New and emerging drug treatments for severe asthma.

Asthma is a common chronic inflammatory condition of the airways affecting over 300 million people world-wide. In 5%-10% of cases, it is severe, with disproportionate healthcare resource utilization including costs associated with frequent exacerbations and the long-term health effects of systemic steroids. Characterization of inflammatory pathways in severe asthma has led to the development of targeted biological and small molecule therapies which aim to achieve disease control while minimizing corticosteroid-associated morbidity. Herein, we review currently licensed agents and those in development, and speculate how drug therapy for severe asthma might evolve and impact on clinical outcomes in the near future.

Elimination of biofilm and microbial contamination reservoirs in hospital washbasin U-bends by automated cleaning and disinfection with electrochemically activated solutions.

BACKGROUND: Washbasin U-bends are reservoirs of microbial contamination in healthcare environments. U-Bends are constantly full of water and harbour microbial biofilm. AIM: To develop an effective automated cleaning and disinfection system for U-bends using two solutions generated by electrochemical activation of brine including the disinfectant anolyte (predominantly hypochlorous acid) and catholyte (predominantly sodium hydroxide) with detergent properties. METHODS: Initially three washbasin U-bends were manually filled with catholyte followed by anolyte for 5min each once weekly for five weeks. A programmable system was then developed with one washbasin that automated this process. This U-bend had three cycles of 5min catholyte followed by 5min anolyte treatment per week for three months. Quantitative bacterial counts from treated and control U-bends were determined on blood agar (CBA), R2A, PAS, and PA agars following automated treatment and on CBA and R2A following manual treatment. FINDINGS: The average bacterial density from untreated U-bends throughout the study was >1×10(5) cfu/swab on all media with Pseudomonas aeruginosa accounting for ∼50% of counts. Manual U-bend electrochemically activated (ECA) solution treatment reduced counts significantly (<100cfu/swab) (P<0.01 for CBA; P<0.005 for R2A). Similarly, counts from the automated ECA-treatment U-bend were significantly reduced with average counts for 35 cycles on CBA, R2A, PAS, and PA of 2.1±4.5 (P<0.0001), 13.1±30.1 (P<0.05), 0.7±2.8 (P<0.001), and 0 (P<0.05) cfu/swab, respectively. P. aeruginosa was eliminated from all treated U-bends. CONCLUSION: Automated ECA treatment of washbasin U-bends consistently minimizes microbial contamination.

Died of wounds: a mortality review.

OBJECTIVES: Combat casualty care is a complex system involving multiple clinicians, medical interventions and casualty transfers. Improving the performance of this system requires examination of potential weaknesses. This study reviewed the cause and timing of death of casualties deemed to have died from their injuries after arriving at a medical treatment facility during the recent conflicts in Iraq and Afghanistan, in order to identify potential areas for improving outcomes. METHODS: This was a retrospective review of all casualties who reached medical treatment facilities alive, but subsequently died from injuries sustained during combat operations in Afghanistan and Iraq. It included all deaths from start to completion of combat operations. The UK military joint theatre trauma registry was used to identify cases, and further data were collected from clinical notes, postmortem records and coroner's reports. RESULTS: There were 71 combat-related fatalities who survived to a medical treatment facility; 17 (24%) in Iraq and 54 (76%) in Afghanistan. Thirty eight (54%) died within the first 24 h. Thirty-three (47%) casualties died from isolated head injuries, a further 13 (18%) had unsurvivable head injuries but not in isolation. Haemorrhage following severe lower limb trauma, often in conjunction with abdominal and pelvic injuries, was the cause of a further 15 (21%) deaths. CONCLUSIONS: Severe head injury was the most common cause of death. Irrespective of available medical treatment, none of this group had salvageable injuries. Future emphasis should be placed in preventative strategies to protect the head against battlefield trauma.

Overcoming the problem of residual microbial contamination in dental suction units left by conventional disinfection using novel single component suction handpieces in combination with automated flood disinfection.

