Preferred Reporting Items for Diagnostic Accuracy Studies in Endodontics (PRIDASE) guidelines: a development protocol

Diagnostic accuracy studies play an important role in informing clinical practice and patient management, by evaluating the ability of diagnostic testing and imaging to identify the presence or absence of a disease or condition. These studies compare the relative diagnostic strength of the test or device with a reference standard, therefore, guiding clinical decisions on the reliability of the test, the need for further tests, and whether to monitor or treat a particular condition. Inadequate and incomplete reporting of diagnostic accuracy studies can disguise methodological deficiencies and ultimately result in study bias and the inability to translate research findings into daily clinical practice. The Preferred Reporting Items for Diagnostic Accuracy Studies in Endodontics (PRIDASE) guidelines are being developed in order to improve the accuracy, transparency, completeness and reproducibility of diagnostic accuracy studies in the speciality of Endodontology. The aim of this paper is to report the process used to develop the PRIDASE guidelines based on a well-established consensus process. The project leaders (PD, VN) formed a steering committee of nine members (PD, VN, PA, AF, DR, SP, CK, MP, HD) to oversee and manage the project. The PRIDASE steering committee will develop the initial draft of the PRIDASE guidelines by adapting and modifying the Standards for Reporting of Diagnostic Accuracy Studies (STARD) 2015 guidelines, adding new items related specifically to the nature of Endodontics and incorporate the Clinical and Laboratory Images in Publication (CLIP) principles. The initial guidelines will consist of a series of domains and individual items and will be validated by the members of a PRIDASE Delphi Group (PDG) consisting of a minimum of 30 individuals who will evaluate independently the individual items based on two parameters: 'clarity' using a dichotomous scoring (yes/no) and 'suitability' for inclusion using a 9-point Likert Scale. The scores awarded by each member and any suggestions for improvement will be shared with the PDG to inform an iterative process that will result in a series of items that are clear and suitable for inclusion in the new PRIDASE guidelines. Once the PDG has completed its work, the steering committee will create a PRIDASE Meeting Group (PMG) of 20 individuals from around the world. Members of the PDG will be eligible to be the part of PMG. The draft guidelines and flowchart approved by the PDG will then be presented for further validation and agreement by the PMG. As a result of these discussions, the PRIDASE guidelines will be finalized and then disseminated to relevant stakeholders through publications and via the Preferred Reporting Items for study Designs in Endodontology (PRIDE) website (http://pride-endodonticguidelines.org). Periodic updates to the PRIDASE guidelines will be made based on feedback from stakeholders and end-users.

Unintended Consequences of Tele Health and their Possible Solutions. Contribution of the IMIA Working Group on Telehealth

OBJECTIVES

Assess unforeseen consequences of Telehealth and suggest solutions Methods: An outline was created collecting all possible ill effects classified into Clinical considerations, Administrative concerns including interpersonal relations, Technical issues, Legal / Ethical concerns and Miscellaneous. Each topic was assigned to a particular WG member to lead, gather opinion and review existing literature.

RESULTS AND CONCLUSION

A wide array of problems have been described. Except for technical issues, literature on this topic is scant, so this article is based more on personal experience and data collected from surveys. Much can be done to prevent such problems, such as a need for standardization with related clinical studies for devices as well as processes used for telehealth is underlined, besides evaluation of outcomes of projects undertaken.

The presence and distribution of bacteria in dentinal tubules of root filled teeth

AIM

To investigate the distribution of bacteria within the dentine tubular network in a two-chamber model in order to determine a possible route of penetration.

METHODOLOGY

Root canals of teeth in the experimental group (n = 16) were instrumented and root filled using AH26 and gutta-percha. Canals in the teeth serving as positive (n = 1) and negative (n = 1) controls were instrumented, but not root filled. A two-chamber model was fabricated for each root - upper chambers were inoculated weekly with Streptococcus gordonii in brain-heart infusion broth over 90 days. Turbidity of the lower chamber was checked daily. Samples that showed turbidity during the experimental period and samples that showed no signs of turbidity at 90 days were fractured and prepared for SEM examination. SEM examination for the presence of bacteria within the dentinal tubules was performed in the cervical, middle and apical root thirds. In each root third, the depth of bacterial penetration was recorded as inner, middle or outer dentine.

RESULTS

Bacteria were most commonly detected in the cervical third (14 of 30 areas). Irrespective of the root third examined, bacteria were most commonly detected in the inner dentine (i.e. adjacent to the root canal). Only two samples demonstrated bacterial penetration in the outer dentine.

