Frightened of the pulp? A qualitative analysis of undergraduate student confidence and stress during the management of deep caries and the exposed pulp.

AIM: To evaluate sources of student confidence and stress during the management of deep carious lesions and the exposed pulp during undergraduate clinics. Further aims were to identify barriers and facilitators, which could result in educational or practical improvements in the delivery of teaching and provision of treatment in this area. METHODOLOGY: A exploratory qualitative study design was used, based on recorded focus group interviews, guided by 12 predetermined questions. The discussions were transcribed verbatim and analysed by inductive qualitative content analysis. Common categories were identified to aid understanding. Forty undergraduate dental students from 4th and 5th years in Dublin Dental University Hospital participated in the study. RESULTS: Student stress and confidence were multifactorial and broadly linked to specific domains: clinical procedure, academic education, clinical training, evaluation/grading, organization and equipment, vital pulp biomaterial and the patient. Most students expressed a preference for one-stage selective carious removal to soft dentine rather than potential pulp exposure in deep carious lesions, noting that although it helped to decrease their immediate stress, it also caused longer-term concern by leaving caries close to the pulp. Nevertheless, their confidence was affected by limited clinical experience of carrying out selective removal procedures in deep caries. A recurrent finding was students citing high levels of stress after pulp exposure. Feelings including anger, fear, embarrassment and denial were associated with pulp exposure during deep caries management. Generally, the students felt able to manage pulp capping procedures, but were less certain about partial pulpotomy, suggesting that although they are aware of its advantages, they were unsure about the appropriate volume of pulp tissue to remove. To reduce stress, students suggested that laboratory teaching should employ new 3-D printed solutions and clinics should establish clear consensus amongst supervising teachers about the best way to manage the exposed pulp. CONCLUSIONS: Students lacked confidence as they neared the pulp and prefer selective caries removal techniques, which reduce the likelihood of pulp exposure. Students identified stressors and suggested improvements in several domains that would improve confidence. These ameliorations could lead to enhancements in student ability to perform these conservative techniques, and improve the provision of treatment in this area.

Japanese encephalitis circulation pattern in swine of northern Vietnam and consequences for swine's vaccination recommendations.

Japanese encephalitis (JE) is the largest worldwide cause of infectious encephalitis in humans and is caused by a mosquito-borne flavivirus. JE transmission cycle involves Culex mosquitoes, pigs and aquatic birds as principal vertebrate amplifying hosts. JE infection is responsible for reproductive disorder in pigs when occurring after sexual maturity. In tropical areas, JE is endemic and the majority of pigs get infected before the age of 6 months. However, in subtropical areas, pigs may be infected after sexual maturity and thus experience clinical signs, inducing economic loss. The study aimed at better characterizing the influence of seasonal temperature variations (through estimates of degree days, DD) on JE circulation in pigs in subtropical area and inferring on the potential impact on JE symptomatic infection in reproductive pigs. Six hundred and forty-one pig's sera sampled in northern Vietnam were analysed for Japanese encephalitis virus (JEV) by pan-flavivirus ELISA. A subset of 108 ELISA-positive samples, representative of each sampling occasion, were confirmed by JEV neutralization test compared with West Nile virus neutralization test. We modelled the seroprevalence of pigs according to a DD variable using a generalized additive model. We then predicted the age of infection in pigs according to their month of birth, using averaged temperature data over 10 years. The model predicts that only 80 percentage of pigs born between July and September will be protected against JEV when reaching sexual maturity contrary to the rest of the year when almost all pigs will seroconvert before sexual maturity. In subtropical area such as northern Vietnam, pigs could thus show symptomatic infection due to JE, and consequently reproductive disorders. Vaccination of future breeder pigs in epidemic areas could avoid the occurrence of JE-associated reproductive disorders.

[Impact of neurological diseases on the prognosis of bullous pemphigoid: A retrospective study of 178 patients]. / Impact pronostique des maladies neurologiques au cours de la pemphigoïde bulleuse : étude rétrospective de 178 cas.