OBJECTIVES: Decontaminating dental chair unit (DCU) suction systems in a convenient, safe and effective manner is problematic. This study aimed to identify and quantify the extent of the problems using 25 DCUs, methodically eliminate these problems and develop an efficient approach for reliable, effective, automated disinfection. METHODS: DCU suction system residual contamination by environmental and human-derived bacteria was evaluated by microbiological culture following standard aspiration disinfection with a quaternary ammonium disinfectant or alternatively, a novel flooding approach to disinfection. Disinfection of multicomponent suction handpieces, assembled and disassembled, was also studied. A prototype manual and a novel automated Suction Tube Cleaning System (STCS) were developed and tested, as were novel single component suction handpieces. RESULTS: Standard aspiration disinfection consistently failed to decontaminate DCU suction systems effectively. Semi-confluent bacterial growth (101-500 colony forming units (CFU) per culture plate) was recovered from up to 60% of suction filter housings and from up to 19% of high and 37% of low volume suction hoses. Manual and automated flood disinfection of DCU suction systems reduced this dramatically (ranges for filter cage and high and low volume hoses of 0-22, 0-16 and 0-14CFU/plate, respectively) (P<0.0001). Multicomponent suction handpieces could not be adequately disinfected without prior removal and disassembly. Novel single component handpieces, allowed their effective disinfection in situ using the STCS, which virtually eliminated contamination from the entire suction system. CONCLUSION: Flood disinfection of DCU suction systems and single component handpieces radically improves disinfection efficacy and considerably reduces potential cross-infection and cross-contamination risks. CLINICAL SIGNIFICANCE: DCU suction systems become heavily contaminated during use. Conventional disinfection does not adequately control this. Furthermore, multicomponent suction handpieces cannot be adequately disinfected without disassembly, which is costly in time, staff and resources. The automated STCS DCU suction disinfection system used with single component handpieces provides an effective solution.

Isomer-specific comparisons of the hydrolysis of synthetic pyrethroids and their fluorogenic analogues by esterases from the cotton bollworm Helicoverpa armigera.

The low aqueous solubility and chiral complexity of synthetic pyrethroids, together with large differences between isomers in their insecticidal potency, have hindered the development of meaningful assays of their metabolism and metabolic resistance to them. To overcome these problems, Shan and Hammock (2001) [7] therefore developed fluorogenic and more water-soluble analogues of all the individual isomers of the commonly used Type 2 pyrethroids, cypermethrin and fenvalerate. The analogues have now been used in several studies of esterase-based metabolism and metabolic resistance. Here we test the validity of these analogues by quantitatively comparing their hydrolysis by a battery of 22 heterologously expressed insect esterases with the hydrolysis of the corresponding pyrethroid isomers by these esterases in an HPLC assay recently developed by Teese et al. (2013) [14]. We find a strong, albeit not complete, correlation (r = 0.7) between rates for the two sets of substrates. The three most potent isomers tested were all relatively slowly degraded in both sets of data but three esterases previously associated with pyrethroid resistance in Helicoverpa armigera did not show higher activities for these isomers than did allelic enzymes derived from susceptible H. armigera. Given their amenability to continuous assays at low substrate concentrations in microplate format, and ready detection of product, we endorse the ongoing utility of the analogues in many metabolic studies of pyrethroids.

A qualitative study of the use of the four quadrant approach to assist ethical decision-making during deployment.

AIM: The aim of the study was to explore how useful clinicians deployed to the Field Hospital in Afghanistan found using the four quadrant approach (4QA) as a tool to aid ethical decision-making. In addition, the study aimed to determine whether the 4QA needed to be amended to make it more effective in assisting the ethical decision-making process for military health professionals on deployment. METHOD: A qualitative pilot study in two phases was undertaken between September 2012 and January 2013. In Phase I, senior deployed clinicians completed a pro forma of the 4QA on cases that potentially raised ethical issues. Thirteen pro formas were submitted on four cases; the Deployed Medical Director submitted a log of 14 cases that had involved using the 4QA. Phase II consisted of interviews with five senior clinicians who had recently returned from deployment in Afghanistan to discuss their experiences and perceptions of using the 4QA. RESULTS: Phase I identified a variation in the level of detail recorded and where that information was placed on the quadrant. Four themes were generated from Phase II. These included the characteristics of ethical decisions; the processes used to make ethical decisions; use, usefulness and limitations of the 4QA; and views about training in ethics. The findings suggested that amendments to the pro forma may improve its utility. CONCLUSIONS: The 4QA is a useful tool within an operational setting but amending its diagrammatic presentation could improve its effectiveness. Pre-deployment training should include practising using the quadrant as described in Clinical Guidelines for Operations. This is particularly important as the participants relied heavily on experience to help them make ethical decisions, and this experience may not be available in future operations outside Afghanistan.

