Do Post-injury Prophylactic Antibiotics Reduce Infection for Isolated Midface Fractures: A Cohort Study.

PURPOSE: Fractures of the midface are a core component to the practice of contemporary oral and maxillofacial trainees and surgeons. As such, in an era where antibiotic resistance is increasing it is important to investigate if antibiotics are required after midface fractures to prevent infections before follow-up in an outpatient setting. The purpose of this study is to determine whether postinjury prophylactic preoperative antibiotics reduce rates of infection after midface fracture. METHODS: A retrospective multicenter cohort study was conducted in Queensland, Australia. Patients who presented to Royal Brisbane Hospital and Townsville Hospital with isolated midface fractures between January 2017 and January 2019 were included. Clinical and demographic data of patients who received postinjury prophylactic antibiotics were compared to those who did not using the χ2 test. Logistic regression was used to determine factors associated with increased odds of postinjury prophylactic antibiotic prescription. RESULTS: In total, 1,353 patients with midfacial fractures over the 2-year period were included. In addition, 724 (53.5%) patients received postinjury antibiotics and 629 (46.5%) patients did not. The overall rate of infection was very low: 1 patient who received postinjury prophylactic antibiotics (0.1%) developed infection compared to 2 patients (0.3%) who did not receive postinjury prophylactic antibiotics, and this difference was not significant (χ2 = 0.49; P = .48). Male sex (odds ratio 1.4; 95% confidence interval, 1.1 to 1.7; P = .02) and tobacco use (odds ratio 1.4; 95% confidence interval, 1.1 to 1.7; P = .008) were associated with an increased odds of postinjury prophylactic antibiotic prescription in the univariate analyses, but were no longer significant once site, age, and fracture type were adjusted for in the multivariate model. CONCLUSIONS: The rate of infection after midface fracture was low and there was no significant difference in infection rates for patients who received postinjury prophylactic antibiotics compared to those who did not. Use of postinjury prophylactic preoperative antibiotics for midfacial fractures should be reconsidered.

PRG2 and AQPEP are misexpressed in fetal membranes in placenta previa and percreta†.

The obstetrical conditions placenta accreta spectrum (PAS) and placenta previa are a significant source of pregnancy-associated morbidity and mortality, yet the specific molecular and cellular underpinnings of these conditions are not known. In this study, we identified misregulated gene expression patterns in tissues from placenta previa and percreta (the most extreme form of PAS) compared with control cases. By comparing this gene set with existing placental single-cell and bulk RNA-Seq datasets, we show that the upregulated genes predominantly mark extravillous trophoblasts. We performed immunofluorescence on several candidate molecules and found that PRG2 and AQPEP protein levels are upregulated in both the fetal membranes and the placental disk in both conditions. While this increased AQPEP expression remains restricted to trophoblasts, PRG2 is mislocalized and is found throughout the fetal membranes. Using a larger patient cohort with a diverse set of gestationally aged-matched controls, we validated PRG2 as a marker for both previa and PAS and AQPEP as a marker for only previa in the fetal membranes. Our findings suggest that the extraembryonic tissues surrounding the conceptus, including both the fetal membranes and the placental disk, harbor a signature of previa and PAS that is characteristic of EVTs and that may reflect increased trophoblast invasiveness.

Utilisation of a brief tobacco smoking cessation intervention tool in public dental services.

ISSUE ADDRESSED: Dental practitioners have an important opportunity to promote smoking cessation. This study aimed to determine how many smokers attended West Moreton Oral Health Service (WMOHS), completion rates for the standardised Smoking Cessation Pathway, and smoking cessation practices, confidence levels and attitudes of dental practitioners in WMOHS. METHODS: A mixed-methods approach collected clinical and demographic data from a retrospective audit of WMOHS reports from 1 August 2017 to 31 July 2019 and a cross-sectional survey of WMOHS dental practitioners. Logistic regression models determined factors associated with smoking status and delivery of the Pathway. RESULTS: Over 24 months, 14,919 courses of care (COC) were completed. Twenty-five percent of patients identified as current smokers. The Pathway was delivered in 54% (n = 1999) of smokers' COC, which was significantly associated with patient age (aOR 0.99 [CI 0.99, 0.99; P < .001]), Indigenous status (aOR 1.47 [CI 1.05, 2.08; P =.02]) and high socio-economic status (aOR 1.41 [CI 1.06, 1.88; P =.02]). Practitioners identified lack of time and training as the main barriers to Pathway completion. CONCLUSIONS: High-risk populations for tobacco use are frequently utilising WMOHS, however not all patients who smoke received smoking cessation support. Understanding and addressing barriers to smoking cessation promotion in oral health care settings may improve general and oral health outcomes for patients. SO WHAT?: Targeted training and utilisation of team-based models of care may better enhance delivery and uptake of the Pathway within the public dental setting, thus improving services to a high-need population and reducing smoking rates in priority populations.

