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Clostridium Perfringens: The Agricultural Significance and Hazards Posed

Clostridium Perfringens: The Agricultural Significance and Hazards Posed. Clostridium perfringens: The Agricultural Significance and Hazards Posed when Virulence and Resistance Combine Clostridium perfringens is among the most ubiquitous pathogens known. C. perfringens is considerably hardy and found in soil, food, water, fecal material, and the intestines of both humans and animals (Uzal et al. 2014). This widespread bacterium is characterized by being a spore-forming anaerobe, which is both Gram positive, and rod-shaped (Kiu and Hall 2018). The importance of this pathogen lies within both its ability to produce a variety of deadly toxins, and the growing concern of antibiotic resistance throughout the globe. C. perfringens is most commonly mentioned for its causation of toxin-dependent infections, such as clostridial myonecrosis, otherwise known as traumatic gas gangrene (Li et al. 2016). However, the complications and breadth of damage that this bacterium causes are not confined to a single method of infection. This highly virulent pathogen has roughly 20 degradative toxins at its disposal, some of which cause more harm than others (Kiu et al. 2017). C. perfringens can infect a multitude of hosts, and each case will vary dependent on the organism, route of infection, and the toxins which are released. While the issues of direct contact with this bacterium are severe, the agricultural impact that is posed by this pathogen threatens nearly every level of food production. From farm fields, to storage, and especially food handling and distribution, C. perfringens cells and toxins are very real threats to quality and safety control aspects of global markets (Hall and Angelotti 1965). These hazards are further exacerbated by the potential for antibiotic resistance to prevent proper treatment of infections. The overuse of antibiotic growth promoters in animal feed for cattle and poultry, among other animals, has led to their antibiotic properties to become ineffective against a variety of pathogens, such as C. perfringens (Gaucher et al. 2017). The ability for bacteria to engage in horizontal gene transfer (HGT) has been extensively studied yet seemingly overlooked and understated in the agricultural business. Keeping farm animals healthy and free of pathogens are among the primary reasons for ample use of AGPs. However, this comes at the risk of stronger, more complex, versions of bacteria to arise and endanger food production (Lacey et al. 2017). Like many bacterial pathogens, C. perfringens ability to alter its outer protein structure when overexposed to certain antibiotics allows for dangerous adaptations in which new antibiotics must be synthesized; which is very costly and not in the interest of many pharmaceutical companies (Uzal et al. 2014). C. perfringens, along with its many toxins and growing resistance to available treatments, is a threat to modern agriculture which must be closely monitored and researched in efforts to prevent outbreaks of resistant strains. It is the responsibility of governments, food producers, and regulatory organizations to understand the potential risks of overusing antibiotics. The agricultural battle to prevent contamination and the spread of C. perfringens begins with properly understanding the arsenal of toxins within both its genome and conjugative plasmids. C. perfringens toxins are separated into different groups based on the diseases they are associated with, the extent of damage they cause, and which toxin or combinations of toxins are normally employed; the groups are identified as A-E. These categories are used when identifying the four major types of bacterial toxins: alpha, beta, epsilon, and iota (Grenda et al. 2017). In addition to these, there are two other clinically significant types named beta-2 and enterotoxin. These major types are accompanied by 12 minor toxins, which are not attributed to play a major role in disease, but nevertheless are harmful to both humans and animals (Fohler et al. 2017). Each toxin is uniquely identified by the gene it carries, allowing for proper genetic and molecular research into the inner workings of toxin production and pathogenicity. Arguably, the most agriculturally prevalent is alpha toxin. Alpha toxin is the major cause of symptoms and damage associated with histotoxic infections such as gas gangrene (Fohler et al. 2017). Furthermore, the gene which encodes to produce alpha toxin, cpa, is highly-conserved and found in all strains of C. perfringens (Li et al. 2016). In circumstances where alpha toxin is combined with a subtype of toxin, named NetB, avian necrotic enteritis in poultry can occur, which is quickly spread and is both a safety and economic burden (Li et al. 2016). Lesser attributed, yet still important, is the ability for alpha toxin to cause human food poisoning along other gastrointestinal diseases. Beta, epsilon, and iota toxins all have significant roles in agriculture as well. Encoded by the cpb gene, beta toxin is attributed to the cause of necrotic enteritis in a variety of species. In instances where this toxin is released by C. perfringens near cattle, lamb, and similar species, enterotoxaemia and dysentery can plague whole farms (Fohler et al. 2017). It is vital for the survival of many farm animals that beta toxin be prevented from contaminating animal food; and the spreading of the C. perfringens infections must be identified and controlled in a timely manner. Epsilon toxin, which is encoded by the gene etx, affects sheep and goats. This toxin is best known for its contribution in the cause of enterotoxaemia, more so in the beforementioned animals, but can occur in cattle (Li et al. 2016). Epsilon toxin belongs to groups D and B of the major toxin categories and is not as commonly found in field isolates as the other types of C. perfringens toxins. The last major toxin, iota, is encoded by the iap and ibp genes, and is found only in group E. Iota toxin has an agricultural impact on cattle, sheep, and rabbit (Li et al. 2016). Although not entirely known, it is suspected that this toxin is also a major cause of enterotoxaemia in many farm animals. Along with their many similarities, these toxins are unique in their combinations of a variety of toxin-encoding genes, virulence, and prevalence in the environment. The consequences of animal feed and livestock contamination are the driving force to eliminate C. perfringens vegetative cells and spores from destroying the hard work of livestock producers. In addition to these major toxins, C. perfringens has very significant beta-2 toxin and enterotoxin at its disposal. Beta-2 toxin is recognized for inducing necrotic enteritis in young pigs, human associated non-foodborne diarrheal illnesses, and multiple gut diseases (Kiu and Hall 2018). This potent toxin has various impacts in agriculture and has developing research into its role in human infections. The most important toxin, enterotoxin, is encoded by the cpe gene. Enterotoxin is produced by C. perfringens and is responsible for a variety of human gastrointestinal diseases (Kaneko et al. 2011). Fortunately, enterotoxin is the least prevalent of the toxins produced by C. perfringens. In many outbreaks, enterotoxin is responsible for only 5% of the discovered bacterium population (Kaneko et al. 2011). The significance of this toxin cannot be understated. Enterotoxin is capable of binding to human cells and inducing apoptosis (Kiu and Hall 2018). However, the toxins mentioned here are not only an issue in cattle, poultry, and other animal farms; they pose threats to vegetable producers, storage and transportation, and the handling and distribution portions of agriculture. While C. perfringens