BACKGROUND: Bullous pemphigoid (BP) mainly affects elderly patients. It is often associated with neurological disorders, which constitute a major risk factor of the disease. The aim of our study was to determine whether neurological disorders, particularly dementia, influence outcome and mortality in BP patients. PATIENTS AND METHODS: We conducted a retrospective study of all patients with BP seen in our dermatology department consecutively between 1997 and 2011. Clinical, immunological and therapeutic data, number of relapses and survival status were compared according to the presence at diagnosis of neurological disorders, particularly dementia. RESULTS: Among the 178 patients included, an associated neurological disease was present in 84 (47.2%) and dementia in 43 (24.2%) at the time of diagnosis of BP. Patients with associated dementia were older and had a lower Karnofsky index. Sixty-four patients (37.8%) had had at least one clinical relapse of BP, chiefly within the first 18 months after starting therapy. Coexistent neurological disease was not associated with BP relapse (P=0.55) contrary to an extensive BP phenotype at diagnosis (P=0.008). Coexistent neurological disease and/or dementia were associated with higher mortality (P=0.03 and P<0.001, respectively), but did not modify the type or the total duration of BP treatment. CONCLUSION: A coexistent neurological disease or dementia at the time of diagnosis of BP significantly increase the risk of mortality and shortens the duration of clinical follow-up of patients with BP, thus limiting the analysis of their influence on the outcome of BP itself.

How to reach the poor? Surveillance in low-income countries, lessons from experiences in Cambodia and Madagascar.

Surveillance of animal diseases in developing countries faces many constraints. Innovative tools and methods to enhance surveillance in remote and neglected areas should be defined, assessed and applied in close connection with local farmers, national stakeholders and international agencies. The authors performed a narrative synthesis of their own publications about surveillance in Madagascar and Cambodia. They analysed the data in light of their fieldwork experiences in the two countries' very challenging environments. The burden of animal and zoonotic diseases (e.g. avian influenza, African swine fever, Newcastle disease, Rift Valley fever) is huge in both countries which are among the poorest in the world. Being poor countries implies a lack of human and financial means to ensure effective surveillance of emerging and endemic diseases. Several recent projects have shown that new approaches can be proposed and tested in the field. Several advanced participatory approaches are promising and could be part of an innovative method for improving the dialogue among different actors in a surveillance system. Thus, participatory modelling, developed for natural resources management involving local stakeholders, could be applied to health management, including surveillance. Data transmission could benefit from the large mobile-phone coverage in these countries. Ecological studies and advances in the field of livestock surveillance should guide methods for enhancing wildlife monitoring and surveillance. Under the umbrella of the One Health paradigm, and in the framework of a risk-based surveillance concept, a combination of participatory methods and modern technologies could help to overcome the constraints present in low-income countries. These unconventional approaches should be merged in order to optimise surveillance of emerging and endemic diseases in challenging environments.

Empirical analysis suggests continuous and homogeneous circulation of Newcastle disease virus in a wide range of wild bird species in Africa.

Newcastle disease (ND) is one of the most important poultry diseases worldwide and can lead to annual losses of up to 80% of backyard chickens in Africa. All bird species are considered susceptible to ND virus (NDV) infection but little is known about the role that wild birds play in the epidemiology of the virus. We present a long-term monitoring of 9000 wild birds in four African countries. Overall, 3·06% of the birds were PCR-positive for NDV infection, with prevalence ranging from 0% to 10% depending on the season, the site and the species considered. Our study shows that ND is circulating continuously and homogeneously in a large range of wild bird species. Several genotypes of NDV circulate concurrently in different species and are phylogenetically closely related to strains circulating in local domestic poultry, suggesting that wild birds may play several roles in the epidemiology of different NDV strains in Africa. We recommend that any strategic plan aiming at controlling ND in Africa should take into account the potential role of the local wild bird community in the transmission of the disease.

A Systematic Scoping Study of the Socio-Economic Impact of Rift Valley Fever: Research Gaps and Needs.