Clinical supervisors' reflections on their role, training needs and overall experience as dental educators.

OBJECTIVES: The aims of this study were to understand the views of clinical supervisors overseeing final year dental students and investigate their perceived role, level of support and training available, and ways to improve the supervisory experience. METHODS: Clinical supervisors who oversaw fifth-year dental students in 2019 were invited to participate in an online survey. Respondents who indicated their willingness to participate were contacted for a semi-structured interview which were analysed using Constant Comparative Methodology. RESULTS: Sixteen supervisors completed the survey, with a response rate of 73%. Respondents reported low levels of formal training in clinical supervision (38%) and most (75%) felt further training would be beneficial for their role. While nearly all (94%) reported they had developed as a dental professional through supervision, most (63%) were not positively encouraged to develop a career as a supervisor, with tensions between health service delivery and academia identified as a key challenge. The driving motivator to supervise was a desire to teach (62.5%). Seven (44%) participants completed the semi-structured interview. Participants' perception of their role varied depending on career stage and clinic location. Lack of recognition and defined career pathways were the biggest challenges reported by participants. CONCLUSION: Retention and morale of supervisors may increase with better-defined career pathways and meaningful professional development opportunities. There is a need to develop tailored training programs for supervisors that enable them to teach critical thinking and clinical judgement while ensuring patient safety.

Aplastic anaemia in pregnancy - a single centre, North American series.

Aplastic anaemia (AA) is infrequently observed in pregnancy. We describe 19 pregnancies in 9 women at a tertiary care centre over a period of 30 years. Spontaneous resolution of AA did not occur postpartum in the five pregnancies where AA was first diagnosed in pregnancy. In the remaining pregnancies, although haematological indices declined and transfusion support was needed in 35% of pregnancies, relapses were not observed. There were no deaths, but complications occurred in 79% of pregnancies. Preterm delivery and postpartum haemorrhage were observed in 21% and 26% of pregnancies, respectively.

Systemic comorbidities are associated with medication-related osteonecrosis of the jaws: Case-control study.

OBJECTIVES: Medication-related osteonecrosis of the jaws (MRONJ) is a serious condition developed in up to 15% of patients who take antiresorptive medications. Its underlying pathogenesis remains unclear. The association between systemic comorbidities and MRONJ was investigated. SUBJECTS AND METHODS: A case-control study was conducted in Brisbane, Australia. Hospital records were used to identify 68 cases of MRONJ between January 2003 and March 2017. Each case was individually matched to three controls (204 in total) according to sex, age, primary disease, and type and duration of antiresorptive therapy. Data on patient demographic, social and clinical characteristics were collected. Systemic comorbidities and medications were quantified as a comorbidity-polypharmacy score (CPS). Associations were investigated using conditional logistic regression. RESULTS: The CPS calculated for patients who developed MRONJ (mean ± SD = 20.2 ± 5.1) was significantly higher than for controls (12.9 ± 4.6). Multivariable analysis determined a significant relationship between CPS and the presence of MRONJ (OR = 1.5; 95% CI = 1.3, 1.8, p < 0.001). CONCLUSIONS: Patients with multiple systemic comorbidities and high levels of polypharmacy were more likely to develop MRONJ. The CPS is a simple and effective tool to quantify the risk of MRONJ attributed to a patient's systemic condition and should be considered in conjunction with the patient's oral health to assess the overall risk of MRONJ.

