When the implementation of water safety plans fail: rethinking the approach to water safety planning following a serious waterborne outbreak and implications for subsequent water sector reforms.

Water suppliers in New Zealand have been preparing the water safety plans (WSPs) since 2005; large drinking water-associated outbreaks of campylobacteriosis occurred in Darfield in 2012 and in Havelock North in 2016. This paper reviews the WSP that was in place for Havelock North, and analyses why it failed to prevent this outbreak. The risk assessment team completing the WSP underestimated the risks to human health of contamination events, while overestimating the security of the groundwater and bore heads. Historical Escherichia coli transgressions were dismissed as likely despite sampler or testing errors, rather than important warning signals. The outbreak was a consequence of multiple factors including an untreated supply, a local animal faecal source, limitations to the aquifer integrity and bore head protection, and a failure to proactively respond to a flooding event. The overarching issue was a focus on narrow compliance with the Health Act rather than the use of the WSP as a valuable tool to proactively understand and manage public health risks. New Zealand plans to focus on the ability of an organisation to manage risk, with the emphasis on promoting conversations with water suppliers about integrated risk management rather than focusing solely on the preparation of a WSP.

Effectiveness of a standardized electronic admission order set for acute exacerbation of chronic obstructive pulmonary disease.

BACKGROUND: Variation in hospital management of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may prolong length of stay, increasing the risk of hospital-acquired complications and worsening quality of life. We sought to determine whether an evidence-based computerized AECOPD admission order set could improve quality and reduce length of stay. METHODS: The order set was designed by a provincial COPD working group and implemented voluntarily among three physician groups in a Canadian tertiary-care teaching hospital. The primary outcome was length of stay for patients admitted during order set implementation period, compared to the previous 12 months. Secondary outcomes included length of stay of patients admitted with and without order set after implementation, all-cause readmissions, and emergency department visits. RESULTS: There were 556 admissions prior to and 857 admissions after order set implementation, for which the order set was used in 47%. There was no difference in overall length of stay after implementation (median 6.37 days (95% confidence interval 5.94, 6.81) pre-implementation vs. 6.02 days (95% confidence interval 5.59, 6.46) post-implementation, p = 0.26). In the post-implementation period, order set use was associated with a 1.15-day reduction in length of stay (95% confidence interval - 0.5, - 1.81, p = 0.001) compared to patients admitted without the order set. There was no difference in readmissions. CONCLUSIONS: Use of a computerized guidelines-based admission order set for COPD exacerbations reduced hospital length of stay without increasing readmissions. Interventions to increase order set use could lead to greater improvements in length of stay and quality of care.

The saprophytic fungus Fusarium solani increases the insecticidal efficacy of the entomopathogenic nematode Steinernema diaprepesi.

In two field surveys, high proportions of Galleria mellonella L. (Lepidoptera: Pyralidae) sentinel larval cadavers were infected by Fusarium solani without evidence of concomitant entomopathogenic nematode (EPN) or entomopathogenic fungus (EPF) reproduction. Because F. solani is not considered entomopathogenic, the survey suggested the possibility that F. solani competes with EPNs. We tested the hypotheses that F. solani attracts the EPN, Steinernema diaprepesi, to facilitate infection of Diaprepes root weevils (Diaprepes abbreviatus L.) and thereafter competes with the nematode in the insect cadaver. In two-choice olfactometer assays where one side was treated with F. solani mycelia and conidia, juvenile S. diaprepesi were attracted to the fungus, in either raw soil, or in autoclaved soil in the presence or absence of insects. However, this attraction was attenuated as the habitat became more complex, by using raw soil in combination with insect larvae. Fusarium oxysporum did not recruit the nematode. When soil microcosms were tested with F. solani conidia and S. diaprepesi, the concomitant infection increased the mortality of the insect (P = 0.02) to 83%, compared to 58% and 0% mortality when nematodes or fungi were individually applied, respectively. Concomitant inoculation also increased the number of cadavers that supported nematode reproduction and increased the population density of fungus in soil. The number of IJs entering the host insect was not affected by F. solani. These results support the possibility that F. solani can facilitate the insecticidal efficiency of S. diaprepesi in order to exploit the resources in the cadaver.

