Setting the context for a complex dental intervention of role substitution in care homes: Initial process evaluation findings.

OBJECTIVES: SENIOR (uSing rolE-substitutioN In care homes to improve oRal health) is a randomised controlled trial designed to determine whether role substitution could improve oral health for this population. A parallel process evaluation was undertaken to understand context. This paper reports on the first phase of the process evaluation. BACKGROUND: The oral health and quality-of-life of older adults residing in care homes is poorer than those in the community. Oral health care provision is often unavailable and a concern and challenge for managers. The use of Dental Therapists and Dental Nurses rather than dentists could potentially meet these needs. MATERIALS AND METHODS: Semi-structured interviews were conducted with 21 key stakeholders who either worked or had experience of dependent care settings. Questions were theoretically informed by the: Promoting Action on Research Implementation in Health Services (PAHRIS) framework. The focus was on contextual factors that could influence adoption in practice and the pathway-to-impact. Interviews were fully transcribed and analysed thematically. RESULTS: Three themes (receptive context, culture, and leadership) and 11 codes were generated. Data show the complexity of the setting and contextual factors that may work as barriers and facilitators to intervention delivery. Managers are aware of the issues regarding oral health and seek to provide best care, but face many challenges including staff turnover, time pressures, competing needs, access to services, and financial constraints. Dental professionals recognise the need for improvement and view role substitution as a viable alternative to current practice. CONCLUSION: Although role substitution could potentially meet the needs of this population, an in-depth understanding of contextual factors appeared important in understanding intervention delivery and implementation.

Light-Responsive Molecular Release from Cubosomes Using Swell-Squeeze Lattice Control.

Stimuli-responsive materials are crucial to advance controlled delivery systems for drugs and catalysts. Lyotropic liquid crystals (LLCs) have well-defined internal structures suitable to entrap small molecules and can be broken up into low-viscosity dispersions, aiding their application as delivery systems. In this work, we demonstrate the first example of light-responsive cubic LLC dispersions, or cubosomes, using photoswitchable amphiphiles to enable external control over the LLC structure and subsequent on-demand release of entrapped guest molecules. Azobenzene photosurfactants (AzoPS), containing a neutral tetraethylene glycol head group and azobenzene-alkyl tail, are combined (from 10-30 wt %) into monoolein-water systems to create LLC phases. Homogenization of the bulk LLC forms dispersions of particles, ∼200 nm in diameter with internal bicontinuous primitive cubic phases, as seen using small-angle X-ray scattering and cryo-transmission electron microscopy. Notably, increasing the AzoPS concentration leads to swelling of the cubic lattice, offering a method to tune the internal nanoscale structure. Upon UV irradiation, AzoPS within the cubosomes isomerizes within seconds, which in turn leads to squeezing of the cubic lattice and a decrease in the lattice parameter. This squeeze mechanism was successfully harnessed to enable phototriggerable release of trapped Nile Red guest molecules from the cubosome structure in minutes. The ability to control the internal structure of LLC dispersions using light, and the dramatic effect this has on the retention of entrapped molecules, suggests that these systems may have huge potential for the next-generation of nanodelivery.

Development and Performance of a Highly Sensitive Model Formulation Based on Torasemide to Enhance Hot-Melt Extrusion Process Understanding and Process Development.

The aim of this work was to investigate the use of torasemide as a highly sensitive indicator substance and to develop a formulation thereof for establishing quantitative relationships between hot-melt extrusion process conditions and critical quality attributes (CQAs). Using solid-state characterization techniques and a 10 mm lab-scale co-rotating twin-screw extruder, we studied torasemide in a Soluplus® (SOL)-polyethylene glycol 1500 (PEG 1500) matrix, and developed and characterized a formulation which was used as a process indicator to study thermal- and hydrolysis-induced degradation, as well as residual crystallinity. We found that torasemide first dissolved into the matrix and then degraded. Based on this mechanism, extrudates with measurable levels of degradation and residual crystallinity were produced, depending strongly on the main barrel and die temperature and residence time applied. In addition, we found that 10% w/w PEG 1500 as plasticizer resulted in the widest operating space with the widest range of measurable residual crystallinity and degradant levels. Torasemide as an indicator substance behaves like a challenging-to-process API, only with higher sensitivity and more pronounced effects, e.g., degradation and residual crystallinity. Application of a model formulation containing torasemide will enhance the understanding of the dynamic environment inside an extruder and elucidate the cumulative thermal and hydrolysis effects of the extrusion process. The use of such a formulation will also facilitate rational process development and scaling by establishing clear links between process conditions and CQAs.