contamination has the potential to begin at an animal breeding facility, it has just as much of an impact and opportunity to do so in the environment. Both vegetative cells and spores can be found on fresh produce, in fecal material, and in various food particles that may not be hospitable hosts; yet these may serve as transmission vectors onto machinery and handler gloves (Bryan and Kilpatrick 1971). Once contamination of a machine, blade, tool, or handler has occurred, the rapid spread of toxin containing cells can be dispersed into such large amounts of food that a catastrophic amount of people can become infected before isolation measures are taken. Ultimately, the introduction of C. perfringens into already cooked foods is of greatest importance (Talukdar et al. 2017). There are a few heat-resistant strains of this pathogen which pose heightened concern among food distributors. Proper cooking may get rid of most C. perfringens cells, however strains which are resistant to normal temperatures of (60° C) may become heat-shocked and induced into rapid germination (Hall and Angelotti 1965). For these reasons, precautions along all areas of food production, from growth and breeding on farms or facilities, to finalizing a customer’s dish, proper sanitation and safety regulations must be followed. Once C. perfringens has been detected, there are methods to determine which strains and toxins are being produced; this is vital to selectively treat the situation. Measures to identify which toxins are infecting animals include the use of the polymerase chain reaction (PCR) and pulsed-field gel electrophoresis (Lacey et al. 2017). Different methods of PCR, such as nested, real-time, and loop-mediated isothermal amplification (LAMP) PCR, exist to quantify results under various temperatures and bacterial concentration conditions. The goal of these molecular assays is to detect and amplify bacterial DNA for reliable identification of the cause of a pathogenic surge (Kaneko et al. 2011). It is often difficult to determine the source of a C. perfringens outbreak. The methods used are categorized as molecular source tracking, which seek to determine where a toxin-producing strain of a pathogen originated; because C. perfringens is so widespread within the environment, proper determination of a single source of infection requires detailed information on the location where the first patients were infected (Kaneko et al. 2011). Treatment for an outbreak cannot begin until the pathogen responsible is correctly identified. Based on C. perfringens virulent strains and toxins, there is no time to be wasted when a threat has occurred; whether it be on a farm, or in the population, direct action must be taken immediately. Molecular assays, enrichment steps, and gel electrophoresis are useful for the amplification and identification of certain C. perfringens positive foods and isolates when low numbers of bacteria are found (Kaneko et al. 2011). These methods are useful during foodborne outbreaks in which a population has been infected and the pathogen has been linked to a source. Enrichment or induced multiplication of the pathogen is often needed before performing gel electrophoresis, to prevent the occurrence of false-negative results (Lacey et al. 2017). While identification and treatment during outbreaks is very necessary, preventing infection in the first place causes much less of an economic and logistical burden. Prevention of pathogenic diseases is a very organized and delicate field of regulations, restrictions, and constant observation. C. perfringens and other virulent pathogens must be handled and monitored with extreme care. Certain prevention measures include vaccines, therapeutics, and antibiotic treatments (Kiu and Hall 2018). However, for many pathogens such as C. perfringens, there isn’t necessarily a vaccine that can be taken, and antibiotic treatment has most recently been abused and qualitatively caused more harm than good. Organizations such as the World Health Organization (WHO) respond to and keep a detailed record of previous foodborne outbreaks. It has been estimated that in 2010 there were roughly 3,998,164 foodborne illnesses caused by C. perfringens (Kirk et al. 2015). Preventing the contraction of this pathogen can be as simple as requiring food handlers to properly sterilize equipment after each use, or to wear proper gloves and hairnets. Food contamination begins with improper safety techniques and overlooked risks, with the benefit of speed and mass production, but at the cost of potential outbreaks. However, a variety of chemical agents such as nitrate can be used as preservatives to combat C. perfringens (Talukdar et al. 2017). Research and development are vital in the race against microbial adaptations; finding new methods of inactivating pathogenic spores and preventing vegetative cell growth are just a couple areas of expertise that are constantly evolving. Nitrates, along with organic acids, phosphates, natural antimicrobials and even essential oils have been shown to offer partial resistance to C. perfringens (Talukdar et al. 2017). The most common, yet controversial means of combating microbial pathogens has been the worldwide overuse of antibiotics. Antimicrobial resistance (AMR) is an emerging threat for various livestock animals and humans. Treatment of many pathogens, including C. perfringens, is becoming increasingly difficult with the emergence of new antimicrobial resistant pathogens (Kiu and Hall 2018). There is a finite amount of antibiotics at the disposal of pharmaceutical and medical professionals. When a pathogen becomes adapted to an antibiotic, it is no longer useful for treatment. Despite this, in the early 2000’s, antibiotic growth promoters were introduced into farm animal feed stock at a staggering amount of 24.6 million pounds for non-therapeutic purposes to prevent contamination (Fair and Tor 2014). This is a pressing issue and is undoubtedly affecting agricultural business both economically and ethically. The preservation and growth of livestock requires a heightened level of control, which one could argue that the use of antibiotics is necessary for preventing mass infection in farm animals; however, this only works if pharmaceutical companies are readily synthesizing new antibiotics which pathogens will have no prior immunity to (Fair and Tor 2014). It is simply not in pharmaceutical companies’ self-interest to produce antibiotics. They are costly to create and are only prescribed for a duration of a couple of weeks. When compared to long-term drugs that treat chronic illnesses, antibiotics are not worth the investment required to pursue (Fair and Tor 2014). AMR has been confirmed in a variety of C. perfringens species which have adapted against tetracycline, gentamycin, and more notably detected the occurrence of mepA, a gene encoding for multi-drug resistance; it is evident that whole genome sequencing techniques will play a vital role in the preparation and development of new antibiotics to treat resistant strains of C. perfringens (Kiu and Hall 2018). Monitoring the everchanging protein structures on pathogen surfaces and staying updated on bacterial genomes are key factors to preventing a future outbreak. The extensive use of antibiotics to keep livestock healthy is not the only cause of growing AMR, doctors have been contributing to its rise for decades. The over-prescription of antibiotics to treat patient symptoms has played a hefty role in resistant strains of pathogens. The Center for Disease Control (CDC) estimates that 50% of all antibiotics are prescribed unnecessarily, and at a yearly cost of roughly $1.1 billion in the United States, alone (Fair and Tor 2014). Based on these results, changes are occurring in the legal system to prevent catastrophe from AMR pathogens. New