The hyper-envelope modeling interface (HEMI): a novel approach illustrated through predicting tamarisk (Tamarix spp.) habitat in the Western USA.

Habitat suitability maps are commonly created by modeling a species' environmental niche from occurrences and environmental characteristics. Here, we introduce the hyper-envelope modeling interface (HEMI), providing a new method for creating habitat suitability models using Bezier surfaces to model a species niche in environmental space. HEMI allows modeled surfaces to be visualized and edited in environmental space based on expert knowledge and does not require absence points for model development. The modeled surfaces require relatively few parameters compared to similar modeling approaches and may produce models that better match ecological niche theory. As a case study, we modeled the invasive species tamarisk (Tamarix spp.) in the western USA. We compare results from HEMI with those from existing similar modeling approaches (including BioClim, BioMapper, and Maxent). We used synthetic surfaces to create visualizations of the various models in environmental space and used modified area under the curve (AUC) statistic and akaike information criterion (AIC) as measures of model performance. We show that HEMI produced slightly better AUC values, except for Maxent and better AIC values overall. HEMI created a model with only ten parameters while Maxent produced a model with over 100 and BioClim used only eight. Additionally, HEMI allowed visualization and editing of the model in environmental space to develop alternative potential habitat scenarios. The use of Bezier surfaces can provide simple models that match our expectations of biological niche models and, at least in some cases, out-perform more complex approaches.

The impacts of an invasive species citizen science training program on participant attitudes, behavior, and science literacy.

Citizen science can make major contributions to informal science education by targeting participants' attitudes and knowledge about science while changing human behavior towards the environment. We examined how training associated with an invasive species citizen science program affected participants in these areas. We found no changes in science literacy or overall attitudes between tests administered just before and after a one-day training program, matching results from other studies. However, we found improvements in science literacy and knowledge using context-specific measures and in self-reported intention to engage in pro-environmental activities. While we noted modest change in knowledge and attitudes, we found comparison and interpretation of these data difficult in the absence of other studies using similar measures. We suggest that alternative survey instruments are needed and should be calibrated appropriately to the pre-existing attitudes, behavior, and levels of knowledge in these relatively sophisticated target groups.

Biological impact of divergent land management practices on tomato crop health.

Development of sustainable food systems is contingent upon the adoption of land management practices that can mitigate damage from soilborne pests. Five diverse land management practices were studied for their impacts on Fusarium wilt (Fusarium oxysporum f. sp. lycopersici), galling of roots by Meloidogyne spp. and marketable yield of tomato (Solanum lycopersicum) and to identify associations between the severity of pest damage and the corresponding soil microbial community structure. The incidence of Fusarium wilt was >14% when tomato was cultivated following 3 to 4 years of an undisturbed weed fallow or continuous tillage disk fallow rotation and was >4% after 3 to 4 years of bahiagrass (Paspalum notatum) rotation or organic production practices that included soil amendments and cover crops. The incidence of Fusarium wilt under conventional tomato production with soil fumigation varied from 2% in 2003 to 15% in 2004. Repeated tomato cultivation increased Fusarium wilt by 20% or more except when tomato was grown using organic practices, where disease remained less than 3%. The percent of tomato roots with galls from Meloidogyne spp. ranged from 18 to 82% in soil previously subjected to a weed fallow rotation and 7 to 15% in soil managed previously as a bahiagrass pasture. Repeated tomato cultivation increased the severity of root galling in plots previously subjected to a conventional or disk fallow rotation but not in plots managed using organic practices, where the percentage of tomato roots with galls remained below 1%. Marketable yield of tomato exceeded 35 Mg ha(-1) following all land management strategies except the strip-tillage/bahiagrass program. Marketable yield declined by 11, 14, and 19% when tomato was grown in consecutive years following a bahiagrass, weed fallow, and disk rotation. The composition of fungal internal transcribed spacer 1 (ITS1) and bacterial 16S rDNA amplicons isolated from soil fungal and bacterial communities corresponded with observed differences in the incidence of Fusarium wilt and severity of root galling from Meloidogyne spp. and provided evidence of an association between the effect of land management practices on soil microbial community structure, severity of root galling from Meloidogyne spp., and the incidence of Fusarium wilt.