Charge-Mediated Localization of Conjugated Polythiophenes in Zwitterionic Model Cell Membranes.

The selective engineering of conjugated polyelectrolyte (CPE)-phospholipid interfaces is poised to play a key role in the design of advanced biomedical and biotechnological devices. Herein, we report a strategic study to investigate the relationship between the charge of the CPE side group and their association with zwitterionic phospholipid bilayers. The interaction of dipalmitoylphosphatidylcholine (DPPC) phospholipid vesicles with a series of poly(thiophene)s bearing zwitterionic, cationic, or anionic terminal groups (P3Zwit, P3TMAHT and P3Anionic, respectively) has been probed. Although all CPEs showed an affinity for the zwitterionic vesicles, the calculated partition coefficients determined using photoluminescence spectroscopy suggested preferential incorporation within the lipid bilayer in the order P3Zwit > P3Anionic ≫ P3TMAHT. The polarity probe Prodan was used to further qualify the position of the CPE inside the vesicle bilayers via Förster resonance energy transfer (FRET) studies. The varying proximity of the CPEs to Prodan was reflected in the Stern-Volmer quenching constants and decreased in the order P3Anionic > P3TMAHT ≫ P3Zwit. Dynamic light scattering measurements showed an increase in the hydrodynamic diameter of the DPPC vesicles upon addition of each poly(thiophene), but to the greatest extent for P3Anionic. Small-angle neutron scattering studies also revealed that P3Anionic specifically increased the thickness of the headgroup region of the phospholipid bilayer. Epifluorescence and atomic force microscopy imaging showed that P3TMAHT formed amorphous agglomerates on the vesicle surface, P3Zwit was buried throughout the bilayer, and P3Anionic formed a shell of protruding chains around the surface, which promoted vesicle fusion. The global data indicate three distinctive modes of interaction for the poly(thiophene)s within DPPC vesicles, whereby the nature of the association is ultimately controlled by the pendant charge group on each CPE chain. Our results suggest that charge-mediated self-assembly may provide a simple and effective route to design luminescent CPE probes capable of specific localization within phospholipid membranes.

Sequential detection of multiple phase transitions in model biological membranes using a red-emitting conjugated polyelectrolyte.

The anionic conjugated polyelectrolyte, poly[3-(6-sulfothioatehexyl)thiophene] (P3Anionic), functions as a highly sensitive probe of membrane order, uniquely capable of sequentially detecting the three key phase transitions occurring within model phospholipid bilayers. The observed sensitivity is the result of charge-mediated, selective localisation of P3Anionic within the head-groups of the phospholipid bilayer.

Anticipated effects of burosumab treatment on long-term clinical sequelae in XLH: expert perspectives.

X-linked hypophosphatemia (XLH) is a rare, progressive, genetic disease with multisystem impact that typically begins to manifest in early childhood. Two treatment options exist: oral phosphate in combination with active vitamin D ("conventional therapy") and a fully human monoclonal anti-FGF23 antibody, burosumab. The clinical benefit of conventional therapy in adults is limited, and poor tolerance and complications are common. Burosumab was first approved as a treatment for XLH in 2018 and its disease-modifying benefits in clinical trials in children suggest burosumab treatment could also alter the disease course in adults. Without long-term clinical data on multiple XLH-related sequelae available, the results of an elicitation exercise are reported, in which eight global experts in XLH posited how long-term treatment with burosumab is anticipated to impact the life course of clinical sequelae in adults with XLH. Based on their clinical experiences, the available evidence and their disease understanding, the experts agreed that some long-term benefits of using burosumab are likely in adults with XLH even if they have a misaligned skeleton from childhood. Burosumab treatment is anticipated to reduce the incidence of fractures and halt the progression of clinical sequelae associated with conventional therapy. While the trajectories for established dental abscesses are not expected to improve with burosumab treatment, dental abscess development may be prevented. Starting treatment with burosumab in childhood to increase the likelihood of an aligned skeleton and continuation into and throughout adulthood to maintain euphosphatemia may optimize patient outcomes, although future real-world investigation is required to support this hypothesis.