Both non-surgical dental treatment and extractions increase the risk of medication-related osteonecrosis of the jaw: case-control study.

OBJECTIVES: Medication-related osteonecrosis of the jaws (MRONJ) is a serious condition whose risk factors remain unclear. The aim of this study is to investigate the role of oral health and of dental treatment in the development of MRONJ. MATERIALS AND METHODS: A case-control study was conducted in Brisbane, Australia. Hospital records were used to identify incident cases of MRONJ between January 2010 and March 2017. Cases were individually matched to up to 3 controls according to age, sex, primary disease, and type of antiresorptive therapy. Demographic data, medical histories and public dental records were collected. Associations between oral health, dental treatment, and MRONJ were investigated using conditional logistic regression. RESULTS: Overall, 44 cases were identified and matched to 115 controls (total sample = 159). Only one-third of patients received a dental examination in the year prior to commencing antiresorptive therapy (27% of cases and 34% of controls). After adjusting for potentially confounding variables, non-surgical dental treatment (OR = 6.3; 95% CI = 2.1, 19.1; p < 0.001) and dental extractions (OR = 8.0; 95% CI = 3.0, 21.0, p < 0.001) were significantly associated with development of MRONJ. CONCLUSIONS: Current levels of preventative dental care are insufficient to eliminate the need for dental treatment and extractions during antiresorptive therapy, and the consequent increase in risk of MRONJ. CLINICAL RELEVANCE: Optimizing the health of the oral cavity and ongoing preventative dental care must be a priority for patients prior to the initiation of antiresorptive medications.

Reducing the hospital burden of heparin-induced thrombocytopenia: impact of an avoid-heparin program.

Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction occurring in up to 5% of patients exposed to unfractionated heparin (UFH). We examined the impact of a hospital-wide strategy for avoiding heparin on the incidence of HIT, HIT with thrombosis (HITT), and HIT-related costs. The Avoid-Heparin Initiative, implemented at a tertiary care hospital in Toronto, Ontario, Canada, since 2006, involved replacing UFH with low-molecular-weight heparin (LMWH) for prophylactic and therapeutic indications. Consecutive cases with suspected HIT from 2003 through 2012 were reviewed. Rates of suspected HIT, adjudicated HIT, and HITT, along with HIT-related expenditures were compared in the pre-intervention (2003-2005) and the avoid-heparin (2007-2012) phases. The annual rate of suspected HIT decreased 42%, from 85.5 per 10 000 admissions in the pre-intervention phase to 49.0 per 10 000 admissions in the avoid-heparin phase ( ITALIC! P< .001). The annual rate of patients with a positive HIT assay decreased 63% from 16.5 to 6.1 per 10 000 admissions ( ITALIC! P< .001), adjudicated HIT decreased 79% from 10.7 to 2.2 per 10 000 admissions ( ITALIC! P< .001), and HITT decreased 91% from 4.6 to 0.4 per 10 000 admissions ( ITALIC! P< .001). Hospital HIT-related expenditures decreased by $266 938 per year in the avoid-heparin phase. To the best of our knowledge, this is the first study demonstrating the success and feasibility of a hospital-wide HIT prevention strategy.

Optimal dose and duration of amoxicillin-plus-metronidazole as an adjunct to non-surgical periodontal therapy: A systematic review and meta-analysis of randomized, placebo-controlled trials.

AIM: This systematic review aimed to determine the optimum dose and duration of amoxicillin-plus-metronidazole prescribed as an adjunct to non-surgical treatment of periodontitis. METHODS: Electronic searching identified 376 records, of which 18 were eligible blinded, randomized placebo-controlled trials. The primary outcomes assessed were periodontal pocket depth and clinical attachment level at 3 months, and secondary outcomes were adverse events and compliance. Subgroup analyses were conducted to compare lower and higher doses, and 7- and 14-day courses. RESULTS: Meta-analysis showed a small beneficial effect of adjunctive amoxicillin-plus-metronidazole for each primary outcome, but there was <0.1 mm variation with antibiotic dose or duration. Risk differences for adverse events in the higher dose and longer duration groups were minimally greater (0.04 and 0.05, respectively), and there was one report of anaphylaxis; 1.3% of patients were not fully compliant. CONCLUSION: There was no clinically meaningful difference between different doses or duration of amoxicillin-plus-metronidazole at 3 months post-treatment. Without compelling evidence to suggest that any one regimen performed superiorly, principles of responsible antibiotic use generally recommend the highest dose for the shortest duration of time to reduce the risk of antibiotic resistance. Therefore, a 7-day regimen of 500/500 mg or 500/400 mg of amoxicillin and metronidazole would be most appropriate.