Regional data refine local predictions: modeling the distribution of plant species abundance on a portion of the central plains.

Species distribution models are frequently used to predict species occurrences in novel conditions, yet few studies have examined the consequences of extrapolating locally collected data to regional landscapes. Similarly, the process of using regional data to inform local prediction for species distribution models has not been adequately evaluated. Using boosted regression trees, we examined errors associated with extrapolating models developed with locally collected abundance data to regional-scale spatial extents and associated with using regional data for predictions at a local extent for a native and non-native plant species across the northeastern central plains of Colorado. Our objectives were to compare model results and accuracy between those developed locally and extrapolated regionally, those developed regionally and extrapolated locally, and to evaluate extending species distribution modeling from predicting the probability of presence to predicting abundance. We developed models to predict the spatial distribution of plant species abundance using topographic, remotely sensed, land cover and soil taxonomic predictor variables. We compared model predicted mean and range abundance values to observed values between local and regional. We also evaluated model prediction performance based on Pearson's correlation coefficient. We show that: (1) extrapolating local models to regional extents may restrict predictions, (2) regional data can help refine and improve local predictions, and (3) boosted regression trees can be useful to model and predict plant species abundance. Regional sampling designed in concert with large sampling frameworks such as the National Ecological Observatory Network may improve our ability to monitor changes in local species abundance.

Optimizing COPD Acute Care Patient Outcomes Using a Standardized Transition Bundle and Care Coordinator: A Randomized Clinical Trial.

BACKGROUND: Acute exacerbations of COPD (AECOPD) are associated with high morbidity and mortality and frequent readmissions. RESEARCH QUESTION: What is the effectiveness of a COPD transition bundle, with and without a care coordinator, on rehospitalizations and ED revisits? STUDY DESIGN AND METHODS: Two patient cohorts were selected: (1) the group exposed to the transition bundle and (2) the group not exposed to the transition bundle (usual care group). Patients exposed subsequently were randomized to a care coordinator. An AECOPD transition bundle was implemented in the hospital; patients randomized to the care coordinator were contacted ≤ 72 h after discharge. Six hundred four patients (320 to the care coordinator and 284 to routine care) who met eligibility criteria from five hospitals across three cities in Alberta, Canada, were exposed to the transition bundle, whereas 3,106 patients discharged from the same hospitals received the usual care. Primary outcomes were 7-day, 30-day, and 90-day readmissions, median length of stay (LOS), and 30-day ED revisits. RESULTS: The transition bundle cohort were 83% (relative risk [RR], 0.17; 95% CI, 0.07-0.35) less likely to be readmitted within 7 days and 26% (RR, 0.74; 95% CI, 0.60-0.91) less likely to be readmitted within 30 days of discharge. Ninety-day readmissions were unchanged (RR, 1.05; 95% CI, 0.93-1.18). The transition bundle was associated with a 7.3% (RR, 1.07; 95% CI, 1.0-1.15) relative increase in LOS and a 76% (RR, 1.76; 95% CI, 1.53-2.02) greater risk of a 30-day ED revisit. The care coordinator did not influence readmission or ED revisits. INTERPRETATION: The COPD transition bundle reduced 7- and 30-day hospital readmissions while increasing LOS and ED revisits. The care coordinator did not improve outcomes. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03358771; URL: www. CLINICALTRIALS: gov.

Project Lazarus: community-based overdose prevention in rural North Carolina.

