Conscious sedation: is this provision equitable? Analysis of sedation services provided within primary dental care in England, 2012-2014.

Aim: Patients receiving primary dental care may occasionally require conscious sedation as an adjunct to care. It is one of a range of options to support anxious patients or those undergoing difficult procedures. The aim of this study was to examine patterns of conscious sedation within primary dental care in relation to patient demography, deprivation status, geography (local authority, region) and type of care (Band) within England to examine equity in distribution of service provision. Materials and Methods: Descriptive analysis of cross-sectional primary dental care data, obtained from national claims held by the National Health Service (NHS) Business Services Authority, on patients who had received one or more courses of care involving sedation. Results: Just under 137,000 episodes of care involving sedation are provided for over 120,000 patients per year, the majority of which are for adults. Four out of ten (41%) patients were children, with 6-12-year-olds forming the largest group; 6% were aged under six years. Eleven per cent of patients had more than one course of care involving sedation, with adults aged 25-34 years having the highest rate: 1.17 (s.d.: 0.887) in 2012/2013 and 1.16 (s.d.: 0.724) in 2013/2014. There was a clear social gradient, whereby the most deprived quintile had the highest volume of patients that had received sedation at least once in primary dental care in both years (31.5%). Whilst there was a clear social gradient amongst children and young adults who received sedation, the gradient flattened among middle-aged and was flat amongst older adults. The majority of courses of care involving sedation were associated with Band 2 claims for care (88.6% in 2012/2013; 88.8 in 2013/2014). Whilst one or more patients in all higher tier local authorities received care involving sedation, there were marked geographic inequalities. Discussion: Patients receive sedation in support of NHS primary dental care across the life course and social spectrum. Whilst the pattern of uptake of care parallels the social gradient in younger age groups overall, there are clear geographical inequalities in provision. As sedation is only one of a series of adjuncts to care which may be provided across different sectors of the health system, a wider systems analysis should be undertaken as the findings raise important issues about equitable access to appropriate care. Furthermore, there should be a greater emphasis on prevention to reduce the need for care. The implications for child oral health, access and quality are discussed

Generalisability of deep learning models in low-resource imaging settings: A fetal ultrasound study in 5 African countries

Most artificial intelligence (AI) research have concentrated in high-income countries, where imaging data, IT infrastructures and clinical expertise are plentiful. However, slower progress has been made in limited-resource environments where medical imaging is needed. For example, in Sub-Saharan Africa the rate of perinatal mortality is very high due to limited access to antenatal screening. In these countries, AI models could be implemented to help clinicians acquire fetal ultrasound planes for diagnosis of fetal abnormalities. So far, deep learning models have been proposed to identify standard fetal planes, but there is no evidence of their ability to generalise in centres with limited access to high-end ultrasound equipment and data. This work investigates different strategies to reduce the domain-shift effect for a fetal plane classification model trained on a high-resource clinical centre and transferred to a new low-resource centre. To that end, a classifier trained with 1,792 patients from Spain is first evaluated on a new centre in Denmark in optimal conditions with 1,008 patients and is later optimised to reach the same performance in five African centres (Egypt, Algeria, Uganda, Ghana and Malawi) with 25 patients each. The results show that a transfer learning approach can be a solution to integrate small-size African samples with existing large-scale databases in developed countries. In particular, the model can be re-aligned and optimised to boost the performance on African populations by increasing the recall to $0.92 \pm 0.04$ and at the same time maintaining a high precision across centres. This framework shows promise for building new AI models generalisable across clinical centres with limited data acquired in challenging and heterogeneous conditions and calls for further research to develop new solutions for usability of AI in countries with less resources

Alternative scenarios: harnessing mid-level providers and evidence-based practice in primary dental care in England through operational research

Background: In primary care dentistry, strategies to reconfigure the traditional boundaries of various dental professional groups by task sharing and role substitution have been encouraged in order to meet changing oral health needs. Aim: The aim of this research was to investigate the potential for skill mix use in primary dental care in England based on the undergraduate training experience in a primary care team training centre for dentists and mid-level dental providers. Methods: An operational research model and four alternative scenarios to test the potential for skill mix use in primary care in England were developed, informed by the model of care at a primary dental care training centre in the south of England, professional policy including scope of practice and contemporary evidence-based preventative practice. The model was developed in Excel and drew on published national timings and salary costs. The scenarios included the following: “No Skill Mix”, “Minimal Direct Access”, “More Prevention” and “Maximum Delegation”. The scenario outputs comprised clinical time, workforce numbers and salary costs required for state-funded primary dental care in England. Results: The operational research model suggested that 73% of clinical time in England’s state-funded primary dental care in 2011/12 was spent on tasks that may be delegated to dental care professionals (DCPs), and 45- to 54-year-old patients received the most clinical time overall. Using estimated National Health Service (NHS) clinical working patterns, the model suggested alternative NHS workforce numbers and salary costs to meet the dental demand based on each developed scenario. For scenario 1:“No Skill Mix”, the dentist-only scenario, 81% of the dentists currently registered in England would be required to participate. In scenario 2: “Minimal Direct Access”, where 70% of examinations were delegated and the primary care training centre delegation patterns for other treatments were practised, 40% of registered dentists and eight times the number of dental therapists currently registered would be required; this would save 38% of current salary costs cf. “No Skill Mix”. Scenario 3: “More Prevention”, that is, the current model with no direct access and increasing fluoride varnish from 13.1% to 50% and maintaining the same model of delegation as scenario 2 for other care, would require 57% of registered dentists and 4.7 times the number of dental therapists. It would achieve a 1% salary cost saving cf. “No Skill Mix”. Scenario 4 “Maximum Delegation” where all care within dental therapists’ jurisdiction is delegated at 100%, together with 50% of restorations and radiographs, suggested that only 30% of registered dentists would be required and 10 times the number of dental therapists registered; this scenario would achieve a 52% salary cost saving cf. “No Skill Mix”. Conclusion: Alternative scenarios based on wider expressed treatment need in national primary dental care in England, changing regulations on the scope of practice and increased evidence-based preventive practice suggest that the majority of care in primary dental practice may be delegated to dental therapists, and there is potential time and salary cost saving if the majority of diagnostic tasks and prevention are delegated. However, this would require an increase in trained DCPs, including role enhancement, as part of rebalancing the dental workforce