The pattern of paediatric trauma on operations.

OBJECTIVES: Recent military campaigns in Iraq and Afghanistan have resulted in the treatment of children in British Medical facilities. In order to determine how care for children may develop in the future, it is necessary to understand the current situation. The aim of this article is to examine the pattern of paediatric trauma on recent operations in Iraq and Afghanistan. METHODS: Data was requested from the Joint Theatre Trauma Registry, held at the Royal Centre for Defence Medicine in Birmingham, on all trauma calls for patients aged under 16 between the dates 21/3/03 and 31/8/09. Data included age, gender, theatre of operation, injury mechanism and type, trauma scores and destination of the child. RESULTS: 176 children were identified with 16.5% from Iraq and 83.5% from Afghanistan. The overall survival rate was 88.6% with survival rates in Iraq of 89.7% and in Afghanistan of 88.4%. Males accounted for 66.5% of admissions and the commonest age group was age 6-8 years. In 59.1% of total admissions the mechanism of injury was related to explosives. This differed between theatres with explosive injury causing 27.6% of admissions in Iraq and 63.5% in Afghanistan. Injury Severity Scores (ISS) showed equal numbers of minor and severe injuries with fewer moderately injured patients. The median ISS of all data was nine. The median ISS from Iraq was 16 and the median ISS from Afghanistan was nine. CONCLUSIONS: The treatment of children in British medical facilities whilst deployed on operations is likely to continue. An assessment of the injury patterns of paediatric patients on current deployments allows development of training and an understanding of logistic requirements. Data collection will also need to be adapted to meet the needs of paediatric patients. These remain issues that are being addressed by the Defence Medical Services.

Control of bacterial contamination of washbasin taps and output water using Ecasol: a one-year study.

BACKGROUND: Contaminated washbasin taps and output water are an important source of bacteria that may cause nosocomial infection. A five-week pretreatment study of hot and cold water from 15 washbasin taps at Dublin Dental Hospital showed consistently heavy contamination by aerobic heterotrophic bacteria: mean bacterial counts of 482.5 [standard deviation (SD) 293] colony-forming units (cfu)/mL and 5022 (SD 4322) cfu/mL, respectively. AIM: To minimize microbial contamination of washbasin taps and output water in the long term using the electrochemically generated, pH-neutral disinfectant, Ecasol. METHODS: Initially, the 15,000-L water tank providing cold and hot water to washbasins, calorifiers and the distribution network were drained and sediment was removed. The system was shock-dosed with Ecasol 100 ppm to eradicate gross contamination and biofilms. Thereafter, tank water was automatically maintained at Ecasol 2.5 ppm prior to distribution. The microbiological quality of water from five sentinel washbasin taps was monitored weekly for 54 weeks using R2A agar. FINDINGS: The mean counts for hot, cold, mains and tank water during the 54-week study period were 1 (SD 4) cfu/mL, 2 (SD 4) cfu/mL, 205 (SD 160) cfu/mL and 0 cfu/mL, respectively. Swab samples of 33/40 taps, each tested on three separate occasions, yielded no growth on R2A agar, while five samples yielded <20 cfu/swab and two samples yielded >200 cfu/swab. No detrimental effects due to Ecasol were observed in the water network. CONCLUSION: Ecasol consistently minimized bacterial contamination of washbasin taps and output water in a dental hospital setting.

Antiviral activity of Ecasol against feline calicivirus, a surrogate of human norovirus.

Human norovirus (NoV) is a major cause of acute gastroenteritis in closed settings such as hospitals, hotels and cruise ships. The virus survives on inanimate surfaces for extended periods of time, and environmental contamination has been implicated in its transmission. The disinfection of contaminated areas is important in controlling the spread of NoV infections. Neutral solutions of electrochemically activated (ECA)-anolyte have been shown to be powerful disinfectants against a broad range of bacterial pathogens. The active chemical ingredient is hypochlorous acid (HOCl), which is registered as an approved food contact surface sanitizer in the United States by the Environmental Protection Agency, pursuant to 40 CFR 180.940. We evaluated the antiviral activity of Ecasol (an ECA-anolyte) against feline calicivirus (FCV), a surrogate of NoV. FCV dried on plastic surfaces was exposed to Ecasol for 1, 2, or 5min. After exposure to Ecasol, the virus titers were compared with untreated controls to determine the virus inactivation efficacy after different contact times. Ecasol was found to decrease the FCV titer by >5log(10) within 1min of contact, indicating its suitability for inactivation of NoV on surfaces.