Rift Valley fever (RVF) is a severe mosquito-borne disease affecting humans and domestic ruminants. RVF virus has been reported in most African countries, as well as in the Arabic Peninsula. This paper reviews the different types of socio-economic impact induced by RVF disease and the attempts to evaluate them. Of the 52 papers selected for this review, 13 types of socio-economic impact were identified according to the sector impacted, the level and temporal scale of the impact. RVF has a dramatic impact on producers and livestock industries, affecting public and animal health, food security and the livelihood of the pastoralist communities. RVF also has an impact on international trade and other agro-industries. The risk of introducing RVF into disease-free countries via the importation of an infected animal or mosquito is real, and the consequent restriction of access to export markets may induce dramatic economic consequences for national and local economies. Despite the important threat of RVF, few studies have been conducted to assess the socio-economic impact of the disease. The 17 studies identified for quantitative analysis in this review relied only on partial cost analysis, with limited reference to mid- and long-term impact, public health or risk mitigation measures. However, the estimated impacts were high (ranging from $5 to $470 million USD losses). To reduce the impact of RVF, early detection and rapid response should be implemented. Comprehensive disease impact studies are required to provide decision-makers with science-based information on the best intervention measure to implement ensuring efficient resource allocation. Through the analysis of RVF socio-economic impact, this scoping study proposes insights into the mechanisms underpinning its often-underestimated importance. This study highlights the need for comparative socio-economic studies to help decision-makers with their choices related to RVF disease management.

Description and analysis of the poultry trading network in the Lake Alaotra region, Madagascar: implications for the surveillance and control of Newcastle disease.

Madagascar's 36.5-million-head poultry industry holds a foremost place in its economy and the livelihood of its people. Unfortunately, regular Newcastle disease outbreaks associated with high mortality causes high losses for smallholders and threatens their livelihood. Therefore, Madagascar is seeking concrete, achievable and sustainable methods for the surveillance and the control of Newcastle disease. In this paper, we present and analyze the results of a field study conducted in Madagascar between December 2009 and December 2010. The study area was the Lac Alaotra region, a landlocked area in the north-eastern part of the country's center. Poultry trading is suspected of playing a major role in the spread of avian diseases, especially in developing countries characterized by many live-bird markets and middlemen. Therefore, the goals of our study were to: (i) describe and analyze smallholders' poultry trading network in the Lake Alaotra region using social network analysis; (ii) assess the role of the network in the spread of Newcastle disease; and (iii) propose the implementation of a targeted disease surveillance based on the characteristics of the poultry trading network. We focused our field study on the harvesting of two data sets. The first is a complete description of the poultry trading network in the landlocked area of Lac Alaotra, including a description of the poultry movements between groups of villages. The second set of data measures the occurrence of outbreaks in the same area by combining a participatory approach with an event-based surveillance method. These data were used to determine the attributes of the network, and to statistically assess the association between the position of nodes and the occurrence of outbreaks. By using social network analysis techniques combined with a classification method and a logistic model, we finally identified 3 nodes (set of villages), of the 387 in the initial network, to focus on for surveillance and control in the Lac Alaotra area. This result is of primary importance in the ongoing efforts to effectively improve the wellbeing of people in the region.

Comparison of anatomical locations of cutaneous melanoma in men and women: a population-based study in France.

BACKGROUND: Identification of differences in melanoma location between the sexes could lead to sex-specific preventive measures. OBJECTIVES: To compare precise melanoma location and side in men and women. METHODS: The location of 1542 incident melanomas diagnosed during the period 2004-2011 in the French Champagne-Ardenne region (1·3 million inhabitants) was recorded using a regional registry and questionnaires sent to physicians. Men and women were compared for frequency of tumours on the head and neck; trunk; upper limb; lower limb; hand and foot. For each location, more precise sublocations were recorded. The laterality (right vs. left) was studied for head/neck and limb tumours. RESULTS: Melanomas predominated on the lower limb in women (32·2% vs. 9·3% in men; P < 0·01) and on the trunk in men (41·8% vs. 14·9%; P < 0·01), while the proportion of upper limb and head/neck tumours was similar in both sexes. Hand and foot melanomas predominated in women (10·3% vs. 6·3%; P < 0·01), with a sex-related distribution between sublocations. Within the head and neck location, 75·1% of tumours in women were located in the central area vs. 53·7% in the peripheral area in men (P < 0·01). Head and neck melanomas were more frequently right-sided in women and left-sided in men (P = 0·04), with the left/right ratio reaching 1·58 in men vs. 0·61 in women for peripheral tumours (P < 0·01). No difference in laterality was observed for other locations. CONCLUSIONS: Sex differences in occupational and leisure time ultraviolet exposure, clothing (including shoes), hairstyle, and side and photo exposure in cars could explain these results. General preventive messages could be completed by sex-specific advice for melanoma prevention.