BACKGROUND: In response to some of the highest drug overdose death rates in the country, Project Lazarus developed a community-based overdose prevention program in Western North Carolina. The Wilkes County unintentional poisoning mortality rate was quadruple that of the state's in 2009 and due almost exclusively to prescription opioid pain relievers, including fentanyl, hydrocodone, methadone, and oxycodone. The program is ongoing. METHODS: The overdose prevention program involves five components: community activation and coalition building; monitoring and surveillance data; prevention of overdoses; use of rescue medication for reversing overdoses by community members; and evaluating project components. Principal efforts include education of primary care providers in managing chronic pain and safe opioid prescribing, largely through the creation of a tool kit and face-to-face meetings. RESULTS: Preliminary unadjusted data for Wilkes County revealed that the overdose death rate dropped from 46.6 per 100,000 in 2009 to 29.0 per 100,000 in 2010. There was a decrease in the number of victims who received prescriptions for the substance implicated in their fatal overdose from a Wilkes County physician; in 2008, 82% of overdose decedents received a prescription for an opioid analgesic from a Wilkes prescriber compared with 10% in 2010. CONCLUSIONS: While the results from this community-based program are preliminary, the number and nature of prescription opioid overdose deaths in Wilkes County changed during the intervention. Further evaluation is required to understand the localized effect of the intervention and its potential for replication in other areas.

The ADEPT study: a comparative study of dentists' ability to detect enamel-only proximal caries in bitewing radiographs with and without the use of AssistDent artificial intelligence software.

Introduction Reversal of enamel-only proximal caries by non-invasive treatments is important in preventive dentistry. However, detecting such caries using bitewing radiography is difficult and the subtle patterns are often missed by dental practitioners.Aims To investigate whether the ability of dentists to detect enamel-only proximal caries is enhanced by the use of AssistDent artificial intelligence (AI) software.Materials and methods In the ADEPT (AssistDent Enamel-only Proximal caries assessmenT) study, 23 dentists were randomly divided into a control arm, without AI assistance, and an experimental arm, in which AI assistance provided on-screen prompts indicating potential enamel-only proximal caries. All participants analysed a set of 24 bitewings in which an expert panel had previously identified 65 enamel-only carious lesions and 241 healthy proximal surfaces.Results The control group found 44.3% of the caries, whereas the experimental group found 75.8%. The experimental group incorrectly identified caries in 14.6% of the healthy surfaces compared to 3.7% in the control group. The increase in sensitivity of 71% and decrease in specificity of 11% are statistically significant (p <0.01).Conclusions AssistDent AI software significantly improves dentists' ability to detect enamel-only proximal caries and could be considered as a tool to support preventive dentistry in general practice.

Repeatability of measuring corneal subbasal nerve fiber length in individuals with type 2 diabetes.

PURPOSE: To analyze the repeatability of measuring nerve fiber length (NFL) from images of the human corneal subbasal nerve plexus using semiautomated software. METHODS: Images were captured from the corneas of 50 subjects with type 2 diabetes mellitus who showed varying severity of neuropathy, using the Heidelberg Retina Tomograph 3 with Rostock Corneal Module. Semiautomated nerve analysis software was independently used by two observers to determine NFL from images of the subbasal nerve plexus. This procedure was undertaken on two occasions, 3 days apart. RESULTS: The intraclass correlation coefficient values were 0.95 (95% confidence intervals: 0.92-0.97) for individual subjects and 0.95 (95% confidence intervals: 0.74-1.00) for observer. Bland-Altman plots of the NFL values indicated a reduced spread of data with lower NFL values. The overall spread of data was less for (a) the observer who was more experienced at analyzing nerve fiber images and (b) the second measurement occasion. CONCLUSIONS: Semiautomated measurement of NFL in the subbasal nerve fiber layer is highly repeatable. Repeatability can be enhanced by using more experienced observers. It may be possible to markedly improve repeatability when measuring this anatomic structure using fully automated image analysis software.

Tooth loss and osteoporosis: the OSTEODENT Study.