Evaluation of vaporized hydrogen peroxide, Citrox and pH neutral Ecasol for decontamination of an enclosed area: a pilot study.

Hydrogen peroxide, Ecasol and Citrox aerosols were each tested for their ability to kill a range of nosocomial pathogens. Hydrogen peroxide had the broadest microbicidal activity but operational issues limit its use. Ecasol was effective against all micro-organisms, except Clostridium difficile, while Citrox aerosols were not effective against Gram-negative bacilli.

Critical decision-making and timelines in the emergency department.

The resuscitation of severely injured patients has evolved during the last decade. Patients are now surviving injuries that previously were thought to be unsurvivable. Systems have been put in place, that reflect the intensity of workload and severity of injury of patients presenting to deployed medical treatment facilities. This paper aims to describe some of the elements that may differ from routine practice in the resuscitation room, and in particular the role of timelines in the management of such patients.

The role of trauma scoring in developing trauma clinical governance in the Defence Medical Services.

This paper discusses mathematical models of expressing severity of injury and probability of survival following trauma and their use in establishing clinical governance of a trauma system. There are five sections: (i) Historical overview of scoring systems--anatomical, physiological and combined systems and the advantages and disadvantages of each. (ii) Definitions used in official statistics--definitions of 'killed in action' and other categories and the importance of casualty reporting rates and comparison across conflicts and nationalities. (iii) Current scoring systems and clinical governance--clinical governance of the trauma system in the Defence Medical Services (DMS) by using trauma scoring models to analyse injury and clinical patterns. (iv) Unexpected outcomes--unexpected outcomes focus clinical governance tools. Unexpected survivors signify good practice to be promulgated. Unexpected deaths pick up areas of weakness to be addressed. Seventy-five clinically validated unexpected survivors were identified over 2 years during contemporary combat operations. (v) Future developments--can the trauma scoring methods be improved? Trauma scoring systems use linear approaches and have significant weaknesses. Trauma and its treatment is a complex system. Nonlinear methods need to be investigated to determine whether these will produce a better approach to the analysis of the survival from major trauma.

British military experience of pre-hospital paediatric trauma in Afghanistan.

INTRODUCTION: Trauma is a leading cause of death in children. Life support courses have been developed to reduce the mortality and morbidity of children suffering trauma; differences in anatomy and physiology may produce different injury patterns to adults when children are exposed to trauma, challenging the care providers. METHODS: A retrospective analysis of all paediatric patients transported by the helicopter-borne MERT between 01 May 2006 and 31 December 2007 in Helmand Province, Afghanistan. RESULTS: 78 children were brought in over the study period by the MERT team representing 7.3% of MERT casualties and 2.2% of the total seen in the Emergency Department. Breakdown by demographics, triage category, mechanism of injury, and treatment is given. CONCLUSION: A significant number of paediatric patients are treated by the deployed pre-hospital team. All military pre-hospital care providers should gain training and experience in the care of the seriously injured child prior to deployment.

Lack of cytotoxicity by Trustwater Ecasol™ used to maintain good quality dental unit waterline output water in keratinocyte monolayer and reconstituted human oral epithelial tissue models.

UNLABELLED: We previously showed that residual treatment of dental chair unit (DCU) supply water using the electrochemically-activated solution Trustwater Ecasol™ (2.5 ppm) provided an effective long-term solution to the problem of dental unit waterline (DUWL) biofilm resulting in DUWL output water quality consistently superior to potable water. OBJECTIVES: To investigate the cytoxicity of Ecasol using cultured keratinocyte monolayers and reconstituted human oral epithelial (RHE) tissue and to extend the study of Ecasol's effectiveness in maintaining the microbiological quality of DUWL output water. METHODS: TR146 human keratinocyte monolayers and RHE tissues were exposed to Ecasol (2.5-100 ppm) for 1h periods after removal of growth medium and washing with phosphate-buffered saline (PBS). Experiments were repeated using Ecasol that had been exposed for 30 min to 1-2mg/mL bovine serum albumin (BSA), equivalent to protein concentrations in saliva. To quantitatively determine cytotoxic effects on monolayers following Ecasol exposure, the Alamar Blue proliferation assay (assesses cell viability) and the Trypan Blue exclusion assay (assesses plasma membrane integrity), were used. Cytotoxicity effects on RHE tissues were assessed by the Alamar Blue assay and by histopathology. RESULTS: Ecasol at >5.0 ppm resulted in significant (P<0.001) cytotoxicity to keratinocyte monolayers following a 1h exposure. These effects, however, were completely negated by BSA pretreatment of Ecasol. No cytotoxicity was observed in the more complex RHE tissue at any of the Ecasol concentrations tested. In a 60-week study of 10 DCUs, tested weekly, the average density of aerobic heterotrophic bacteria in Ecasol-treated (2.5 ppm) DCU supply water was <1cfu/mL and in DUWL output water was 6.5cfu/mL. CONCLUSIONS: Ecasol present as a residual disinfectant in DUWL output water is very unlikely to have adverse effects on human oral tissues at levels effective in maintaining DUWL output water quality at better than potable standard water quality.