Increasing Use of Intensive Care Unit for Odontogenic Infection Over One Decade: Incidence and Predictors.

PURPOSE: To determine whether intensive care unit (ICU) admissions for odontogenic infections have increased during the past decade and whether certain clinical features are associated with a greater rate of ICU admission. MATERIALS AND METHODS: The data from patients undergoing surgery for odontogenic infections at the Royal Brisbane and Women's Hospital in the 24 month from January 2003 to December 2004 were compared with those from patients treated from January 2013 to December 2014. A χ2 analysis was used to compare the demographic, admission, and clinical patient data in each cohort. A multiple logistic regression model was used to determine which clinical features were associated with greater rates of ICU admission. RESULTS: The rate of ICU admission increased significantly from 7 to 24% during the decade (χ2 = 12.74; P = .000), although the clinical presentation of patients admitted to the ICU was similar in both cohorts. The mean number of days spent in the ICU increased significantly from 1.7 ± 0.5 to 3.24 ± 2.5 days (t = -3.63; P = .001), and the overall length of stay increased from 1.7 ± 0.5 to 3.5 ± 4.1 days (t = 2.99; P = .004). The use of preoperative computed tomography (CT) increased significantly from 42.9 to 93.3% (χ2 = 13.25; P = .000). The most significant predictors of ICU admission were lower third molar involvement (P = .026), dysphagia (P = .020), and C-reactive protein (CRP) levels exceeding 150 mg/L (P = .039). CONCLUSIONS: The use of the ICU in the management of odontogenic infection has increased significantly at the Royal Brisbane and Women's Hospital over 1 decade. The demographic data and clinical presentation of the patients admitted to the ICU did not change significantly. However, the length of ICU stay and the total length of stay have both increased. A significant increase in CT usage for odontogenic infections also occurred. Third molar infections, dysphagia, and elevated CRP might be relevant clinical predictors of a more complicated course of care requiring ICU admission. More judicious use of CT scanning, combined with prompt surgical consultation and intervention, might reduce the rate of ICU admissions for odontogenic infections.

Insufficient Evidence to Compare the Efficacy of Treatments for Medication-Related Osteonecrosis of the Jaws.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Effectiveness of treatments for medication-related osteonecrosis of the jaw: A systematic review and meta-analysis. El-Rabbany M, Sgro A, Lam DK, Shah PS, Azarpazhooh A. J Am Dent Assoc 2017; 148(8):584-94. SOURCE OF FUNDING: Nonprofit: Canadian Association of Oral and Maxillofacial Surgeons and the Alpha Omega Foundation of Canada TYPE OF STUDY/DESIGN: Systematic review with meta-analysis of data.

Perspectives of Low-Income African-American Women Non-adherent to Mammography Screening: the Importance of Information, Behavioral Skills, and Motivation.

Although information-motivation-behavioral skills (IMB) adherence model has been successfully used in many illness domains and with other populations, it has not been used in understanding mammogram screening among low-income African-American women. Thus, a qualitative examination is needed to theoretically and collectively understand the barriers to screening, given the disparities in breast cancer mortality rates among this population. Semi-structured telephone interviews were conducted with 28 low-income uninsured and underinsured African-American women, 40 to 70 years, who had not had a mammogram within the past 12 months. Women were recruited from 21 hair and nail salons and Laundromats within the five North St. Louis city zip codes with the highest breast cancer mortality rates. Transcripts were analyzed and rooted in grounded theory. This study found that the individual relevancy of information, behavioral skills-both procedural and systematic-and motivation seemed to affect screening adherence; (the results suggest the importance of reordering traditional IMB components into the following sequential order: information, behavioral skills, and motivation (IBM)). Future analyses should include a larger, more representative sample of unscreened women, in which quantitative statistical analyses could be conducted to assist in strengthening assertions about information, behavioral skills, and motivational aspects and their relationship to screening.