AIM: To determine the cross-sectional association of the osteoporotic status of patients with the number of their teeth, with and without taking into account age and/or smoking. MATERIAL & METHODS: At four centres, the study recruited 665 females aged 45-70 years and the number of teeth was counted for 651 subjects. Bone density was measured at the total hip, femoral neck and lumbar spine. RESULTS: The mean number of teeth in the osteoporotic subjects was 3.3 fewer than normal subjects and 2.1 fewer if those with no teeth were excluded. The association between osteoporosis and having <6 or having <28 teeth remained significant after adjusting for age, smoking and centre with p-values of 0.016 and 0.011, respectively. A single regression model for tooth count with normal errors would not fit all the data. By fitting mixture regression models to subjects with tooth count >0, three clusters were identified corresponding to different degrees of tooth loss. The overall effect of osteoporosis was as follows: -1.8 teeth before and after adjusting for smoking, -1.2 teeth after adjusting for age, and -1.1 teeth after adjusting for both age and smoking. CONCLUSIONS: We have established a significant association between osteoporosis and tooth loss after adjusting the effect for age and smoking.

Integrated monitoring and information systems for managing aquatic invasive species in a changing climate.

Changes in temperature, precipitation, and other climatic drivers and sea-level rise will affect populations of existing native and non-native aquatic species and the vulnerability of aquatic environments to new invasions. Monitoring surveys provide the foundation for assessing the combined effects of climate change and invasions by providing baseline biotic and environmental conditions, although the utility of a survey depends on whether the results are quantitative or qualitative, and other design considerations. The results from a variety of monitoring programs in the United States are available in integrated biological information systems, although many include only non-native species, not native species. Besides including natives, we suggest these systems could be improved through the development of standardized methods that capture habitat and physiological requirements and link regional and national biological databases into distributed Web portals that allow drawing information from multiple sources. Combining the outputs from these biological information systems with environmental data would allow the development of ecological-niche models that predict the potential distribution or abundance of native and non-native species on the basis of current environmental conditions. Environmental projections from climate models can be used in these niche models to project changes in species distributions or abundances under altered climatic conditions and to identify potential high-risk invaders. There are, however, a number of challenges, such as uncertainties associated with projections from climate and niche models and difficulty in integrating data with different temporal and spatial granularity. Even with these uncertainties, integration of biological and environmental information systems, niche models, and climate projections would improve management of aquatic ecosystems under the dual threats of biotic invasions and climate change.

Corneal Nerve Fractal Dimension: A Novel Corneal Nerve Metric for the Diagnosis of Diabetic Sensorimotor Polyneuropathy.

Objective: Corneal confocal microscopy (CCM), an in vivo ophthalmic imaging modality, is a noninvasive and objective imaging biomarker for identifying small nerve fiber damage. We have evaluated the diagnostic performance of previously established CCM parameters to a novel automated measure of corneal nerve complexity called the corneal nerve fiber fractal dimension (ACNFrD). Methods: A total of 176 subjects (84 controls and 92 patients with type 1 diabetes) with and without diabetic sensorimotor polyneuropathy (DSPN) underwent CCM. Fractal dimension analysis was performed on CCM images using purpose-built corneal nerve analysis software, and compared with previously established manual and automated corneal nerve fiber measurements. Results: Manual and automated subbasal corneal nerve fiber density (CNFD) (P < 0.0001), length (CNFL) (P < 0.0001), branch density (CNBD) (P < 0.05), and ACNFrD (P < 0.0001) were significantly reduced in patients with DSPN compared to patients without DSPN. The areas under the receiver operating characteristic curves for identifying DSPN were comparable: 0.77 for automated CNFD, 0.74 for automated CNFL, 0.69 for automated CNBD, and 0.74 for automated ACNFrD. Conclusions: ACNFrD shows comparable diagnostic efficiency to identify diabetic patients with and without DSPN.

Robust and accurate registration of 2-D electrophoresis gels using point-matching.