CONCLUSION

The dentine tubular network provides a potential pathway for bacteria to penetrate tooth roots in a two-chamber model.

Advice for Decision Makers Based on an Electronic Health Record Evaluation at a Program for All-inclusive Care for Elders Site

OBJECTIVE

Provide evidence-based advise to "Program of All-inclusive Care for the Elderly" (PACE) decision makers considering implementing an electronic health record (EHR) system, drawing on the results of a mixed methods study to examine: (1) the diffusion of an EHR among clinicians documenting direct patient care in a PACE day care site, (2) the impact of the use of the EHR on the satisfaction levels of clinicians, and (3) the impact of the use of the EHR on patient functional outcomes.

METHODS

Embedded mixed methods design with a post-test design quantitative experiment and concurrent qualitative component. Quantitative methods included: (1) the EHR audit log used to determine the frequency and timing during the week of clinicians' usage of the system; (2) a 22-item clinician satisfaction survey; and (3) a 16-item patient functional outcome questionnaire related to locomotion, mobility, personal hygiene, dressing, feeding as well the use of adaptive devices. Qualitative methods included observations and open-ended, semi-structured follow-up interviews. Qualitative data was merged with the quantitative data by comparing the findings along themes. The setting was a PACE utilizing an EHR in Philadelphia: PACE manages the care of nursing-home eligible members to enable them to avoid nursing home admission and reside in their homes. Participants were 39 clinicians on the multi-disciplinary teams caring for the elders and 338 PACE members.

RESULTS

Clinicians did not use the system as intended, which may help to explain why the benefits related to clinical processes and patient outcomes as expected for an EHR were not reflected in the results. Clinicians were satisfied with the EHR, although there was a non-significant decline between 11 and 17 months post implementation of the EHR. There was no significant difference in patient functional outcome the two time periods. However, the sample size of 48 was too small to allow any conclusive statements to be made. Interpretation of findings underscores the importance of the interaction of workflow and EHR functionality and usability to impact clinician satisfaction, efficiency, and clinician use of the EHR.

CONCLUSION

This research provides insights into EHR use in the care of the older people in community-based health care settings. This study assessed the adoption of an EHR outside the acute hospital setting and in the community setting to provide evidence-based recommendations to PACE decision makers considering implementing an EHR.

A consensus protocol for the determination of the threshold doses for allergenic foods: how much is too much?

BACKGROUND

While the ingestion of small amounts of an offending food can elicit adverse reactions in individuals with IgE-mediated food allergies, little information is known regarding these threshold doses for specific allergenic foods. While low-dose challenge trials have been conducted on an appreciable number of allergic individuals, a variety of different clinical protocols were used making the estimation of the threshold dose very difficult.

OBJECTIVE

A roundtable conference was convened to develop a consensus clinical protocol for low-dose challenge trials for the estimation of threshold doses for specific allergenic foods.

METHODS

In May 2002, 20 clinical allergists and other interested parties were invited to participate in a roundtable conference to develop consensus of the key elements of a clinical protocol for low-dose challenge trials.

RESULTS

A consensus protocol was developed. Patients with convincing histories of food allergies and supporting diagnostic evidence including past challenge trials or high CAP-RAST scores can be enrolled in low-dose challenge trials. Care must be taken with younger patients to assure that they have not outgrown their food allergy. An approach was developed for the medication status of patients entering such trials. Challenge materials must be standardized, for example, partially defatted peanut flour composed of equal amounts of the three major varieties of peanuts (Florunner, Virginia, Spanish). Challenge materials must be appropriately blinded with sensory evaluation used to confirm the adequacy of blinding. A double-blind, placebo-controlled design should be used for low-dose challenge trials. Low-dose challenge trials would begin at doses of 10 microg of the allergenic food and would continue with doses of 100 microg and 1 mg followed by specific higher doses up to 100 mg depending upon the expert judgement of the physician; even higher doses might be applied to assure that the patient is indeed reactive to the particular food. A 30-min time interval would be used between doses, and reactive doses would be expressed as both discrete and cumulative doses. The goal of each challenge would be to develop objective symptoms; trials should not be discontinued on the basis of subjective symptoms only. Statistically, a minimum of 29 patients would be enrolled in low-dose challenge trials for each allergenic food because 0 reactors out of 29 patients at a particular dose allow the conclusion that there is 95% certainty that 90% of allergic individuals will not react to that dose.