programs are arising to address issues of antibiotic resistance. Furthermore, plasmid-mediated conjugative transfer of AMR genes has and will continue to produce more virulent strains of C. perfringens (Gaucher et al. 2017). It is important to note that bacteria have been evolving against natural antibiotics far before any human interference. Bacterial DNA has been isolated from over 30,000 years ago and have been proven to be resistant to natural antibiotic products, and when compared to current strains, bacteria have had much more time to grow in their resistance, than humans have had to synthesize new antibiotics (Fair and Tor 2004). The nature of bacteria, their rapid growth and adaptation, has led to interesting, yet dangerous strains of pathogens to develop. It is a combination of these traits, and the human misuse of antibiotics, which have placed unintentional pressures on bacteria to produce AMR strains, and to ultimately thrive in the absence of antibiotics (Fair and Tor 2004). The most pressing danger lies in C. perfringens ability to transform nonpathogenic strains into virulent, and potentially fatal, necrotic enteritis causing strains. Resistance related genes, virulence factors, multiple enzymes and toxins, have the capability to be included in the accessory genome of C. perfringens (Lacey et al. 2017). This allows for the risk of AMR strain development to arise in the presence of the human misuse of antibiotics; whether by farmers, medical professionals, natural adaptations, or a failure of collective responsibility, C. perfringens will eventually outcompete modern antibiotics. Food production relies on multiple levels of protection from harmful pathogens, contamination, and quality control. Demand for rises in the production of beef and chicken, along many other foods, has caused an increase in the widespread use of antibiotics (Uzal et al. 2014). Antibiotic resistance is not anything new to this era, and in fact affects many pathogens unrelated to C. perfringens. The attributes which constitute C. perfringens to be an agriculturally significant pathogen include its ubiquitous living conditions, its diverse arsenal of lethal toxins, and its history of economic burden for farmers, medical professionals, and patients alike (Talukdar et al. 2017). The ability for C. perfringens to occupy a variety of living conditions complicates the treatment of foodborne outbreaks. Narrowing the source of an infectious pathogen relies on extensive laboratory testing; this is a challenge with hardy, widespread pathogens. The multiple toxins which C. perfringens has at is disposal further complicates treatment of both animal and human outbreaks. Determining which strain, or if multiple strains, of C. perfringens are involved in a single outbreak is a challenge. However, by identifying the toxins which are released, it is possible to narrow the search and apply known antibiotics or other chemical agents for treatment. The process of inactivating toxins can take years of testing, resources, and capital to pursue (Fair and Tor 2014). Pharmaceutical companies, and researchers alike, have a responsibility to pursue the creation of new antibiotics. Although costly, it is necessary to form new treatments against a variety of pathogens. C. perfringens is just one example that will forever be constantly adapting and forming resistant strains. The agricultural battle to prevent foodborne outbreaks begins with bringing attention to the consequences that will result from a lack of action. Becoming well-educated and raising awareness towards these issues are productive steps, which must be taken, to outcompete C. perfringens ability to contaminate global markets. Literature Cited Uzal, Francisco A et al. “Towards an Understanding of the Role of Clostridium Perfringens Toxins in Human and Animal Disease.” Future microbiology 9.3 (2014): 361–377. PMC. Web. 5 Oct. 2018. Kiu, Raymond, and Lindsay J. Hall. “An Update on the Human and Animal Enteric Pathogen Clostridium Perfringens.” Emerging MicrobesClostridium Perfringens: The Agricultural Significance and Hazards Posed
New Zealand Oral Health Practitioners’ Preparedness. Title: An update on New Zealand oral health practitioners’ preparedness for medical emergencies Running title: Medical emergencies Authors: C L Hong, A W Lamb, J M Broadbent, H L De Silva, W M Thomson Corresponding author: C L Hong, Department of Oral Rehabilitation, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054. Abstract Background and objectives: To update information on the preparedness of New Zealand general dental practitioners (GDPs) and other oral health practitioners (OHPs) for medical emergencies. Methods: Electronic and paper survey of a sample of 889 OHPs (comprising GDPs, specialists, hygienists, therapists and clinical dental technicians) randomly selected from the Dental Register. Results: The response rate was 39.7%. About half of the respondents (43.3%) reported encountering at least one emergency event during the last ten years. Vaso-vagal syncope was the most commonly reported emergency event, followed by hyperventilation. The mean ten-year incidence of emergency events (excluding vaso-vagal syncope and hyperventilation) was 2.6 events (SD, 7). Dentists were 6.8 times more likely to experience emergency events than other OHPs (p<0.001). The majority of OHPs had access to an emergency kit (96.9%). Of the dentists who reported using sedation (excluding relative analgesia), only 27.6% had an opioid antagonist, 52.6% had an advanced airway adjunct, and 59.2% had glucagon. A majority dentists not using sedation (97.2%) and other OHPs (90.2%) had a NZRC certificate at level 4 or above, but only 76.2% of dentists using sedation (excluding relative analgesia) had a NZRC certificate at level 5 or above. Conclusion: The majority of New Zealand OHPs were equipped in training, and equipment for medical emergencies, and New Zealand appears better than many other countries in this respect. However, some OHPs still lacked some of the required emergency equipment, drugs, and training. Introduction The New Zealand population (as with other developed countries) is ageing (Statistics New Zealand, 2015). This means that oral health practitioners (OHPs) are (and will continue to be) providing care for an increasing proportion of elderly patients. This demographic shift towards a greying population is not without its dental implications. Ageing is accompanied by chronic diseases, disabilities and poly-pharmacy (Hung et al., 2011), all of which are risk factors for the occurrence of medical emergencies in dental practices. Thus, the risk of medical emergency events is likely to be increasing. Most medical emergencies can be anticipated, and all OHPs should be well-versed in their prevention and management. Training in the provision of basic life support is considered an essential and fundamental component of dentistry. Despite this, studies have shown general dental practitioners (GDPs) to be inadequately trained for medical emergencies (Alhamad et al., 2015; Arsati et al., 2010; Chapman, 1997; Muller et al., 2008). Only about half of German GDPs were able to provide basic life support (Muller et al., 2008). About two in five Belgian dentists had never had adult basic life support training following graduation, and four in five never had pediatric basic life support training (Marks et al., 2013). Some years ago, only half of New Zealand GDPs had a current CPR or first-aid certificate, and one in five lacked an emergency equipment kit (Broadbent and Thomson, 2001). Overseas studies have indicated that the incidence of medical emergencies in dental practice (excluding syncope) is between 3.3 and 7.0 emergency events per practitioner during a ten-year practice period (Arsati et al., 2010; Atherton et al., 1999; Atherton et