Structural basis for oseltamivir resistance of influenza viruses.

Oseltamivir, one of the two anti-neuraminidase drugs, is currently the most widely used drug against influenza. Resistance to the drug has occurred infrequently among different viruses in response to drug treatment, including A H5N1 viruses, but most notably has emerged among recently circulating A H1N1 viruses and has spread throughout the population in the absence of drug use. Crystal structures of enzyme-drug complexes, together with enzymatic properties, of mutants of H5N1 neuraminidase have provided explanations for high level oseltamivir resistance due to the common H275Y mutation, with retention of zanamivir susceptibility, and intermediate level resistance due to the N295S mutation. Complementation of enhanced NA activity due to a D344N mutation by the H275Y mutation suggests an explanation for the recent emergence and predominance of oseltamivir-resistant influenza A H1N1 viruses.

A centralised, automated dental hospital water quality and biofilm management system using neutral Ecasol maintains dental unit waterline output at better than potable quality: a 2-year longitudinal study.

UNLABELLED: Most studies addressing biofilm formation in dental chair unit waterlines (DUWLs) have focused on a range of individual dental chair units (DCUs) and no studies on a centralised approach in a large number of DCUs have been reported to date. OBJECTIVES: To develop a centralised, automated water quality and biofilm management system serving the distribution network providing water to Dublin Dental Hospital's 103 DCUs, capable of maintaining DUWL supply and output water at better than potable quality standards in the long-term and requiring a minimum of human intervention. The potable water standard for the European Union does not specify an upper limit of aerobic heterotrophic bacteria, whereas a maximum of 100 cfu/mL is permitted in bottled water. METHODS: Mains water of varying quality was treated by specifically selected automated filtration units to provide DCUs with water of consistent chemical composition. This water was then automatically disinfected using an electrochemically activated solution Ecasol (Trustwater Group, Clonmel, Ireland) (2.5 ppm) prior to distribution to DCUs. Microbiological quality of both DUWL supply and output water was monitored weekly by culture on R2A agar for 10 sentinel DCUs for a 100-week period. DUWLs were tested for the presence of biofilm by electron microscopy. RESULTS: Chemical composition of processed mains water consistently bettered potable water standards. DUWL supply water and output water aerobic heterotrophic bacterial counts averaged <1 and 18.1 cfu/mL, respectively, from the 10 DCUs, compared to 88 cfu/mL for unprocessed mains water. This correlated with the absence of biofilm in DUWLs. No adverse effects due to Ecasol treatment of supply water were observed for DUWLs or DCU instruments. CONCLUSIONS: This centralised and automated water treatment and biofilm management system consistently maintains DUWL output water at better than potable quality simultaneously in a large number of DCUs over the long-term.

Biofilm problems in dental unit water systems and its practical control.

Dental chair units (DCUs) contain integrated systems that provide the instruments and services for a wide range of dental procedures. DCUs use water to cool and irrigate DCU-supplied instruments and tooth surfaces during dental treatment. Water is supplied to these instruments by a network of interconnected narrow-bore (2-3 mm) plastic tubes called dental unit waterlines (DUWLs). Many studies over the last 40 years demonstrated that DUWL output water is often contaminated with high densities of micro-organisms, predominantly Gram-negative aerobic heterotropic environmental bacteria, including Legionella and Pseudomonas species. Untreated DUWLs host biofilms that permit micro-organisms to multiply and disperse through the water network and which are aerosolized by DCU instrument use, thus exposing patients and staff to these micro-organisms, to fragments of biofilm and bacterial endotoxins. This review concentrates on how practical developments and innovations in specific areas can contribute to effective DUWL biofilm control. These include the use of effective DUWL treatment agents, improvements to DCU supply water quality, DCU design changes, development of automated DUWL treatment procedures that are effective at controlling biofilm in the long-term and require minimal human intervention, are safe for patients and staff, and which do not cause deterioration of DCU components following prolonged use.