A Novel Evidence-Based Periodontal Prognosis Model.

OBJECTIVE: Patients with periodontal disease and the dental professionals responsible for their care want to know which teeth are expected to respond favorably to periodontal treatment and which teeth are likely to be lost in the short and long term. A number of different periodontal prognosis systems have been previously proposed but do not consider important patient-level factors, such as smoking and diabetic control, in the calculation of the expected outcome and often use subjective measures that introduce potential inaccuracies. The aim of this report is to translate the best available evidence on periodontal prognosis into a clinical model to facilitate decision-making and improve patient outcomes. METHODS: Criteria for an ideal prognostic system were proposed and used to assess the previously reported models. With an emphasis on the inclusion of patient-level modifiers (PLMs) and the exclusive use of objective parameters, a new evidence-based model was developed. RESULTS: This report proposes a new tooth-level prognosis model that uses 9 evidence-based quantifiable parameters to provide a prognosis of secure, doubtful, poor, or irrational to treat. Six tooth-level risk predictors (bone loss:age, pocket depth, furcation involvement, infrabony defects, anatomical factors, and mobility) and 3 PLMs (smoking, diabetes, and bleeding on probing) are used to determine the expected course of disease with specific reference to the suitability of the tooth for future dental treatment. CONCLUSIONS: PLMs must be considered when determining the prognosis of a tooth with periodontal disease. The model proposed in this report is based on the best available evidence for factors affecting tooth survival and has been designed to be as simple and objective as possible to facilitate its adoption in clinical practice. It will be retrospectively and prospectively validated to determine its ability to accurately predict the course of disease.

Stakeholders' preferences for the design and delivery of virtual care services: A systematic review of discrete choice experiments.

This systematic review aimed to synthesise evidence from discrete choice experiments (DCEs) eliciting preferences for virtual models of care, as well as to assess the quality of those DCEs and compare the relative preferences for different stakeholder groups. Articles were included if published between January 2010 and December 2022. Data were synthesised narratively, and attributes were assessed for frequency, significance, and relative importance using a semi-quantitative approach. Overall, 21 studies were included encompassing a wide range of virtual care modalities, with the most common setting being virtual consultations for outpatient management of chronic conditions. A total of 135 attributes were identified and thematically classified into six categories: service delivery, service quality, technical aspects, monetary aspects, health provider characteristics and health consumer characteristics. Attributes related to service delivery were most frequently reported but less highly ranked. Service costs were consistently significant across all studies where they appeared, indicating their importance to the respondents. All studies examining health providers' preferences reported either system performance or professional endorsement attributes to be the most important. Substantial heterogeneity in attribute selection and preference outcomes were observed across studies reporting on health consumers' preferences, suggesting that the consideration of local context is important in the design and delivery of person-centred virtual care services. In general, the experimental design and analysis methods of included studies were clearly reported and justified. An improvement was observed in the quality of DCE design and analysis in recent years, particularly in the attribute development process. Given the continued growth in the use of DCEs within healthcare settings, further research is needed to develop a standardised approach for quantitatively synthesising DCE findings. There is also a need for further research on preferences for virtual care in post-pandemic contexts, where emerging evidence suggests that preferences may differ to those observed in pre-pandemic times.

Ancestry dynamics and trait selection in a designer cat breed.

