest significance were satisfaction reports by PGY. Residents in the third year of training were more likely than those in earlier years to report that information provided by librarians during rounds: A) changed their short-term and/or long-term treatment plans (chi2=13.61, p=.009); B) helped them locate useful information more efficiently than in the past (chi2=10.99, p=.027); and C) helped increase their knowledge about a medical or community health issue (chi2=16.15, p=.003). CONCLUSIONS: After reviewing these results and discussing possible interpretations by site and by PGY, several changes have been made or are proposed for this and the 2011-2012 academic year, e.g. participation of librarians in PGY1 practice settings such as inpatient morning report. These changes will address areas where lower satisfaction scores were reported. A specific follow-up survey targeting librarian participation is planned for 2012

Pregnancy outcomes for women with rare autoimmune diseases

Objective: To examine pregnancy outcomes and pregnancy-related health service utilisation among women with rare autoimmune diseases. Methods: This population-based cohort study of an Australian obstetric population (New South Wales 2001-2011) used birth records linked to hospital records for identification of rare autoimmune diseases including systemic vasculitis, vasculitis limited to skin, systemic sclerosis, dermatopolymyositis and other systemic involvement of connective tissue. We excluded births to women with systemic lupus erythematosus or rheumatoid arthritis and births >6 months before the first documented diagnosis of the rare autoimmune disease. Modified Poisson regression was used to compare study outcomes between women with autoimmune diseases and the general obstetric population. Results: There were 991,701 births including 409 (0.04%) births to 293 women with rare autoimmune diseases. Of the 409 pregnancies, 202 (49%) delivered by cesarean delivery and 72 (18%) were preterm; these rates were significantly higher than those in the general obstetric population (28% and 7% respectively). Compared to the general population, women with autoimmune diseases had higher rates of hypertensive disorders, antepartum hemorrhage and severe maternal morbidity, and required longer hospitalization at delivery and more hospital admissions and tertiary obstetric care. Compared to other infants, those whose mothers had a rare autoimmune disease were at increased risk of admission to neonatal intensive care unit, severe neonatal morbidity and perinatal death. Conclusions: Women with rare autoimmune diseases were at increased risk of having both maternal complications and adverse neonatal outcomes; their pregnancies should be closely monitored.NHMRC; Rolf Edgar Lake Postdoctoral Fellowship, University of Sydne

Egg-derived anti-SARS-CoV-2 Immunoglobulin Y (IgY) with broad variant activity as intranasal prophylaxis against COVID-19

UNLABELLED: COVID-19 emergency use authorizations and approvals for vaccines were achieved in record time. However, there remains a need to develop additional safe, effective, easy-to-produce, and inexpensive prevention to reduce the risk of acquiring SARS-CoV-2 infection. This need is due to difficulties in vaccine manufacturing and distribution, vaccine hesitancy, and, critically, the increased prevalence of SARS-CoV-2 variants with greater contagiousness or reduced sensitivity to immunity. Antibodies from eggs of hens (immunoglobulin Y; IgY) that were administered the receptor-binding domain (RBD) of the SARS-CoV-2 spike protein were developed for use as nasal drops to capture the virus on the nasal mucosa. Although initially raised against the 2019 novel coronavirus index strain (2019-nCoV), these anti-SARS-CoV-2 RBD IgY surprisingly had indistinguishable enzyme-linked immunosorbent assay binding against variants of concern that have emerged, including Alpha (B.1.1.7), Beta (B.1.351), Delta (B.1.617.2), and Omicron (B.1.1.529). This is different from sera of immunized or convalescent patients. Culture neutralization titers against available Alpha, Beta, and Delta were also indistinguishable from the index SARS-CoV-2 strain. Efforts to develop these IgY for clinical use demonstrated that the intranasal anti-SARS-CoV-2 RBD IgY preparation showed no binding (cross-reactivity) to a variety of human tissues and had an excellent safety profile in rats following 28-day intranasal delivery of the formulated IgY. A double-blind, randomized, placebo-controlled phase 1 study evaluating single-ascending and multiple doses of anti-SARS-CoV-2 RBD IgY administered intranasally for 14 days in 48 healthy adults also demonstrated an excellent safety and tolerability profile, and no evidence of systemic absorption. As these antiviral IgY have broad selectivity against many variants of concern, are fast to produce, and are a low-cost product, their use as prophylaxis to reduce SARS-CoV-2 viral transmission warrants further evaluation. CLINICAL TRIAL REGISTRATION: https://www.clinicaltrials.gov/ct2/show/NCT04567810, identifier NCT04567810

Exploring the role of pain as an early predictor of category 2 pressure ulcers: a prospective cohort study