al., 2000; Chapman, 1997; Girdler and Smith, 1999). A 2001 study of 314 New Zealand GDPs reported a mean 4.5 emergency events per dentist during a ten-year practice period (Broadbent and Thomson, 2001). While this falls within the reported range, most of those studies are dated, and there is a need for more contemporary information, particularly in light of the ageing population (and its greater tooth retention). Published studies also tended to focus on GDPs. There is a lack of published data on the preparedness of other OHPs for medical emergencies. Only one study investigated the incidence of medical emergencies among both dentists and dental auxiliaries. Atherton et al. (2000) noted that dentists experienced more emergency events than dental auxiliaries (nursing staff, hygienists and radiographers). This suggests that other OHPs also encounter medical emergencies, but evidence for this within the New Zealand dental workforce remains unknown. Moreover, in September 2014, the Dental Council of New Zealand (DCNZ) updated its ‘Codes of Practice for Medical Emergencies in Dental Practice’ (Dental Council of New Zealand, 2014). In this updated standard, the New Zealand Resuscitation Council Certificate of Resuscitation and Emergency Care (CORE) certification level required of OHPs was updated, along with the period of recertification. Little is known about the adherence of OHPs to this updated practice standard. Accordingly, this study investigated the preparedness of New Zealand GDPs and other OHPs for medical emergencies in dental practice. Methods This study was approved by the University of Otago Ethics Committee. Data were collected between March and July 2016. OHPs were randomly selected from the 2015-2016 Dental Register, obtained from the DCNZ. The 896 randomly selected OHPs represented 20% of the source population for each OHP type (GDPs, dental specialists, hygienists, therapists, and clinical dental technicians). A small number (7) who did not have a clinical role or were not practising in New Zealand were considered ineligible and were excluded from the sample, leaving 889 eligible participants. The electronic survey used Qualtrics TM software. A link to the online questionnaire was emailed to each participant in March 2016. Participants who failed to respond within two weeks were sent a reminder email. Those who did not respond to the electronic survey were then sent a questionnaire with a cover letter and reply-paid envelope. Questionnaire The questionnaire sought information on the respondents’ socio-demographic characteristics (specifically gender, age, ethnicity, year of primary dental qualification, and practice location), experience and preparedness for medical emergencies. The frequency of specific medical emergencies was also assessed. To maximise the accuracy of recall, the question on the incidence of vaso-vagal syncope and hyperventilation was limited to the past practising year, while other medical emergencies events to the past ten practising years, or as long as the practitioner had been practising if less than ten years. Information on the availability of emergency equipment and drugs (and confidence in administering these) was also sought. The list of emergency equipment and drugs was derived from the DCNZ’s practice standard (Dental Council of New Zealand, 2014) . Statistical analysis Data were entered electronically and analyzed using version 21 of the Statistical Package for Social Sciences (for Windows) (IBM).The level of statistical significance was set at p < 0.05. For a small number of items, extreme outliers were recoded to the next lowest value for that variable. The statistical significance of observed differences was tested using Analysis of Variance for continuous dependent variables, or Chi-Square tests and Fisher's Exact test (as appropriate) for categorical dependent variables. Results Responses were received from 353 of the 889 invited practitioners giving a response rate of 39.7%. Dentists (GDPs and dental specialists) represented 65.7% of respondents, while the remainder were other OHPs. Comparison with the 2011-2012 Workforce Analysis suggested an over-representation of New Zealand qualified dentists and dentists aged above 50 years within the sample (Table 1). For analysis purposes, the respondent age was dichotomized to less than 50 years old and 50 years or older. Similarly, the year in which practitioners obtained their primary qualification was also divided into two groups for analytical purposes: before 1990 and after 1990. More than half of the respondents (64.4%) listed their ethnicity as New Zealand European. The mean number of patients seen by a dentist in a week was 49 (SD, 26), and 44 (SD, 23) for other OHPs. Most dentists (96.6%) reported treating patients with local analgesia (mean, 49 per week; SD, 26); 36.2% reported using intravenous sedation (IV), oral sedation (OS) or relative analgesia (RA) (IV: mean, 0.6; SD, 3, OS: mean, 0.3; SD, 1, RA: mean, 0.2; SD, 1); and 8.0% reported treating patients under general anesthesia. The use of local analgesia during dental procedures was reported by 74.4% (n=90) of other OHPs (mean, 19; SD, 14). Almost half (48.7%) of OHPs reported updating each patient’s medical history at every visit; 45.8% did it at every new treatment plan/check-up, and the remaining 5.4% updated the medical history only occasionally. Vaso-vagal syncope was the most commonly reported emergency, followed by hyperventilation. Excluding hyperventilation and vaso-vagal events, there were 828 emergency events reported, corresponding to a mean of 2.4 events per respondent during the ten-year period (range, 0-62; SD, 7). Nearly half of respondents (43.3%) reported encountering at least one medical emergency during the last ten years. Dentists experienced a mean of 3.4 events (range, 0-62; SD, 8) and other OHPs a mean of 0.5 events (range, 0-11; SD, 1). Dentists were significantly more likely to experience more emergency events. Other significant emergency events reported were 78 episodes of tachycardia, five episodes of allergic reaction to latex, four episodes of Bell’s palsy, four episodes of vomiting and three episodes of bleeding (Table 2). Most respondents (96.9%) reported having a medical emergency kit available. Only 38.1% reported checking their medical emergency kit more than twice annually. Details of the emergency equipment and drugs kept by respondents are shown in Table 3. Most respondents reported having an ambubag and airway (82.1%), breathing apparatus for oxygen delivery (82.9%), an oxygen cylinder and regulator (82.3%) and a basic airway adjunct (77.2%) available. Among those who reported keeping these items, fewer than three in four were confident in using them. Dentists were further asked to provide information on the availability of a spacer device to deliver salbutamol and disposable hypodermic syringe and/or needles. Of the 70.1% who reported having a spacer device to deliver salbutamol, 82.6% were confident in using the device. A higher proportion of dentists reported having a disposable hypodermic syringe and/or needle available (82.5%), and 76.7% of dentists were confident in using it. A majority of dentists reported having adrenaline (91.3%), glyceryl trinitrate spray or tablets (86.9%), aspirin tablets (82.1%) or a salbutamol inhaler (79.0%) available in their emergency kit. Most respondents (92.9%) reported holding a current NZRC certificate. The majority (97.2%) of dentists who did not use sedation reported holding a NZRC certificate of level 4 or above. Three dentists did not provide information on their NZRC certificate level and one dentist reported having NZRC certificate level 3. For dentists who reported using any form of sedation excluding RA, 76.1% had a NZRC level 5 certificate or above, 22.5% reported having a NZRC level