Point-matching is a widely applied image registration method and many algorithms have been developed. Registration of 2-D electrophoresis gels is an important problem in biological research that presents many of the technical difficulties that beset point-matching: large numbers of points with variable densities, large nonrigid transformations between point sets, paucity of structural information and large numbers of unmatchable points (outliers) in either set. In seeking the most suitable algorithm for gel registration we have evaluated a number of approaches for accuracy and robustness in the face of these difficulties. Using synthetic images we test combinations of three algorithm components: correspondence assignment, distance metrics and image transformation. We show that a version of the iterated closest point (ICP) algorithm using a non-Euclidean distance metric and a robust estimation of transform parameters provides best performance, equalling SoftAssign in the presence of moderate image distortion, and providing superior robustness against large distortions and high outlier proportions. From this evaluation we develop a gel registration algorithm based on robust ICP and a novel distance metric combining Euclidean, shape context and image-related features. We demonstrate the accuracy of gel matching using synthetic distortions of real gels and show that robust estimation of transform parameters using M-estimators can enforce inverse consistency, ensuring that matching results are independent of the order of the images.

Detecting reduced bone mineral density from dental radiographs using statistical shape models.

We describe a novel method of estimating reduced bone mineral density (BMD) from dental panoramic tomograms (DPTs), which show the entire mandible. Careful expert width measurement of the inferior mandibular cortex has been shown to be predictive of BMD in hip and spine osteopenia and osteoporosis. We have implemented a method of automatic measurement of the width by active shape model search, using as training data 132 DPTs of female subjects whose BMD has been established by dual-energy X-ray absorptiometry. We demonstrate that widths measured after fully automatic search are significantly correlated with BMD, and exhibit less variability than manual measurements made by different experts. The correlation is highest towards the lateral region of the mandible, in a position different from that previously employed for manual width measurement. An receiver-operator characterstic (ROC) analysis for identifying osteopenia (T < -1: BMD more than one standard deviation below that of young healthy females) gives an area under curve (AUC) value of 0.64. Using a minimal interaction to initiate active shape model (ASM) search, the measurement can be made at the optimum region of the mandible, resulting in an AUC value of 0.71. Using an independent test set, AUC for detection of osteoporosis (T < -2.5) is 0.81.

An Automatic Tool for Quantification of Nerve Fibers in Corneal Confocal Microscopy Images.

OBJECTIVE: We describe and evaluate an automated software tool for nerve-fiber detection and quantification in corneal confocal microscopy (CCM) images, combining sensitive nerve- fiber detection with morphological descriptors. METHOD: We have evaluated the tool for quantification of Diabetic Sensorimotor Polyneuropathy (DSPN) using both new and previously published morphological features. The evaluation used 888 images from 176 subjects (84 controls and 92 patients with type 1 diabetes). The patient group was further subdivided into those with ( n = 63) and without ( n = 29) DSPN. RESULTS: We achieve improved nerve- fiber detection over previous results (91.7% sensitivity and specificity in identifying nerve-fiber pixels). Automatic quantification of nerve morphology shows a high correlation with previously reported, manually measured, features. Receiver Operating Characteristic (ROC) analysis of both manual and automatic measurement regimes resulted in similar results in distinguishing patients with DSPN from those without: AUC of about 0.77 and 72% sensitivity-specificity at the equal error rate point. CONCLUSION: Automated quantification of corneal nerves in CCM images provides a sensitive tool for identification of DSPN. Its performance is equivalent to manual quantification, while improving speed and repeatability. SIGNIFICANCE: CCM is a novel in vivo imaging modality that has the potential to be a noninvasive and objective image biomarker for peripheral neuropathy. Automatic quantification of nerve morphology is a major step forward in the early diagnosis and assessment of progression, and, in particular, for use in clinical trials to establish therapeutic benefit in diabetic and other peripheral neuropathies.

Primary Care Pathway for Childhood Asthma: Protocol for a Randomized Cluster-Controlled Trial.