Relevance of Rift Valley fever to public health in the European Union.

Rift Valley fever (RVF), a vector-borne zoonotic disease caused by a phlebovirus (family Bunyaviridae), is considered to be one of the most important viral zoonoses in Africa. It is also a potential bioterrorism agent. Transmitted by mosquitoes or by direct contact with viraemic products, RVF affects both livestock and humans, causing abortion storms in pregnant ruminants and sudden death in newborns. The disease provokes flu syndrome in most human cases, but also severe encephalitic or haemorrhagic forms and death. There is neither a treatment nor a vaccine for humans. The disease, historically confined to the African continent, recently spread to the Arabian Peninsula and Indian Ocean. Animal movements, legal or illegal, strongly contribute to viral spread, threatening the Mediterranean basin and Europe, where competent vectors are present. Given the unpredictability of virus introduction and uncertainties about RVF epidemiology, there is an urgent need to fill the scientific gaps by developing large regional research programmes, to build predictive models, and to implement early warning systems and surveillance designs adapted to northern African and European countries.

A geographical information system-based multicriteria evaluation to map areas at risk for Rift Valley fever vector-borne transmission in Italy.

Rift Valley fever (RVF) is a severe mosquito-borne disease that is caused by a Phlebovirus (Bunyaviridae) and affects domestic ruminants and humans. Recently, its distribution widened, threatening Europe. The probability of the introduction and large-scale spread of Rift Valley fever virus (RVFV) in Europe is low, but localized RVF outbreaks may occur in areas where populations of ruminants and potential vectors are present. In this study, we assumed the introduction of the virus into Italy and focused on the risk of vector-borne transmission of RVFV to three main European potential hosts (cattle, sheep and goats). Five main potential mosquito vectors belonging to the Culex and Aedes genera that are present in Italy were identified in a literature review. We first modelled the geographical distribution of these five species based on expert knowledge and using land cover as a proxy of mosquito presence. The mosquito distribution maps were compared with field mosquito collections from Italy to validate the model. Next, the risk of RVFV transmission was modelled using a multicriteria evaluation (MCE) approach, integrating expert knowledge and the results of a literature review on host sensitivity and vector competence, feeding behaviour and abundance. A sensitivity analysis was performed to assess the robustness of the results with respect to expert choices. The resulting maps include (i) five maps of the vector distribution, (ii) a map of suitable areas for vector-borne transmission of RVFV and (iii) a map of the risk of RVFV vector-borne transmission to sensitive hosts given a viral introduction. Good agreement was found between the modelled presence probability and the observed presence or absence of each vector species. The resulting RVF risk map highlighted strong spatial heterogeneity and could be used to target surveillance. In conclusion, the geographical information system (GIS)-based MCE served as a valuable framework and a flexible tool for mapping the areas at risk of a pathogen that is currently absent from a region.

Evidence for freedom from swine influenza in a remote area of Northern Vietnam.

Swine influenza is responsible for one of the most prevalent disease affecting the swine industry worldwide. Epidemiological surveys rarely focus on remote areas, because traditional farming systems characterized by locally consumed production and low pig densities are considered as having little influence on the emergence, re-emergence, persistence or spread of swine influenza viruses. In addition, routine disease investigations in remote areas are often neglected due to logistic and economical constraints. A bank of swine sera collected in 2005 in the ethnic minorities households of Ha Giang province (Northern Vietnam) located adjacent to the Chinese border was analyzed to estimate the seroprevalence of swine influenza (SI) and to identify potential risk factors for infection. The results suggest that this specific agro-ecological system is free from SI and is not favourable to SI spread either through pig-to-pig transmission, or through poultry-to-pig transmission.

Risk factors for avian influenza and Newcastle disease in smallholder farming systems, Madagascar highlands.