of 4, and 1.4% did not provide information on their certificate level. Most other OHPs (90.2%) had a NZRC level of 4 and above. Four other practitioners had a NZRC level of 3 and two reported having a NZRC level of 2. Five other OHPs did not provide information on their certification level. Data on the emergency items available among dentists who uses any form of sedation (including no sedation) are presented in Table 4. Just over one in four dentists using sedation (excluding RA) reported having an opioid antagonist. Excluding opioid antagonists, dentists who reported not using IV sedation were significantly more likely to have these emergency items than dentist not practicing sedation. The mean number of emergency events reported by dentists over the past ten years by the use of varying modes of sedation (including no sedation) are presented in Table 5. A statistically significant difference was observed in the frequency of angina pectoris, respiratory depression, allergic reaction to a drug, acute asthma and prolonged epileptic seizures between dentists who reported using sedation and those who did not practice sedation. Dentists using GA sedation reported significantly higher occurrence of angina pectoris than dentists used other form of sedation or did not use sedation, and those using RA reported more episodes of acute asthma than those who did not use sedation. Discussion This survey aimed to investigate the preparedness of New Zealand GDPs and other OHPs for medical emergencies. It was found that dentists were significantly more likely to encounter emergency events than other OHPs and that the majority of New Zealand OHPs were adequately prepared to manage a medical emergency. The response rate of 39.7% was higher than that reported by Muller et al. (2008) but lower than other studies (Atherton et al., 2000; Broadbent and Thomson, 2001).This may be attributed to the use of an online survey, which are less likely to achieve responses rates as high as surveys administered on paper (Shih and Xitao Fan, 2008). As with other self-administered survey, there is a tendency to under- or over-report the incidence of medical emergencies. Certain characteristics of the study respondents and differed significantly from the wider New Zealand dental workforce (Table 1). Dentists aged under 50 years and those who qualified overseas were under-represented. Such a difference may affect the generalizability of the findings. Despite these limitations, this is the first cross-sectional survey study which attempts to evaluate the incidence and preparedness of all New Zealand OHPs for medical emergencies in dental practices. Vaso-vagal syncope is the most commonly reported emergency by OHPs, followed by hyperventilation. This is in accordance with previously published studies (Alhamad et al., 2015; Marks et al., 2013; Muller et al., 2008) with the exception of Broadbent and Thomson (2001) who reported hyperventilation as the most common emergency event. Comparison of the findings of the current study in respect of GDPs to those of Broadbent and Thomson (2001) found that while the percentage of GDPs reporting vaso-vagal syncope and hyperventilation was lower than the 2001 study, the overall mean number of events per reporting participant in this study was higher. The incidence of respiratory depression reported by GDPs was 1.5 times lower than in the 2001 study (Broadbent and Thomson, 2001). This may be due to greater awareness and preparedness among GDPs, combined with stricter regulations imposed by the DCNZ. The use of sedation in dentistry has a positive influence on patients, but while it reduces anxiety and fear, it also increases the risk of respiratory depression. This was reflected in this study. Dentists using IV sedation reported a significantly greater incidence of respiratory depression than those who did not. This is, perhaps, unsurprising, as airway complications are the greatest threat to the safety of sedated patients (Tobias and Leder, 2011). However, the overall incidence of hypoglycemia reported by OHPs in our study was higher than that reported by Arsati et al. (2010) and Broadbent and Thomson (2001). Proper diagnosis of hypoglycemia is dependent on the observation of the Whipple’s triad; elevated plasma glucose concentration, hypoglycemic symptoms and relief of symptoms following carbohydrate administration, (Nelson, 1985). It is possible that any one of these symptoms may be overlooked by the practitioner when making a diagnosis resulting in over-diagnosis. Excluding vaso-vagal syncope and hyperventilation, the overall rate of medical emergency events among OHPs in New Zealand was lower than reported in previous overseas studies (Table 6). Comparison with Broadbent and Thomson (2001) suggests a decrease in the incidence of emergency events reported by GDPs, dipping from 4.5 to 2.9 emergency event per practitioner over a ten-year period in this study, p<0.05 (Figure 1). Dentists were 6.8 times more likely to experience an emergency event than other OHPs. This is consistent with findings of the 2000 United Kingdom survey, which also reported a greater frequency of emergency events by dentists than ancillary staff (Atherton et al., 2000). Several factors could contribute the latter difference. First, dentists are more likely to provide more complicated treatment than other OHPs. Second, patients who have more complex medical problems (or who are more anxious) may be more likely to attend a dentist than other OHPs for dental treatment. Being prepared with the proper equipment and drugs for the management of an emergency event is important, and most OHPs did have access to an emergency kit. With respect to GDPs, an 18.2% increase over 2001 was observed in the proportion of GDPs with an emergency kit (Broadbent and Thomson, 2001). The four basic emergency pieces of equipment meant to be contained within an emergency kit (regardless of practitioner type) are an ambubag and airway, breathing apparatus for oxygen delivery, oxygen cylinder and regulator, and basic airway adjuncts. The majority of GDPs (85%-89%) had these items, which was a marked improvement from the 2001 study where it ranged between 24% and 81%. Other OHPs were lacking in the availability of an ambubag and airways (30.3%) and basic airway adjunct (35.2%). The drugs required by the DCNZ practice standard were available to the majority of GDPs, but a relatively high proportion of specialists lacked some drugs, namely glyceryl trinitrate spray or tablets (21.9%), aspirin tablets (40.6%), and salbutamol inhaler (34.4%). The availability of oxygen was not specifically asked about in this survey, instead, the availability of an oxygen cylinder and regulator was assessed. We did not specifically asked OHPs whether the oxygen cylinder was filled. It was assumed that, if respondents had this equipment, oxygen would available. Dentists using sedative agents would be expected to be best prepared with appropriate medications and equipment. While they were well equipped (>86%) with the four basic pieces of equipment (listed in the previous paragraph), they were not well equipped with the additional equipment required for sedation, especially in the availability of an opioid antagonist (27.6%). This study found that overall, dentists practising sedation were better prepared with these additional items than those who did not. It is likely that some practitioners may be using a form of sedation that negates the use of these equipment. However, regardless of the form of sedation used, the requirement set by the DCNZ should always be followed. Proper training in the management of medical emergencies is important. A majority of dentists not using sedation (97.2%) and other OHPs (90.2%) had the appropriate NZRC CORE Level 4. Comparison with other overseas studies found OHPs in