Cationic polythiophene-surfactant self-assembly complexes: phase transitions, optical response, and sensing.

The absorption and photoluminescence spectra of the cationic conjugated polyelectrolyte poly[3-(6-trimethylammoniumhexyl)thiophene] (P3TMAHT) were observed to be dramatically altered in the presence of anionic surfactants due to self-assembly through ionic complex formation. Small-angle neutron scattering (SANS), UV/vis, and photoluminescence spectroscopy were used to probe the relationship between the supramolecular complex organization and the photophysical response of P3TMAHT in the presence of industrially important anionic surfactants. Subtle differences in the surfactant mole fraction and chemical structure (e.g., chain length, headgroup charge density, perfluorination) result in marked variations in the range and type of complexes formed, which can be directly correlated to a unique colorimetric and fluorimetric fingerprint. Our results show that P3TMAHT has potential as an optical sensor for anionic surfactants capable of selectively identifying distinct structural subgroups through dual mode detection.

uSing rolE-substitutioN In care homes to improve ORal health (SENIOR): a study protocol.

BACKGROUND: Dental service provision in the care home sector is poor, with little emphasis on prevention. Emerging evidence suggests that the use of Dental Care Professionals (dental therapists and dental nurses) as an alternative to dentists has the potential to improve preventive advice, the provision of care and access to services within care homes. However, robust empirical evidence from definitive trials on how to successfully implement and sustain these interventions within care homes is currently lacking. The aim of the study is to determine whether Dental Care Professionals could reduce plaque levels of dentate older adults (65 + years) residing in care homes. METHODS: This protocol describes a two-arm cluster-randomised controlled trial that will be undertaken in care homes across Wales, Northern Ireland and England. In the intervention arm, the dental therapists will visit the care homes every 6 months to assess and then treat eligible residents, where necessary. All treatment will be conducted within their Scope of Practice. Dental nurses will visit the care homes every month for the first 3 months and then three-monthly afterwards to promulgate advice to improve the day-to-day prevention offered to residents by carers. The control arm will be 'treatment as usual'. Eligible care homes (n = 40) will be randomised based on a 1:1 ratio (20 intervention and 20 control), with an average of seven residents recruited in each home resulting in an estimated sample of 280. Assessments will be undertaken at baseline, 6 months and 12 months and will include a dental examination and quality of life questionnaires. Care home staff will collect weekly information on the residents' oral health (e.g. episodes of pain and unscheduled care). The primary outcome will be a binary classification of the mean reduction in Silness-Löe Plaque Index at 6 months. A parallel process evaluation will be undertaken to explore the intervention's acceptability and how it could be embedded in standard practice (described in a separate paper), whilst a cost-effectiveness analysis will examine the potential long-term costs and benefits of the intervention. DISCUSSION: This trial will provide evidence on how to successfully implement and sustain a Dental Care Professional-led intervention within care homes to promote access and prevention. TRIAL REGISTRATION: ISRCTN16332897 . Registered on 3 December 2021.

Structure and "surfactochromic" properties of conjugated polyelectrolyte (CPE): surfactant complexes between a cationic polythiophene and SDS in water.

We report on the phase transitions, solution structure, and consequent effect on the photophysical properties of poly[3-(6-trimethylammoniumhexyl)thiophene] bromide (P3TMAHT) in aqueous sodium dodecylsulfate (SDS). Polythiophene was mixed with SDS or deuterated SDS to form P3TMAHT(SDS)(x) complex (x = the molar ratio of surfactant over monomer units) in D(2)O and studied by small-angle neutron and X-ray scattering (SANS/SAXS) and optical spectroscopy. At room temperature, P3TMAHT forms charged aggregates with interparticle order. The addition of SDS eliminates the interparticle order and leads to rod-like (x = 1/5) or sheet-like polymer-SDS aggregates (x = 1/2 to 1) containing rod-like (x = 1/5 to 1/2) or sheet-like (x = 1/2 to 1) polymer associations. Partial precipitation occurs at the charge compensation point (x = 1). Ellipsoidal particles without interparticle order, reminiscent of SDS micelles modified by separated polymer chains, occur for x = 2 to 5. Free SDS micelles dominate for x = 20. Structural transitions lead to a concomitant variation in the solution color from red (P3TMAHT) to violet (x = 1/5 to 1) to yellow (x > 2). The photoluminescence fingerprint changes progressively from a broad featureless band (x = 0) through the band narrowing and appearance of vibronic structure (x = 1/5 to 1) to the return to a blue-shifted broad emission band (x = 5). The polymer stiffness reaches a maximum for x = 1, which leads to minimization of the Stokes shift (0.08 eV). This work gives fundamental information upon how surfactant complexation can influence both the solution structure and photophysical properties of a water-soluble polythiophene.