The Bengal cat breed was developed from intercrosses between the Asian leopard cat, Prionailurus bengalensis, and the domestic cat, Felis catus, with a last common ancestor approximately 6 million years ago. Predicted to derive ∼94% of their genome from domestic cats, regions of the leopard cat genome are thought to account for the unique pelage traits and ornate color patterns of the Bengal breed, which are similar to those of ocelots and jaguars. We explore ancestry distribution and selection signatures in the Bengal breed by using reduced representation and whole-genome sequencing from 947 cats. The mean proportion of leopard cat DNA in the Bengal breed is 3.48%, lower than predicted from breed history, and is broadly distributed, covering 93% of the Bengal genome. Overall, leopard cat introgressions do not show strong signatures of selection across the Bengal breed. However, two popular color traits in Bengal cats, charcoal and pheomelanin intensity, are explained by selection of leopard cat genes whose expression is reduced in a domestic cat background, consistent with genetic incompatibility resulting from hybridization. We characterize several selective sweeps in the Bengal genome that harbor candidate genes for pelage and color pattern and that are associated with domestic, rather than leopard, cat haplotypes. We identify the molecular and phenotypic basis of one selective sweep as reduced expression of the Fgfr2 gene, which underlies glitter, a trait desired by breeders that affects hair texture and light reflectivity.

Reduced ribosomal protein gene dosage and p53 activation in low-risk myelodysplastic syndrome.

Reduced gene dosage of ribosomal protein subunits has been implicated in 5q- myelodysplastic syndrome and Diamond Blackfan anemia, but the cellular and pathophysiologic defects associated with these conditions are enigmatic. Using conditional inactivation of the ribosomal protein S6 gene in laboratory mice, we found that reduced ribosomal protein gene dosage recapitulates cardinal features of the 5q- syndrome, including macrocytic anemia, erythroid hypoplasia, and megakaryocytic dysplasia with thrombocytosis, and that p53 plays a critical role in manifestation of these phenotypes. The blood cell abnormalities are accompanied by a reduction in the number of HSCs, a specific defect in late erythrocyte development, and suggest a disease-specific ontogenetic pathway for megakaryocyte development. Further studies of highly purified HSCs from healthy patients and from those with myelodysplastic syndrome link reduced expression of ribosomal protein genes to decreased RBC maturation and suggest an underlying and common pathophysiologic pathway for additional subtypes of myelodysplastic syndrome.

Disposable and reusable instruments in dental health practice: A comparison of cost factors in a public provider organization in Queensland, Australia.

OBJECTIVES: Choosing between reusable instruments (RIs) and disposable instruments (DIs) for dental care provision requires a careful consideration of costs and their contributing factors, alongside other choice criteria. This study aimed to assess the current use of instruments in the West Moreton Oral Health Service (WMOHS) in Queensland, Australia, with a broader goal of informing future practice in this and comparable organizations. METHODS: A cost model was developed reflecting costs arising from procurement, reprocessing and disposal, depending on the RI and DI composition of instrumentation. The current practice in WMOHS was compared to modular (RI-only and DI-only) strategies by considering four standard instrument sets (examination, simple extraction, surgical extraction, restoration) and the annual use of instruments in the organization at large. The use of resources (water, electricity) and emissions (waste) were quantified for each strategy. The robustness of findings was explored across a range of scenarios that involved varying instrument prices, lifespans, factors impacting on the cost of reprocessing (labour, water, energy), the cost of waste disposal and couriering. RESULTS: At the organization level, the current mix of instruments (A$1.28 m per year) was 4% more costly than the lower cost, RI-only alternative (A$1.23 m). However, with lower DI prices or higher labour costs current practice would become the lowest cost option. Results for specific instrument sets varied by service type. DI-only offered the lowest cost option for oral examinations (A$6.29), and the current practice of mixed instrumentation for simple extractions (A$16.56). RI-only sets were less costly in more resource intensive procedures such as surgical extractions (A$40.19) and restorations (A$43.83). In terms of environmental impacts, the use of instruments based on current practice required 37% of water and energy use of an RI-only alternative and generated 36% waste of the DI-only alternative. CONCLUSIONS: Reusable instruments are generally less costly than DIs, but for specific instrument sets the outcome depends on the type of procedure. In some circumstances, mixed instrumentation can provide the lowest cost alternative. While the WMOHS instrument mix used in current practice does not minimize cost for the provider, it may be justified in light of operational risks, logistics and uncertainty regarding cost factors.

Economic evaluation of an integrated virtual care programme for people with chronic illness who are frequent users of health services in Australia.