New Zealand to be better equipped in this area. Arsati et al. (2010) showed that only 59.6% of Brazilian dentists had undergone some form of resuscitation training, while only 47.5% of Belgium dentists (Marks et al., 2013) and 64% of Australian GDPs had undertaken basic life support trainings or CPR courses (Chapman, 1997). However, additional reinforcement is necessary to ensure that all OHPs have the appropriate NZRC CORE level, and thus the skills required to manage medical emergencies. For dentists using sedation, NZRC CORE Level 5 as outlined by the DCNZ guideline (implemented in 2014) is mandatory. However, almost one in four dentists using sedation (excluding RA) did not have a NZRC Level 5 or above certificate. This may be a concern because these practitioners are likely to undertake more complex procedures, possibly in patients with complicated medical conditions. We observed that they were more likely to experience emergency events in their practices. Conclusion Most New Zealand OHPs were equipped in training and equipment for medical emergencies, and New Zealand appears better than many other countries in this respect. However, the different groups of OHPs were still lacking some of the required emergency equipment and drugs. Our findings also clearly show that while there has been a marked improvement from the 2001 study, some OHPs still lacked training (NZRC CORE), and so, it is possible that these practitioners may lack competence in treating medical emergencies. References Alhamad M, Alnahwi T, Alshayeb H, Alzayer A, Aldawood O, Almarzouq A, Nazir MA(2015). Medical emergencies encountered in dental clinics: A study from the Eastern Province of Saudi Arabia. J Fam Community Med 22(3):175-179. Arsati F, Montalli VA, Florio FM, Ramacciato JC, da Cunha FL, Cecanho R, de Andrade ED, Motta RHL (2010). Brazilian dentists’ attitudes about medical emergencies during dental treatment. J Dent Educ 74(6):661-666. Atherton GJ, McCaul JA, Williams SA (1999). Medical emergencies in general dental practice in Great Britain. Part 1: Their prevalence over a 10-year period. BDJ 186(2):72-79. Atherton GJ, Pemberton MN, Thornhill MH (2000). Medical emergencies: the experience of staff of a UK dental teaching hospital. BDJ 188(6):320-324. Broadbent JM, Thomson WM (2001). The readiness of New Zealand general dental practitioners for medical emergencies. NZ Dent J 97(429):82-86. Chapman PJ (1997). Medical emergencies in dental practice and choice of emergency drugs and equipment: a survey of Australian dentists. Aust Dent J 42(2):103-108. Dental Council of New Zealand (2014). Medical Emergencies in Dental Practice – Practice Standard. Wellington: Dental Council of New Zealand. Girdler NM, Smith DG (1999). Prevalence of emergency events in British dental practice and emergency management skills of British dentists. Resuscitation 41(2):159-167. Hung WW, Ross JS, Boockvar KS, Siu AL (2011). Recent trends in chronic disease, impairment and disability among older adults in the United States. BMC 11(1):1-12. Marks LA, Van Parys C, Coppens M, Herregods L (2013). Awareness of dental practitioners to cope with a medical emergency: a survey in Belgium. Int Dent J 63(6):312-316. Muller MP, Hansel M, Stehr SN, Weber S, Koch T (2008). A state-wide survey of medical emergency management in dental practices: incidence of emergencies and training experience. EMJ 25(5):296-300. Nelson RL (1985). Hypoglycemia: fact or fiction? Mayo Clin Proc 60(12):844-850. Shih T-H, Xitao Fan (2008). Comparing Response Rates from Web and Mail Surveys: A Meta-Analysis. Field Methods 20(3):249-271. Statistics New Zealand (2015). 2013 Census QuickStats about people aged 65 and over. Wellington: Statistics New Zealand. Tobias J, Leder M (2011). Procedural sedation: A review of sedative agents, monitoring, and management of complications. SJA 5(4):395-410. Author details: C L Hong BDS. Department of Oral Rehabilitation, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054. A W Lamb BDS. Dental and oral health department, Level 10, Wellington Hospital, Riddiford St, Newton, 6021. J M Broadbent BDS, PGDipComDent, PhD. Department of Oral Rehabilitation, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054. H L De Silva BDS, MS, FDSRCS, FFDRCSI. Department of Oral Diagnostic and Surgical Sciences, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054. W M Thomson BSc, BDS, MA, MComDent, PhD. Department of Oral Sciences, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054. Table 1. Comparison of respondents’ sociodemographic characteristics with those of the New Zealand (NZ) dental profession. Dentist (%) Dentists in NZ dental profession a (%) Other OHPs (%) Other OHPs in NZ dental profession a (%) Sex Male Female 140 (60.6) 91(39.4) 1347 (64.6) 738 (35.4) 9 (7.4) 112 (92.6) 54 (4.3)c 1191 (95.7)c Age Less than 50 50 and over 104 (45.6) b 124 (54.4) b 1220 (58.5)b 865 (41.5) b 68 (56.2) 53 (43.8) 881 (61.1) 561 (38.9) Country of qualification New Zealand Other 184 (81.4) b 42 (18.6) b 1456 (69.8) b 629 (30.2) b 112 (92.6) 9 (7.4) NR NR a Dental Council of New Zealand (Workforce Analysis 2011-2012) b p<0.05 c Excludes clinical dental technicians NR: not reported Table 2. Incidence of medical emergencies by practitioner type. Cite This Work To export a reference to this article please select a referencing stye below: APA MLA MLA-7 Harvard Vancouver Wikipedia OSCOLA UKEssays. (November 2018). New Zealand Oral Health Practitioners’ Preparedness. Retrieved from https://www./essays/biology/zealand-oral-health-practitioners-4589.php?vref=1 Copy to Clipboard Reference Copied to Clipboard. “New Zealand Oral Health Practitioners’ Preparedness.” .com. 11 2018. UKEssays. 07 2021 . Copy to Clipboard Reference Copied to Clipboard. “New Zealand Oral Health Practitioners’ Preparedness.” UKEssays., November 2018. Web. 16 July 2021. . Copy to Clipboard Reference Copied to Clipboard. UKEssays. November 2018. New Zealand Oral Health Practitioners’ Preparedness. [online]. Available from: [Accessed 16 July 2021]. Copy to Clipboard Reference Copied to Clipboard. UKEssays. New Zealand Oral Health Practitioners’ Preparedness [Internet]. November 2018. [Accessed 16 July 2021]; Available from: Copy to Clipboard Reference Copied to Clipboard. {{cite web|last=Answers |first=All |url= |title=New Zealand Oral Health Practitioners’ Preparedness | |date=November 2018 |accessdate=16 July 2021 |location=Nottingham, UK}} Copy to Clipboard Reference Copied to Clipboard. All Answers ltd, ‘New Zealand Oral Health Practitioners’ Preparedness’ (, July 2021) accessed 16 July 2021 Copy to Clipboard Reference Copied to Clipboard. Related Services View all Essay Writing Service From £124 Dissertation Writing Service From £124 Assignment Writing Service From £124 DMCA / Removal Request If you are the original writer of this essay and no longer wish to have your work published on then please: Request the removal of this essay Related Services Our academic writing and marking services can help you! Find out more about ourEssay Writing Service Dissertation Writing Service Assignment Writing Service Marking Service Samples of our Service Full Service Portfolio Related Lectures Study for free with our range of university lectures! All Available Lectures Freelance Writing Jobs Looking for a flexible role? Do you have a 2:1 degree or higher? Apply Today! Study Resources Free resources to assist you with your university studies! Dissertation Resources at How to Write an Essay Essay Buyers Guide Referencing Tools Essay Writing Guides Masters Writing Guides Essays Biology Facebook logo Twitter logo Reddit logo LinkedIn logo WhatsApp logo Mendeley logo Researchgate logo We’ve received widespread press coverage since 2003 We can help with your essay Find out more SafeNew Zealand Oral Health Practitioners’ Preparedness