Synthesis and characterisation of biocompatible organic-inorganic core-shell nanocomposite particles based on ureasils.

Organic-inorganic core-shell nanocomposites have attracted increasing attention for applications in imaging, controlled release, biomedical scaffolds and self-healing materials. While tunable properties can readily be achieved through the selection of complementary building blocks, synergistic enhancement requires management of the core-shell interface. In this work, we report a one-pot method to fabricate hybrid core-shell nanocomposite particles (CSNPs) based on ureasils. The native structure of ureasils, which are poly(oxyalkylene)/siloxane hybrids, affords formation of an organic polymer core via nanoprecipitation, while the terminal siloxane groups act as a template for nucleation and growth of the silica shell via the Stöber process. Through optimisation of the reaction conditions, we demonstrate the reproducible synthesis of ureasil CSNPs, with a hydrodynamic diameter of ∼150 nm and polydispersity <0.2, which remain electrostatically stabilised in aqueous media for >50 days. Selective functionalisation, either through the physical entrapment of polarity-sensitive fluorescent probes (coumarin 153, pyrene) or covalent-grafting to the silica shell (fluorescein isothiocyanate) is also demonstrated and provides insight into the internal environment of the particles. Moreover, preliminary studies using a live/dead cell assay indicate that ureasil CSNPs do not display cytotoxicity. Given the simple fabrication method and the structural tunability and biocompatability of the ureasils, this approach presents an efficient route to multifunctional core-shell nanocomposite particles whose properties may be tailored for a targeted application.

Holistic QbD approach for hot-melt extrusion process design space evaluation: Linking materials science, experimentation and process modeling.

The aim of this work was to investigate the relationship between formulation material properties, process parameters and process performance for the manufacturing of amorphous solid dispersions via hot-melt extrusion (HME) using experimentation coupled with process modeling. Specifically, we evaluated the impact of the matrix copovidone melt rheology with and without the addition of a plasticizing surfactant, polysorbate 80, while also varying the process parameters, barrel temperature and screw speed, and keeping fill volume constant. To correlate the process performance to a critical quality attribute, we used telmisartan as an indicator substance by processing at temperatures below its solubility temperature in the polymeric matrix. We observed a broader design space of HME processes for the plasticized formulation with respect to screw speed than for the copovidone-only matrix formulation. This observation was determined by the range of observed melt temperatures in the extruder, both measured and simulated. The reason was not primarily linked to a reduced shear-thinning behavior, characterized by the power law index, n, but instead more to an overall reduced melt viscosity during extrusion and zero-shear rate viscosity, η0, accordingly. We also found that the amount of residual crystallinity of telmisartan correlated with the simulated maximum melt temperature in the extruder barrel. This finding confirmed the applicability of the temperature-dependent API-matrix solubility phase diagram for HME to process development. Given the complex inter-dependent relationships between material properties, process and performance, process modeling combined with reduced laboratory experimentation was established as a holistic approach for the evaluation of Quality-by-Design-based HME process design spaces.

From benchtop to pilot scale-experimental study and computational assessment of a hot-melt extrusion scale-up of a solid dispersion of dipyridamole and copovidone.