Objective To explore pressure area related pain as a predictor of category ≥2 pressure ulcer (PU) development. Design Multicentre prospective cohort study. Setting UK hospital and community settings. Participants inclusion Consenting acutely ill patients aged ≥18 years, defined as high risk (Braden bedfast/chairfast AND completely immobile/very limited mobility; pressure area related pain or; category 1 PU). Exclusion Patients too unwell, unable to report pain, 2 or more category ≥2 PUs. Follow-up Twice weekly for 30 days. Primary and secondary outcome measures Development and time to development of one or more category ≥2 PUs. Results Of 3819 screened, 1266 were eligible, 634 patients were recruited, 32 lost to follow-up, providing a 602 analysis population. 152 (25.2%) developed one or more category ≥2 PUs. 464 (77.1%) patients reported pressure area related pain on a healthy, altered or category 1 skin site of whom 130 (28.0%) developed a category ≥2 PU compared with 22 (15.9%) of those without pain. Full stepwise variable selection was used throughout the analyses. (1) Multivariable logistic regression model to assess 9 a priori factors: presence of category 1 PU (OR=3.25, 95% CI (2.17 to 4.86), p<0.0001), alterations to intact skin (OR=1.98, 95% CI (1.30 to 3.00), p=0.0014), pressure area related pain (OR=1.56, 95% CI (0.93 to 2.63), p=0.0931). (2) Multivariable logistic regression model to account for overdispersion: presence of category 1 PU (OR=3.20, 95% CI (2.11 to 4.85), p<0.0001), alterations to intact skin (OR=1.90, 95% CI (1.24 to 2.91), p=0.0032), pressure area related pain (OR=1.85, 95% CI (1.07 to 3.20), p=0.0271), pre-existing category 2 PU (OR=2.09, 95% CI (1.35 to 3.23), p=0.0009), presence of chronic wound (OR=1.66, 95% CI (1.06 to 2.62), p=0.0277), Braden activity (p=0.0476). (3) Accelerated failure time model: presence of category 1 PU (AF=2.32, 95% CI (1.73 to 3.12), p<0.0001), pressure area related pain (AF=2.28, 95% CI (1.59 to 3.27), p<0.0001). (4) 2-level random-intercept logistic regression model: skin status which comprised 2 levels (versus healthy skin); alterations to intact skin (OR=4.65, 95% CI (3.01 to 7.18), p<0.0001), presence of category 1 PU (OR=17.30, 95% CI (11.09 to 27.00), p<0.0001) and pressure area related pain (OR=2.25, 95% CI (1.53 to 3.29), p<0.0001). Conclusions This is the first study to assess pain as a predictor of category ≥2 PU development. In all 4 models, pain emerged as a risk factor associated with an increased probability of category ≥2 PU development

Dietary intake and peripheral arterial disease incidence in middle-aged adults: the Atherosclerosis Risk in Communities (ARIC) Study

Background: Peripheral arterial disease (PAD) is a costly source of morbidity and mortality among older persons in the United States. Dietary intake plays a role in the development of atherosclerotic cardiovascular disease; however, few studies have examined the relation of food intake or dietary patterns with PAD

Combined Beta-Agonists and Corticosteroids Do Not Inhibit Extracellular Matrix Protein Production In Vitro

Background. Persistent asthma is characterized by airway remodeling. Whereas we have previously shown that neither β2-agonists nor corticosteroids inhibit extracellular matrix (ECM) protein release from airway smooth muscle (ASM) cells, the effect of their combination is unknown and this forms the rationale for the present study. Methods. ASM cells from people with and without asthma were stimulated with TGFβ1 (1 ng/ml) with or without budesonide (10−8 M) and formoterol (10−10 and 10−8 M), and fibronectin expression and IL-6 release were measured by ELISA. Bronchial rings from nonasthmatic individuals were incubated with TGFβ1 (1 ng/ml) with or without the drugs, and fibronectin expression was measured using immunohistochemistry. Results. Budesonide stimulated fibronectin deposition, in the presence or absence of TGFβ1, and this was partially reversed by formoterol (10−8 M) in both asthmatic and nonasthmatic cells. Budesonide and formoterol in combination failed to inhibit TGFβ-induced fibronectin in either cell type. A similar pattern of expression of fibronectin was seen in bronchial rings. TGFβ1-induced IL-6 release was inhibited by the combination of drugs. Conclusion. Current combination asthma therapies are unable to prevent or reverse remodeling events regulated by ASM cells

Therapeutic Periocular Vaccination with a Subunit Vaccine Induces Higher Levels of Herpes Simplex Virus-Specific Tear Secretory Immunoglobulin A Than Systemic Vaccination and Provides Protection against Recurrent Spontaneous Ocular Shedding of Virus in Latently Infected Rabbits

AbstractRabbits latently infected with herpes simplex virus type 1 (HSV-1) were vaccinated either periocularly or systemically with a subunit vaccine (gB2 + gD2) plus adjuvant or adjuvant alone. Tear films were collected daily to measure recurrent infectious HSV-1 shedding. After systemic vaccination, the latently infected rabbits were not protected against recurrent ocular viral shedding (HSV-1-positive tear film cultures/total cultures) compared with either the systemic or periocular adjuvant controls (systemic vaccination = 49 of 972, 5.0%; systemic control = 46 of 972, 4.7%; periocular control = 43 of 930, 4.6%;P> 0.8). In contrast, latently infected rabbits vaccinated periocularly with the same vaccine had significantly reduced recurrent shedding (20 of 1026, 2.0%) compared with controls (P< 0.001) or systemic vaccination (P= 0.0002). Thus, recurrent HSV-1 shedding was significantly reduced by therapeutic local periocular subunit vaccination but not by therapeutic systemic subunit vaccination. Neutralizing antibody titers in the serum of systemically and ocularly vaccinated rabbits was similar. In contrast, HSV-specific tear secretory immunoglobulin A was significantly higher in the ocularly vaccinated group (P< 0.01). These results strongly suggest that in the rabbit, and presumably in humans, the local ocular (mucosal) immune response is much more important than the systemic immune response for therapeutic protection against recurrent ocular HSV-1. Thus development of a therapeutic vaccine against recurrent ocular HSV-1 should be directed at enhancing the local ocular (mucosal) immune response