CONCLUSION

A consensus protocol was developed. Using this protocol, it will be possible to estimate threshold doses for allergenic foods, the lowest amount that elicits mild, objective symptoms in highly sensitive individuals.

The neuropsychological profile associated with variant Creutzfeldt-Jakob disease

We report the neuropsychological profile associated with variant Creutzfeldt-Jakob disease (vCJD). A retrospective study was carried out of data from neuropsychological reports prepared on 24 patients with vCJD. While there was some variability in neuropsychological profiles, the overall pattern was one of a combined cortical and subcortical dementia, with impaired performance being particularly prominent on tests of memory, executive function, speed of attention, and visuoperceptual reasoning. Across 16 cases where Wechsler Adult Intelligence Scale-Revised intelligence quotient (IQ) scores were available, this profile was in part reflected by an invariably low performance IQ (<90 in all patients). All patients who received tests of verbal fluency, digit-symbol substitution and faces recognition memory showed deficits on these tests. Basic vocabulary, digit span and verbal reasoning skills were relatively preserved in most patients. In four cases who underwent more detailed cognitive testing, additional observations were made of relatively intact long-term autobiographical memory and faces perception. Cognitive impairment may represent one of the earliest features of vCJD and it is possible that, at least in some cases, neuropsychological deficits precede the onset of psychiatric or neurological symptoms. Our findings may help in the early detection and management of patients with vCJD.

Vaccination against influenza: UK health care workers not on-message

Vaccination of health care workers against influenza is considered to be important as a means of protecting patients from nosocomial infection. Vaccine uptake rates have been reported to be no more than 40% and often between 20 and 30%. An evaluation of the performance of UK National Health Service trusts, following a governmental directive to implement vaccination during the winter of 2000-2001, has shown a poor uptake of vaccine. Reasons for accepting or declining vaccine are discussed. There is a need for global leadership on this issue to promote the value of vaccination and to change the behaviour of health care workers.

A neuropsychological-neuropathological case study of variant Creutzfeldt-Jakob disease

We report the first neuropsychological-neuropathological case study of a patient with variant Creutzfeldt-Jakob disease (vCJD) who was seen at the early stages of the disease, and whose cognitive functioning was monitored in the following months until his death. At presentation, his neuropsychological profile included impaired ability to retain new episodic information, deficits on tests of retrieval from semantic memory, and impairments on tests of memory for public knowledge, such as famous personalities. Tests of executive function were also performed poorly. Picture recognition memory and autobiographical memory were relatively spared, as was performance on tests of face perception and complex copying ability. Neuropsychological testing may be useful in monitoring the progression of vCJD, and we provide evidence to show a steady rate of decline in perceptual and naming tasks over a 4-month period. Post-mortem findings showed neuronal loss in the caudate, putamen, dorsal thalamus, cerebellum and occipital cortex. Spongiform changes were found throughout the brain, including the entorhinal cortex and anterior thalamus. Prion protein accumulation was noted in the hippocampus. We hypothesize that primary subcortical damage to structures in the thalamus and neostriatum, together with secondary frontal lobe dysfunction, combine to yield the pattern of neuropsychological impairment and neuropsychological sparing that was found.

Vancomycin pharmacokinetics and Bayesian estimation in pediatric patients

The vancomycin pharmacokinetic profile was characterized in six pediatric patients and the potential of nonlinear mixed effects modeling and Bayesian forecasting for vancomycin monitoring was explored using NONMEM V (1.1). Based on steady state serial vancomycin concentrations, the estimates of mean t1/2, Vd, and Cl derived by the Sawchuk and Zaske method (1) were 3.52 hours, 0.57 L/kg, and 0.12 L/h per kg, respectively. NONMEM analysis demonstrated that a weight-adjusted two-compartment model described individual patients' data better than a comparable one-compartment model. The two-compartment estimates of mean t1/2alpha, t1/2beta, Vss, and Cl were 0.80 hour, 5.63 hours, 0.63 L/kg, and 0.11 L/h per kg, respectively. The relatively long mean t1/2alpha suggests that peak vancomycin concentrations measured earlier than 4 hours postdose do not reflect postdistributional serum concentrations. NONMEM population modeling revealed that a weight-adjusted two-compartment model provided a better fit than a comparable one-compartment model. The resulting population parameters and variances were fixed in NONMEM to obtain Bayesian predictions of individual vancomycin serum concentrations. Bayesian estimation with either a single midinterval or trough sample has the potential to provide accurate and precise predictions of vancomycin concentrations. This should be evaluated using a vancomycin population pharmacokinetic model based on a larger sample of pediatric patients.