Dental Treatment in a State-Funded Primary Dental Care Facility: Contextual and Individual Predictors of Treatment Need?

OBJECTIVE:This study examined individual and contextual factors which predict the dental care received by patients in a state-funded primary dental care training facility in England. METHODS:Routine clinical and demographic data were extracted from a live dental patient management system in a state-funded facility using novel methods. The data, spanning a four-year period [2008-2012] were cleaned, validated, linked by means of postcode to deprivation status, and analysed to identify factors which predict dental treatment need. The predictive relationship between patients' individual characteristics (demography, smoking, payment status) and contextual experience (deprivation based on area of residence), with common dental treatments received was examined using unadjusted analysis and adjusted logistic regression. Additionally, multilevel modelling was used to establish the isolated influence of area of residence on treatments. RESULTS:Data on 6,351 dental patients extracted comprised of 147,417 treatment procedures delivered across 10,371 courses of care. Individual level factors associated with the treatments were age, sex, payment exemption and smoking status and deprivation associated with area of residence was a contextual predictor of treatment. More than 50% of children (<18 years) and older adults (≥65 years) received preventive care in the form of 'instruction and advice', compared with 46% of working age adults (18-64 years); p = 0.001. The odds of receiving treatment increased with each increasing year of age amongst adults (p = 0.001): 'partial dentures' (7%); 'scale and polish' (3.7%); 'tooth extraction' (3%; p = 0.001), and 'instruction and advice' (3%; p = 0.001). Smokers had a higher likelihood of receiving all treatments; and were notably over four times more likely to receive 'instruction and advice' than non-smokers (OR 4.124; 95% CI: 3.088-5.508; p = 0.01). A further new finding from the multilevel models was a significant difference in treatment related to area of residence; adults from the most deprived quintile were more likely to receive 'tooth extraction' when compared with least deprived, and less likely to receive preventive 'instruction and advice' (p = 0.01). CONCLUSION:This is the first study to model patient management data from a state-funded dental service and show that individual and contextual factors predict common treatments received. Implications of this research include the importance of making provision for our aging population and ensuring that preventative care is available to all. Further research is required to explain the interaction of organisational and system policies, practitioner and patient perspectives on care and, thus, inform effective commissioning and provision of dental services

The satisfactory growth and development at 2 years of age of the INTERGROWTH-21st Fetal Growth Standards cohort support its appropriateness for constructing international standards.