The aim of our work was to study and define a computationally-based adiabatic scale-up methodology for a hot-melt extrusion (HME) process to produce an amorphous solid dispersion (ASD). As a drug product becomes commercially viable, there is a need for scaling up the manufacturing process. In the case of HME used for the formation of ASDs, scale-up can be challenging due to the fundamental differences in how heat is generated in extruders of differing scale, i.e. conduction vs. viscous dissipation and the significant role heat generation plays in determining the final product attributes. Using a 30%w/w dipyridamole-in-copovidone formulation, 11 mm-, 16 mm- and 24 mm-diameter extruders with L/D 40, solid-state characterization tools, a geometric scaling equation, and Ludovic® twin-screw extrusion software, we compared the total imparted material energy, the conducted energy and the difference between barrel and melt temperature at die exit for various feed rates and screw speeds. Numerical simulation identified desirable adiabatic conditions at multiple extruder scales in agreement with the chosen scaling factor. With the use of computational tools, the energetics in an extrusion process can be evaluated and processing conditions can be selected to identify the most efficient scaling of a HME process.

Optimising prescription and titration of oxygen for adult inpatients using novel silicone wristbands: results of a pilot project at three centres.

Oxygen is the most commonly used drug in the acute hospital setting. Oxygen can be lifesaving but there is increasing evidence that it can cause harm if it is not given correctly. Prescription of oxygen, according to target saturations, has been advocated since 2008 but compliance remains at low levels. This paper describes a novel approach to improve oxygen prescription and titration in three acute hospital trusts using a colour-coded silicone wristband. The project ran for 3 months and covered more than 2,000 emergency admissions to hospital. Data was collected for oxygen prescription and titration rates for 270 patients during the project period. The wristbands showed an improvement in prescription and titration of oxygen in two out of three sites. The results support a wider controlled study of colour-coded wristbands to improve oxygen safety in secondary care.

An oral health curriculum for medical students at the University of Washington.

Oral health disparities are a major public health problem, according to the U.S. Surgeon General. Physicians could help prevent oral disease, but lack the knowledge to do so. To create an oral health curriculum for medical students at the University of Washington School of Medicine, the authors (beginning in 2003) (1) reviewed current evidence of medical education and physician training in oral health, (2) developed oral health learning objectives and competencies appropriate for medical students, and (3) identified current oral health content in the undergraduate curriculum and opportunities for including additional material. The authors identified very few Medline articles on medical student education and training in oral health. The United States Medical Licensing Examination Steps 2 and 3 require specific clinical knowledge and skills in oral and dental disorders, but other national curriculum databases and the Web site of the Liaison Committee on Medical Education devote no significant attention to oral health. To develop learning objectives, the authors reviewed major oral health reports, online oral health educational resources, and consulted with dental faculty. The curriculum was assessed by interviewing key medical school faculty and analyzing course descriptions, and was found to be deficient in oral health content. The authors developed five learning themes: dental public health, caries, periodontal disease, oral cancer, and oral-systemic interactions, and recommend the inclusion of corresponding competencies in targeted courses through a spiral curriculum. Current progress, the timeline for curriculum changes at the University of Washington, and the ethical values and attitudinal shifts needed to support this effort are discussed.

The association between hematological and inflammatory factors and stress fractures among female military recruits.

BACKGROUND: With the growing number of females accepted for combat-related military duties in the Israeli Defense Forces, their special needs should be addressed. Previous studies on females in combat training have found a high prevalence of iron deficiency at recruitment as well as an increased rate of stress fractures (SF) and overuse injuries during training when compared with males. The aim of this study was to assess the correlation between hematological and inflammatory variables and SF occurrence among military recruits during basic training. METHODS: Three gender-integrated light infantry units were followed prospectively. Female recruits inducted for medic and dental assistants' courses were followed for comparison. Hemoglobin, iron, transferrin, ferritin, C-reactive protein, and interleukin-6 levels were measured for all participants at recruitment and at 2 and 4 months of training. SF were diagnosed radiographically or scintigraphically according to the Israeli Defense Forces protocol. RESULTS: A total of 438 subjects were recruited (female combatants = 227, male combatants = 83, noncombatant females = 128). At induction, 18% of female combatants had anemia compared with 8% of males and 19% of noncombatants. Iron deficiency was noted in 40%, 6%, and 38%, respectively. There were no clinically significant changes during training. Twelve percent of female combatants developed SF, whereas none occurred among male combatants or noncombatants. Subjects sustaining an SF had significantly lower levels of serum iron and iron saturation. CONCLUSIONS: A high incidence of anemia as well as iron deficiency was found in this young asymptomatic cohort, with no significant change during training. The lower level of iron in female combatants sustaining SF warrants further investigation.