OBJECTIVE: The MeCare programme is a tailored virtual care initiative targeted at frequent users of health services who have at least one chronic condition including cardiovascular disease, chronic respiratory disease, diabetes or chronic kidney disease. The programme aims to prevent unnecessary hospitalisations by helping patients to self-manage, improve their health literacy and engage in positive health behaviours. This study investigates the impact of the MeCare programme on healthcare resource use, costs and patient-reported outcomes. METHODS AND ANALYSIS: A retrospective pre-post study design was adopted. Data on emergency department presentations, hospital admissions, outpatient appointments and their associated costs were obtained from administrative databases. Probabilistic sensitivity analysis using Monte Carlo simulation was used to model changes in resource use and costs prior to, and following, participant enrolment on the MeCare programme. Generalised linear models were used to investigate the observed changes in patient-reported outcomes. RESULTS: The MeCare programme cost $A624 per participant month to deliver. Median monthly rates of ED presentations, hospital admissions and average length of stay post-MeCare reduced by 76%, 50% and 12%, respectively. This translated to a median net cost saving of $A982 per participant month (IQR: -1936; -152). A significant, positive trend in patient experience based on responses to the Patient Assessment of Care for Chronic Conditions Questionnaire was observed over the duration of programme enrolment. DISCUSSION: The MeCare programme is likely to result in substantial cost savings to the health system, while maintaining or improving patient-reported outcomes. Further research in multisite randomised studies is needed to confirm the generalisability of these results.

Genetic architecture and evolution of color variation in American black bears.

Color variation is a frequent evolutionary substrate for camouflage in small mammals, but the underlying genetics and evolutionary forces that drive color variation in natural populations of large mammals are mostly unexplained. The American black bear, Ursus americanus (U. americanus), exhibits a range of colors including the cinnamon morph, which has a similar color to the brown bear, U. arctos, and is found at high frequency in the American southwest. Reflectance and chemical melanin measurements showed little distinction between U. arctos and cinnamon U. americanus individuals. We used a genome-wide association for hair color as a quantitative trait in 151 U. americanus individuals and identified a single major locus (p < 10-13). Additional genomic and functional studies identified a missense alteration (R153C) in Tyrosinase-related protein 1 (TYRP1) that likely affects binding of the zinc cofactor, impairs protein localization, and results in decreased pigment production. Population genetic analyses and demographic modeling indicated that the R153C variant arose 9.36 kya in a southwestern population where it likely provided a selective advantage, spreading both northwards and eastwards by gene flow. A different TYRP1 allele, R114C, contributes to the characteristic brown color of U. arctos but is not fixed across the range.

SMS reminders to improve outpatient attendance for public dental services: A retrospective study.

Patients who miss scheduled appointments reduce clinical productivity and delay access to care for other patients. Reminders have improved attendance for healthcare appointments previously, but it is not known if short message service (SMS) implementation reduces incidence of patients unable to attend (UTA) or who fail to attend (FTA) appointments in the public dental service. This paper studied the effectiveness of SMS reminders in increasing appointment attendance at outpatient public dental services in Queensland. Data were sourced from the adult service and the children and adolescent oral health service (CAOHS) at West Moreton Hospital and Health Service, a public dental service in Queensland. A total of 63,238 appointments pre-implementation of SMS reminders and 55,028 appointments post-implementation over a period of 2 years were analysed for rates of attendance, UTA and FTA. Characteristics of UTA and FTA appointments were analysed to identify factors that hindered improvement after implementation of reminders. For the CAOHS, the attendance rate decreased 4% (95% CI: 2%, 6%) following SMS implementation. The UTA rate also increased by 20% (95% CI: 15%, 25%). Following SMS implementation in the adult service, the attendance rate increased from 73.5 (95% CI: 72.6, 74.4) to 77.7 (95% CI: 76.6-78.8) per 100 appointments. The FTA rate post-implementation was 1.08 (95% CI: 1.00, 1.16) times that from pre-intervention, and the UTA rate decreased from 21.7 (95% CI: 21.2, 22.2) to 17.1 (95% CI: 16.6, 17.7) per 100 appointments. The SMS reminders had a mixed effect on the attendance, UTA and FTA rates for the CAOHS and adult services. Reminders reduced the rates of UTA for the CAOHS service and increased the rate of attendance for the adult service. There was an increase in the FTA rate for both services.