Newcastle disease (ND) and avian influenza (AI) are issues of interest to avian producers in Madagascar. Newcastle disease virus (NDV) is the major constraint for village aviculture, and avian influenza viruses type A (AIAV) are known to circulate in bird flocks. This study aims at classifying smallholder poultry farms, according to the combination of risk factors potentially associated with NDV and AIAV transmission and to assess the level of infection for each farm class. Two study sites, Lake Alaotra and Grand Antananarivo, were chosen with respect to their differences in terms of agro-ecological features and poultry productions. A typology survey involving 526 farms was performed to identify possible risk factors for (i) within-village, and (ii) between-village virus transmission. A cross-sectional serological study was also carried out in 270 farms to assess sero-prevalences of NDV and AIAV for each farm class and the link between them and risk factor patterns. For within-village transmission, four classes of farms were identified in Grand Antananarivo and five in Lake Alaotra. For between-village virus transmission, four classes of farms were identified for each site. In both sites, NDV sero-prevalence was higher than for AIAV. There was no evidence of the presence of H5 or H7 subtypes of AIAV. Sero-prevalences were significantly higher in Lake Alaotra than in Grand Antananarivo for both viruses (OR=2.4, p=0.02 for NDV, and OR=9.6, p<0.0001 for AIAV). For within-village NDV transmission in Grand Antananarivo, backyard chicken farms (OR=3.6, p<0.001), and chicken farms with biosecurity awareness (OR=3.4, p<0.01) had greater odds of having antibodies against NDV than the others. For between-village virus transmission, farms with multiple external contacts, and farms using many small markets had greater odds of having antibodies against NDV than the others (OR=5.4, p<0.01). For AIAV, there were no differences in sero-prevalences among farm classes. In Lake Alaotra, the observed high density of palmipeds and widespread rice paddies were associated with high sero-prevalences for both viruses, and a homogeneous risk of virus transmission between the different farm classes. In Grand Antananarivo, farm visits by collectors or animal health workers, and farm contacts with several markets were identified as potential risk factors for NDV transmission. Further studies are needed to identify the circulating virus genotypes, model their transmission risk, and provide adapted control measures.

Looking for avian influenza in remote areas. A case study in Northern Vietnam.

Epidemiological surveys of avian influenza infections rarely focus on backyard poultry systems in remote locations because areas with low levels of poultry production are considered to have little influence on the emergence, re-emergence, persistence or spread of avian influenza viruses. In addition, routine disease investigations in remote areas often are neglected due to the lower availability and relatively high cost of veterinary services there. A bank of avian sera collected in 2005 from ethnic minority households in Ha Giang province (Northern Vietnam), located on the Chinese border, was analysed to estimate the seroprevalence of avian influenza virus (AIV) during a H5N1 epidemic and to identify potential risk factors for infection. The results suggest that the chicken population had been exposed to AIV with a seroprevalence rate of 7.2% [1.45; 10.5]. The H5 and H9 subtypes were identified with a seroprevalence of 3.25% [2.39; 4.11] and 1.12% [0.61; 1.63], respectively. The number of inhabitants in a village and the distance to the main national road were the most influential risk factors of AIV infection, and high-risk clusters were located along the road leading to China. These two results suggest a virus spread through commercial poultry exchanges and a possible introduction of AIV from southern China. Remote areas and small-scale farms may play an under-estimated role in the spread and persistence of AIV.

Facial palsy after inferior alveolar nerve block: case report and review of the literature.

Bell's palsy is an idiopathic and acute, peripheral nerve palsy resulting in inability to control facial muscles on the affected side because of the involvement of the facial nerve. This study describes a case of Bell's palsy that developed after dental anaesthesia. A 34-year-old pregnant woman at 35 weeks of amenorrhea, with no history of systemic disease, was referred by her dentist for treatment of a mandibular left molar in pulpitis. An inferior alveolar nerve block was made prior to the access cavity preparation. 2h later, the patient felt the onset of a complete paralysis of the left-sided facial muscles. The medical history, the physical examination and the complementary exams led neurologists to the diagnosis of Bell's palsy. The treatment and results of the 1-year follow-up are presented and discussed. Bell's palsy is a rare complication of maxillofacial surgery or dental procedures, the mechanisms of which remain uncertain.