BACKGROUND: The World Health Organization recommends that human growth should be monitored with the use of international standards. However, in obstetric practice, we continue to monitor fetal growth using numerous local charts or equations that are based on different populations for each body structure. Consistent with World Health Organization recommendations, the INTERGROWTH-21st Project has produced the first set of international standards to date pregnancies; to monitor fetal growth, estimated fetal weight, Doppler measures, and brain structures; to measure uterine growth, maternal nutrition, newborn infant size, and body composition; and to assess the postnatal growth of preterm babies. All these standards are based on the same healthy pregnancy cohort. Recognizing the importance of demonstrating that, postnatally, this cohort still adhered to the World Health Organization prescriptive approach, we followed their growth and development to the key milestone of 2 years of age. OBJECTIVE: The purpose of this study was to determine whether the babies in the INTERGROWTH-21st Project maintained optimal growth and development in childhood. STUDY DESIGN: In the Infant Follow-up Study of the INTERGROWTH-21st Project, we evaluated postnatal growth, nutrition, morbidity, and motor development up to 2 years of age in the children who contributed data to the construction of the international fetal growth, newborn infant size and body composition at birth, and preterm postnatal growth standards. Clinical care, feeding practices, anthropometric measures, and assessment of morbidity were standardized across study sites and documented at 1 and 2 years of age. Weight, length, and head circumference age- and sex-specific z-scores and percentiles and motor development milestones were estimated with the use of the World Health Organization Child Growth Standards and World Health Organization milestone distributions, respectively. For the preterm infants, corrected age was used. Variance components analysis was used to estimate the percentage variability among individuals within a study site compared with that among study sites. RESULTS: There were 3711 eligible singleton live births; 3042 children (82%) were evaluated at 2 years of age. There were no substantive differences between the included group and the lost-to-follow up group. Infant mortality rate was 3 per 1000; neonatal mortality rate was 1.6 per 1000. At the 2-year visit, the children included in the INTERGROWTH-21st Fetal Growth Standards were at the 49th percentile for length, 50th percentile for head circumference, and 58th percentile for weight of the World Health Organization Child Growth Standards. Similar results were seen for the preterm subgroup that was included in the INTERGROWTH-21st Preterm Postnatal Growth Standards. The cohort overlapped between the 3rd and 97th percentiles of the World Health Organization motor development milestones. We estimated that the variance among study sites explains only 5.5% of the total variability in the length of the children between birth and 2 years of age, although the variance among individuals within a study site explains 42.9% (ie, 8 times the amount explained by the variation among sites). An increase of 8.9 cm in adult height over mean parental height is estimated to occur in the cohort from low-middle income countries, provided that children continue to have adequate health, environmental, and nutritional conditions. CONCLUSION: The cohort enrolled in the INTERGROWTH-21st standards remained healthy with adequate growth and motor development up to 2 years of age, which supports its appropriateness for the construction of international fetal and preterm postnatal growth standards

Identification and functional characterization of a novel monotreme-specific antibacterial protein expressed during lactation

Monotremes are the only oviparous mammals and exhibit a fascinating combination of reptilian and mammalian characters. They represent a component of synapsidal reproduction by laying shelled eggs which are incubated outside the mother’s body. This is accompanied by a prototherian lactation process, marking them as representatives of early mammals. The only extant monotremes are the platypus, and the short- and long- beaked echidnas, and their distributions are limited to Australia and New Guinea. Apart for a short weaning period, milk is the sole source of nutrition and protection for the hatchlings which are altricial and immunologically naive. The duration of lactation in these mammals is prolonged relative to the gestational length and period of incubation of eggs. Much of the development of monotreme young occurs in the non-sterile ex-utero environment. Therefore the role of milk in the growth, development and disease protection of the young is of significant interest. By sequencing the cDNA of cells harvested from monotreme milk, we have identified a novel monotreme- specific transcript, and the corresponding gene was designated as the EchAMP. The expression profile of this gene in various tissues revealed that it is highly expressed in milk cells. The peptides corresponding to the EchAMP protein have been identified in a sample of echidna milk In silico analysis indicated putative antimicrobial potential for the cognate protein of EchAMP. This was further confirmed by in vitro assays using a host of bacteria. Interestingly, EchAMP did not display any activity against a commensal gut floral species. These results support the hypothesis of enhancement of survival of the young by antimicrobial bioactives of mammary gland origin and thus emphasize the protective, non- nutritional role of milk in mammals.Swathi Bisana, Satish Kumar, Peggy Rismiller, Stewart C. Nicol, Christophe Lefèvre, Kevin R. Nicholas, Julie A. Shar

Identification of SNP and SSR Markers in Finger Millet Using Next Generation Sequencing Technologies

Finger millet is an important cereal crop in eastern Africa and southern India with excellent grain storage quality and unique ability to thrive in extreme environmental conditions. Since negligible attention has been paid to improving this crop to date, the current study used Next Generation Sequencing (NGS) technologies to develop both Simple Sequence Repeat (SSR) and Single Nucleotide Polymorphism (SNP) markers. Genomic DNA from cultivated finger millet genotypes KNE755 and KNE796 was sequenced using both Roche 454 and Illumina technologies. Non-organelle sequencing reads were assembled into 207 Mbp representing approximately 13% of the finger millet genome. We identified 10,327 SSRs and 23,285 non-homeologous SNPs and tested 101 of each for polymorphism across a diverse set of wild and cultivated finger millet germplasm. For the 49 polymorphic SSRs, the mean polymorphism information content (PIC) was 0.42, ranging from 0.16 to 0.77. We also validated 92 SNP markers, 80 of which were polymorphic with a mean PIC of 0.29 across 30 wild and 59 cultivated accessions. Seventy-six of the 80 SNPs were polymorphic across 30 wild germplasm with a mean PIC of 0.30 while only 22 of the SNP markers showed polymorphism among the 59 cultivated accessions with an average PIC value of 0.15. Genetic diversity analysis using the polymorphic SNP markers revealed two major clusters; one of wild and another of cultivated accessions. Detailed STRUCTURE analysis confirmed this grouping pattern and further revealed 2 sub-populations within wild E. coracana subsp. africana. Both STRUCTURE and genetic diversity analysis assisted with the correct identification of the new germplasm collections. These polymorphic SSR and SNP markers are a significant addition to the existing 82 published SSRs, especially with regard to the previously reported low polymorphism levels in finger millet. Our results also reveal an unexploited finger millet genetic resource that can be included in the regional breeding programs in order to efficiently optimize productivity