Targeted Topics in ABA Unit 5 Discussion

Targeted Topics in ABA Unit 5 Discussion. I’m working on a Psychology question and need guidance to help me study.

Watch the Unit 5 Lecture. (Transcripts)
Read the following scenario.

Setting the Scene:
Sherry is a 15-year-old girl diagnosed with autism and severe intellectual disabilities. Her Individualized Education Program (IEP) team met to discuss Sherry’s serious, self-injurious behavior of hand biting that has resulted in significant tissue damage requiring medical attention. Prior interventions attempted by the school staff were response blocking, physical restraint, and mechanical restraint (arm splints). An initial Functional Behavior Assessment (FBA) conducted by the consulting Board Certified Behavior Analyst (BCBA) revealed that the apparent function of the hand biting was negative reinforcement in the form of escape from task demands. Based on this assessment, the BCBA developed a Differential Reinforcement of Alternative behavior (DRA) intervention in which Sherry was taught to use her hand to squeeze a stress ball when non-preferred demands were presented. The teacher and other individuals involved with Sherry were trained to allow immediate escape whenever Sherry squeezed the stress ball during instruction. In addition, instructional material was altered so that the learning tasks were easier with the goal of gradually increasing task difficulty. Baseline data was taken for 10-days and the DRA intervention was implemented on day 11. On day 21, the BCBA employed a reversal design in which the intervention was stopped to verify that it was indeed the intervention that was responsible for the behavior change.