Jhe in Gryllus assimilis: cloning, sequence-activity associations and phylogeny.

The 458 amino acid sequence of a mature JHE protein from the cricket Gryllus assimilis was identified after isolating the partial cDNA sequence encoding this protein from a fat body and midgut cDNA library. This hemimetabolan JHE sequence shows over 40% amino acid similarity to the known JHE sequences of several holometabolous insects. It also includes previously determined peptide sequences for G. assimilis JHE as well as two other motifs associated with JHE enzymes in holometabolous insects. The predicted molecular weight of the protein agrees with that of the JHE previously purified from G. assimilis. Partial genomic sequence encoding the Jhe contains two large (1330 and 2918bp) introns. No coding DNA sequence variation was observed over a 1293bp region between selected lines differing six to eight-fold in hemolymph JHE activity. However, a 19bp indel was found in one of the introns; the insertion was strongly associated with elevated hemolymph activity, both in the selected lines and in the F(2) progeny of crosses between them. Phylogenetic analyses localised the G. assimilis JHE to a clade containing dipteran and coleopteran JHEs, with lepidopteran JHEs occurring in a separate clade.

Hydrolysis of individual isomers of fluorogenic pyrethroid analogs by mutant carboxylesterases from Lucilia cuprina.

We previously showed that wild-type E3 carboxylesterase of Lucilia cuprina has high activity against Type 1 pyrethroids but much less for the bulkier, alpha-cyano containing Type 2 pyrethroids. Both Types have at least two optical centres and, at least for the Type 1 compounds, we found that wild-type E3 strongly prefers the less insecticidal configurations of the acyl group. However, substitutions to smaller residues at two sites in the acyl pocket of the enzyme substantially increased overall activity, particularly for the more insecticidal isomers. Here we extend these analyses to Type 2 pyrethroids by using fluorogenic analogs of all the diastereomers of cypermethrin and fenvalerate. Wild-type E3 hydrolysed some of these appreciably, but, again, not those corresponding to the most insecticidal isomers. Mutations in the leaving group pocket or oxyanion hole were again generally neutral or deleterious. However, the two sets of mutants in the acyl pocket again improved activity for the more insecticidal acyl group arrangements as well as for the more insecticidal configuration of the cyano moiety on the leaving group. The activities of the best mutant enzyme against the analogs of the most insecticidal isomers of cypermethrin and fenvalerate were more than ten and a hundred fold higher, respectively, than those of wild-type. The implications for resistance development are discussed.

The role of manufacturers in reducing biofilms in dental chair waterlines.

OBJECTIVES: This paper reviews how dental chair unit (DCU) manufacturers can contribute practically to resolving the problem of biofilm formation in dental unit waterlines (DUWs). STUDY SELECTION: The review concentrates on how novel developments and changes in a range of specific areas have, and might contribute to DUW biofilm control. These include (i) DCU engineering and design changes; (ii) improvements to DCU supply water quality; (iii) development of automated DUW treatment procedures that are effective at controlling biofilm in the long-term, safe for patients and dental staff, environmentally friendly and which do not exhibit adverse effects on DCU components after prolonged use. SOURCES: The majority of the material contained in this review is based on, or supported by the peer-reviewed literature. DATA: The current consensus from the literature reveals that the emphasis on DUW biofilm and its control has focused on describing the problem and its control using a range of periodic and residual DUW treatment agents. Unfortunately, until recently, DCU manufacturers have provided very little specific guidance in this regard. Indeed, ensuring that DCUs provide good quality output water has generally been regarded to be the responsibility of dental practitioners. Some recent studies have shown that novel DCUs with integral semi-automated or automated DUW cleaning systems can effectively control DUW biofilm in the long-term. However, there are other potential DCU engineering and design changes that DCU manufacturers could undertake to further improve DUW biofilm control. CONCLUSIONS: DCU manufacturers can significantly contribute to controlling the problem of DUW biofilm.