BACKGROUND: Asthma is the most common chronic condition in children. For many, the disease is inadequately controlled, which can burden the lives of children and their families as well as the health care system. Improved use of the best available scientific evidence by primary care practitioners could reduce the need for hospital care and improve quality of life and asthma control, thereby reducing overall costs to society and families. OBJECTIVE: The Primary Care Pathway for Childhood Asthma aims to improve the management of children with asthma by (1) providing primary care practitioners with an electronic guide (a clinical pathway) incorporated into the patient's electronic medical record, and (2) providing train-the-trainer education to chronic disease management health professionals to promote the provision of asthma education in primary care. METHODS: The research will utilize a pragmatic cluster-controlled design, quantitative and qualitative research methodologies, and economic evaluation to assess the implementation of a pathway and education intervention in primary care. The intervention will be analyzed for effectiveness, and if the results are positive, a strategy will be developed to implement delivery to all primary care practices in Alberta. RESULTS: The research has been successfully funded and ethics approvals have been obtained. Practice recruitment began fall 2015, and we expect all study-related activities to be concluded by March 2018. CONCLUSIONS: The proposed pathway and education intervention has the potential to improve pediatric asthma management in Alberta. The intervention is anticipated to result in better quality of care for equal or lesser cost. CLINICALTRIAL: ClinicalTrials.gov NCT02481037; https://clinicaltrials.gov/ct2/show/NCT02481037 (Archived by WebCite at http://www.webcitation.org/6fPIQ02Ma).

A freely accessible, evidence based, objective system of analysis of posterior capsular opacification; evidence for its validity and reliability.

BACKGROUND: The aim of this study was to develop a system of computerised analysis of digital images of posterior capsule opacification (PCO) that is evidence based, objective and freely available. The paper will present evidence for the reliability and validity of the developed system. METHODS: The system of PCO analysis was developed considering current published evidence on visual significance of PCO and additional investigative analysis of PCO images. Details of the image processing and analysis steps are discussed and a final system that measures an entropy score weighted toward proximity to central areas is described. In order to assess validity, the systems ability to measure PCO progression is assessed along with the visual significance of its final computerised scores. Reliability of the system is also assessed. RESULTS: The final system runs successfully and is simple to use. Analyses of PCO by the system show an ability to detect early progression of PCO as well as detection of visually significant PCO. Images with no clinical PCO produce very low scores in the analysis. Reliability of the system of analysis is shown to be satisfactory. CONCLUSION: This paper presents a system of PCO analysis that is evidence based, objective and clinically useful. Substantial evidence is provided for its validity and reliability.

The effect of ovariectomy on mandibular cortical thickness in the rat.

OBJECTIVES: The purpose of this study was to investigate the effects of long-term oestrogen deficiency on mandibular cortical thickness in ovariectomized rats. METHODS: Twelve female rats either underwent ovariectomy or received a sham-operation. One year later images of the left side of the mandible were made using a standardized radiographic protocol. Manual measurements were made of the lower mandibular cortical thickness at three locations. The mean cortical thickness was also assessed using a specially developed image analysis program by placing points at three positions, identical to those used for the manual measurements, and additionally at 20 points evenly distributed along the mandibular cortex. RESULTS: The mean mandibular cortical thickness of the ovariectomized mandibles was significantly less than that of the sham-operated rats, measured using the computer image analysis (p=0.016, 95% CI=0.125, 0.016) and measured manually (p=0.011, 95% CI=0.0218, 0.1309). When 20 computational points were used, the mean mandibular cortical width of the ovariectomized rats was significantly less than that for the control rats (p=0.016, 95% CI=0.127, 0.018). CONCLUSIONS AND CLINICAL IMPLICATIONS: Long-term oestrogen deficiency in ovariectomized rats decreased the mandibular cortical thickness. If our result is applicable to human studies, a considerable duration of oestrogen deficiency may be necessary before a reduction of mandibular cortical bone loss can be observed. Because mandibular cortical bone is resistant to resorption, the value of clinically determined mandibular cortical thickness measurements as a method of detecting patients at risk of osteoporosis may have a reduced importance in younger postmenopausal patients.