According to your readings, what are the six primary benefits of using graphs as tools to measure the effectiveness of interventions, and why are they important? Discuss two of the benefits that you feel are most relevant to the current case and explain your reasons for your choices.
Based on your visual analysis of the data in the graph (above), was the DRA effective in reducing Sherry’s hand biting? Discuss the purpose of the reversal design and identify the type of reversal design reflected in the graph.

Guided Response Posts:
Respond to a peer’s primary post by explaining the benefits (purposes) of reversal/withdrawal designs and the risks.
Respond to a second peer’s post by discussing two specific ethical guidelines that are relevant in Sherry’s case.

Reading and Resources
Read the following:
Chapter 6 in Applied Behavior Analysis (3rd edition): “Constructing and Interpreting Graphic Displays of Behavioral Data” (pp. 124-131)
The purpose and benefits of the graphic display of data are introduced. The importance of the visual analysis of behavior data is explained, as are the various formats for the graphic display of data. Level, trend, and variability are discussed in terms of the visual analysis of graphically displayed data and the determination of intervention effectiveness.
Chapter 8 in Applied Behavior Analysis 3rd edition): “Reversal and Multielement Designs” (pp. 171-191)
Two experimental designs commonly used in applied behavior analysis (ABA) research are introduced. The reversal and multi-element (alternating treatments) designs are explained and advantages and disadvantages for their use are presented. An explanation of baseline logic (prediction, verification, and replication), as it relates to these experimental designs, is provided.
Chapter 16 in Ethics for Behavior Analysts (3rd edition): “Conducting a Risk-Benefit Analysis”
Chapter 16 introduces you to the Risk-Benefit Analysis that is recommended in Code 4.05. The authors provide a detailed explanation of the purpose and process of this analysis.

Bailey, J. (2016). Ethics for Behavior Analysts. (3rd ed.)
Cooper, J. O., Heron, T. E., Heward, W. L. (2019). Applied Behavior Analysis. (3rd ed.)
Targeted Topics in ABA Unit 5 Discussion

International Business

essay order International Business. I’m studying for my Business class and need an explanation.

In this assignment, you will take a position on an international business topic that interests you and is
included in one of the course’s learning units. The basis of your position papers will be an article from a
peer reviewed journal that is relevant to your topic.
Position papers should be from 4-6 pages in length with an 11-size font, 1.5-line spacing, and 1″ margins.
They should be prepared in the following format with the following subheadings.

Prepare a concise summary of the topic and recent reference articles, including a citation from an article from a peer reviewed journal. (Recent articles are no more than four years old). Briefly discuss why you selected this issue.

Position of the Author(s).
State the position of the author(s) of the article you selected that relate to your issue.

Analysis of the Issue.
Using critical thinking skills, analyze the articles, including a discussion of the areas in which you agree and disagree. Discuss what you agree AND disagree with keeping in mind that it should be applicable to international business. You may address specific issues or apply the principles involved in the issue.

Relation to Class Material.
Discuss the relation of the articles to applicable topics of interest from our textbook, including the text content and mini lectures located in Course Documents.
Key Contribution to International Business.
Identify and discuss the contribution this topic/issue and articles make to the field of international business. Implications for international managers and /or entrepreneurs should be thoroughly discussed.

NOTE: Professional writing skills are expected (check for proper spelling and grammar before submitting)
and will be factored in your grade. You must select an article from a peer review journal such as
Academy of Management Journal, Academy of Management Review, Journal of Management, Journal
of International Business Studies, Strategic Management Journal, Journal of World Business,
and Management International Review.

Magazines such as Time, Newsweek, The Wall Street Journal, and Fortune are not peer reviewed and are not acceptable.

Grading explanation for position papers:
To receive an “A” on the position paper assignment (135-150 points)
You will use researched reference articles and a supplemental bibliography to support your claims, critique, or proposition. Your analysis will be focused, detailed, and well-grounded with specific examples or theories. Paper will demonstrate careful preparation and critical thinking about the issues you choose to address. Paper will be free of spelling and major grammar errors and will be well-written, adhering to APA guides.
International Business

Justice William

Justice William.

This is a discussion and not a major essayDiscuss the following quotation from Justice William J. Brennan’s dissenting opinion in United States v. Ash, 413 U.S. 300, 344 (1973), in which the U.S. Supreme Court held that there is no right to counsel at any photographic identification procedure: “There is something ironic about the Court’s conclusion today that a pretrial lineup identification is a ‘critical stage’ of the prosecution because counsel’s presence can help to compensate for the accused’s deficiencies as an observer, but that a pretrial photographic identification is not a ‘critical stage’ of the prosecution because the accused is not able to observe at all.”
Justice William

University of California Irvine Banduras Study Discussion

University of California Irvine Banduras Study Discussion.

You should write a original post and reply to 3 persons. ( check the documents. there are rubric and examples from other classmates)In famous studies by Albert Bandura (1963) and his colleagues, children watched adult actors beat up on a big, plastic inflatable toy called Bobo the Clown. The children saw adults punching and kicking the plastic clown. Then the children were allowed to play with the clown, and most of them punched and kicked it too. That research has been used for over 50 years to argue that when children see violence, they will act it out. It has especially been used to argue that children and teens should not be allowed to watch TV shows or movies that depict violence, or to play video games that include violence. What do you think of these arguments? Does this line of reasoning make sense to you? Does it match up with what you’ve seen in your own life? Explain why you think that it is correct or incorrect to interpret Bandura’s studies as evidence that media violence makes children act violently. (And if you think it is not correct, what kind of evidence would make more sense to you?)
University of California Irvine Banduras Study Discussion

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