[On call emergency dental hospital service: creation and preliminary results]. / Astreinte odontologique au sein d'un CHU : mise en place et résultats préliminaires d'activité

BACKGROUND: In France, few hospitals are able to provide uninterrupted care for dental emergencies. To meet the legal and deontological requirements, since October 2007, the Brest University Hospital has set up a dental emergency unit with on call consultants. Prior to this set-up, the needs had been evaluated through surveys conducted in Brest hospital. This study deals with the results of these surveys, and reports the experience of this call emergency service after 1 year of operation. METHODS: The needs of the general population concerning emergency dental care were quantified in three units of Brest hospital (general, pediatric and ENT emergencies) for 6 months and the mobile emergency unit (Samu 29) for 1 year. The findings led to setting up an emergency dental unit during week-ends. The activities of this unit after 1 year of operation were evaluated retrospectively. Variables concerning attendance and activity level, patient parameters and out-of-hours emergency activity were studied. For this purpose, data from the medical record and from complementary "information sheets" completed by the clinicians were analyzed. RESULTS: The preliminary step of needs-quantification recorded an important demand for dental service in both emergencies units of Brest hospital and Samu 29. During the first year of operation, attendance level was on average 6.3 (+/-4.3) consultations per week-end. Peak activity levels were reached on saturday and sunday afternoons and also during the summer months. Male patients were more numerous than females and the mean age of the population was 32.6 years (+/-17.6). By decreasing order of frequency, the diseases encountered were mainly infectious, then trauma-related, inflammatory and others. Clinical interventions were mainly in endodontics, conservative dentistry and surgery. CONCLUSION: This on call emergency service meets the needs of the general population concerning emergency dental care when hospital dental departments and regular dental offices are closed. This is a public health issue.

Rift Valley fever--a threat for Europe?

Rift Valley fever (RVF) is a severe mosquito-borne disease affecting humans and domestic ruminants, caused by a Phlebovirus (Bunyaviridae). It is widespread in Africa and has recently spread to Yemen and Saudi Arabia. RVF epidemics are more and more frequent in Africa and the Middle East, probably in relation with climatic changes (episodes of heavy rainfall in eastern and southern Africa), as well as intensified livestock trade. The probability of introduction and large-scale spread of RVF in Europe is very low, but localized RVF outbreaks may occur in humid areas with a large population of ruminants. Should this happen, human cases would probably occur in exposed individuals: farmers, veterinarians, slaughterhouse employees etc. Surveillance and diagnostic methods are available, but control tools are limited: vector control is difficult to implement, and vaccines are only available for ruminants, with either a limited efficacy (inactivated vaccines) or a residual pathogenic effect. The best strategy to protect Europe and the rest of the world against RVF is to develop more efficient surveillance and control tools and to implement coordinated regional monitoring and control programmes.

Environmental risk factors of West Nile virus infection of horses in the Senegal River basin.

In 2005, a serological study was carried out on horses in five ecologically contrasted zones of the Senegal River basin (Senegal) to assess West Nile virus (WNV) transmission and investigate underlying environmental risk factors. In each study zone, horses were randomly selected and blood samples taken. A land-cover map of the five study areas was built using two satellite ETM+ images. Blood samples were screened by ELISA for anti-WNV IgM and IgG and positive samples were confirmed by seroneutralization. Environmental data were analysed using a principal components analysis. The overall IgG seroprevalence rate was 85% (n=367; 95% CI 0.81-0.89). The proximity to sea water, flooded banks and salted mudflats were identified as protective factors. These environmental components are unfavourable to the presence of Culex mosquitoes suggesting that in Senegal, the distribution of the vector species is more limiting for WNV transmission than for the hosts' distribution.

Endemic transmission of Rift Valley Fever in Senegal.

Rift Valley fever (RVF) is an expanding zoonotic disease transmitted from ruminant to ruminant by Culicidae mosquitoes. In 2004, a longitudinal serological survey was performed on small ruminants in the Ferlo are (Senegal) to study RVF transmission and compared the results with those obtained from the same study in 2003. The results confirm that the disease is endemic and that the spatial transmission of RVF is highly heterogeneous. The virus could be maintained during dry season by transovarian transmission in Aedes vexans. Further studies are needed to improve the understanding of the epidemiological cycle of RVF in this region to implement adapted surveillance measures.