Are dental radiographs safe?

Dental patients are often aware that radiation has the potential to harm them but they do not usually understand how or why and what potential harmful effects may arise from dental radiographs. The potential for undesirable effects must be balanced against the benefits obtained from radiographs. Dentists should address the concerns of patients who question the need for radiographs and allow them to make an informed decision. Data are available that relate radiation exposure levels from medical and dental radiographs to normal background exposure levels and allow comparisons with everyday risks in life. Recognized radiation authorities publish guidelines to help dentists with their use of radiographs, although, due to the time lag associated with testing and the publication of results, some of the published data may not always be entirely relevant to currently used X-ray machines and techniques. Dentists also have professional obligations not only to limit the use of radiographs to potentially beneficial situations but also to take good quality diagnostic radiographs, to limit the doses used, to use good radiation safety measures and to use modern equipment to achieve the best possible films. Radiographs must then be properly developed and viewed under appropriate conditions to gain the maximum possible diagnostic information from each exposure.

Endodontic management of combined endodontic-periodontal lesions

Endodontic-periodontal lesions can provide many challenges to clinicians. Although there may be difficulties in establishing a correct diagnosis, this is the most important phase of their management as the diagnosis will determine the type and sequence of treatment required. In general, if the root canal system is infected, endodontic treatment should be commenced prior to any periodontal therapy in order to remove the intra-canal infection before any cementum is removed. This avoids several complications and provides a favourable situation for tissue repair. The endodontic treatment can be completed before periodontal treatment is provided except where there is a "combined endodontic-periodontal lesion with communication"--in these cases, the root canals should be medicated until the periodontal treatment has been completed and the overall prognosis has been reassessed as being favourable. The use of non-toxic intra-canal therapeutic medicaments is essential to destroy bacteria and to encourage tissue healing.

Retrograde amnesia: clinical and methodological caveats

Several clinical and methodological caveats are outlined as they pertain to retrograde amnesia research, and data relevant to these caveats are presented. Three caveats in particular are noted in relation to recently published cases of marked retrograde amnesia; (i) temporal lobe epilepsy may influence memory for news events; (ii) there may be additional, unsuspected pathology in cases of amnesia, such as those with cerebral hypoxia; (iii) degree of media exposure is closely related to performance on the types of news events memory tests that are commonly used in retrograde amnesia research.

Towards internationally acceptable standards for food additives and contaminants based on the use of risk analysis

Internationally acceptable norms need to incorporate sound science and consistent risk management principles in an open and transparent manner, as set out in the Agreement on the Application of Sanitary and Phytosanitary Measures (the SPS Agreement). The process of risk analysis provides a procedure to reach these goals. The interaction between risk assessors and risk managers is considered vital to this procedure. This paper reports the outcome of a meeting of risk assessors and risk managers on specific aspects of risk analysis and its application to international standard setting for food additives and contaminants. Case studies on aflatoxins and aspartame were used to identify the key steps of the interaction process which ensure scientific justification for risk management decisions. A series of recommendations were proposed in order to enhance the scientific transparency in these critical phases of the standard setting procedure.

Recovery of function processes in human amnesia: evidence from transient global amnesia

There are few clues as to the processes that underlie recovery of function from human amnesia. Evidence is offered from the perspective of a study of recovery of function during an episode of transient global amnesia (TGA) that occurred as a complication of a cerebral angiographic procedure being carried out in a neurosciences centre, and where there was therefore a unique opportunity to examine acute changes in memory function. This allowed us to conduct the first quantitative study where shrinkage of anterograde and retrograde memory loss was plotted at four separate intervals throughout the acute recovery process, and also 24 hr later. Recovery of retrograde amnesia preceded recovery from anterograde amnesia. Resolution of a naming deficit more closely paralleled recovery from retrograde amnesia rather than anterograde amnesia. Within retrograde amnesia for public events, there was a temporal gradient of memory loss, with more recent events affected to a greater degree than earlier events. Within anterograde amnesia, picture recognition memory preceded recovery of story recall memory. On the basis of these findings, and related observations in the published literature, it is proposed that recovery from some types of human amnesia, such as that associated with TGA, follows a 'lateral-to-medial' rule--lateral inferotemporal areas that play a major role in retrograde amnesia recover first from hypometabolism related to the TGA attack, followed by 'interface' areas such as the rhinal and parahippocampal cortices that are considered to have a role in both anterograde and retrograde memory functioning, with the last areas to recover physiological integrity being discrete limbic-diencephalic structures such as the hippocampus.