Social dimensions of adolescent substance use

OBJECTIVES

The aim of this study was to explore in detail the relationship between various social aspects of young people's lives and substance use and differences in the degree of influence exerted by the different social factors as a function of age. Design, setting, participants. The study was a survey of pupils aged 11-16 in a stratified sample of five English schools. Data from 4516 participants were obtained in relation to their cigarette, alcohol and illicit drug use and their contact with the police, perceived academic achievements and future expectations, religious beliefs, family structure, the importance of family versus peer opinions and suspension from school.

MEASURES

Cumulative, age-specific preferences of substance misuse were compared. Logistic regression was used to rank the various risk factors.

RESULTS

Substantial differences were found between substance users and non-users and the various risk factors being examined. For example, of those who had only been in trouble with the police, 18.8% used illegal drugs compared with 1.6% of those who had not had a police contact and who had no other risk factors. Many of these relationships were age-sensitive. For instance, the negative relationship between belief in God and illicit drug use became stronger as age increased (non-believers: y = 8.1886x - 9.16 R(2) = 0.9484; believers: y = 5.1514x - 8.08 R(2) = 0.9247). These results suggest that, within this sample of English adolescents, there was a strong relationship between substance use and the social factors examined. Although there were differences depending upon whether cigarette, alcohol or illicit drug use was being modelled, logistic regression indicated that the social factors could be ranked in the following order of importance: concurrent use of the second and third substances, having been in trouble with the police, perceived poor academic performance and low future academic expectations, a lack of religious belief, coming from a non-intact family, favouring peer over family opinion and having been suspended from school. Many of these relationships were age-sensitive with substance use peaking at age 15.

CONCLUSION

The models and relationships presented in this paper show that a constellation of behaviours are related to adolescent substance use. Also demonstrated is that behaviours cannot be considered in isolation, but need to be examined from an holistic or biopsychosocial standpoint. These relationships are complex and future research should consider not only causality of adolescent substance use, but also of the aetiology of the satellite behaviours.

Trends in community violence in England and Wales 1995-1998: an accident and emergency department perspective

OBJECTIVES

To identify overall, seasonal, sex and age specific national trends in community violence from an accident and emergency (A&E) department perspective.

DESIGN AND SETTING

Prospective collection of national violence data from a stratified random sample of 33 A&E departments in England and Wales.

METHODS

Data were analysed for the three years from May 1995 to April 1998. Time series statistical methods were used to detect trends among those aged 0-10, 11-17, 18-30, 31-50 and 51 + years.

RESULTS

121475 assaults were identified: 89533 (74%) men sustained injury. Forty five per cent were aged 18-30. The significant trends were an increase in injured women and those aged 31-50. Significant seasonal trends were identified for both sexes and all age groups: peaks were found in July to September and troughs in February to April.

CONCLUSIONS

There was no overall significant change in levels of violence between 1995-1998 from an A&E department perspective. Numbers of women injured and those aged 31-50 increased significantly. The incidence of injury sustained in community violence is biphasic: is highest during July to September and lowest during February to April. National A&E department violence surveillance provides a unique perspective.

Comparison of decisions regarding prophylactic removal of mandibular third molars in Sweden and Wales

OBJECTIVE

To test the hypothesis that Swedish dentists schedule more mandibular third molars for prophylactic removal compared with UK dentists and oral surgeons.

DESIGN

Clinical and radiographic information relating to a stratified sample of 36 disease-free mandibular third molars (equal distribution of males and females, patients' age, angular position and degree of impaction) was presented to 26 general dental practitioners (GDPs) and 10 oral surgeons in Sweden and 18 GDPs and 10 oral surgeons in Wales who were asked to decide whether or not the third molars should be removed.

RESULTS

There was no evidence of any difference in mean number of molars scheduled for removal by the GDPs, but the Swedish oral surgeons scheduled significantly more third molars for removal than oral surgeons in Wales.

CONCLUSION

The less interventionist approach among oral surgeons in the UK may reflect the development and application of authoritative guidelines in the UK and an extensive debate concerning appropriateness of prophylactic removal there.

Secondary bone grafting of alveolar clefts: a densitometric comparison of iliac crest and tibial bone grafts

OBJECTIVE

To evaluate changes in the optical density of secondary alveolar cleft bone grafts obtained from two different donor sites over time and to determine whether one donor site gives a higher recipient bone density than the other.

METHODS

A prospective study was performed evaluating 40 healthy patients with congenital cleft lip and palate undergoing secondary alveolar bone grafting, 20 (14 boys and 6 girls) having iliac crest and 20 (12 boys and 8 girls) receiving tibial bone grafts. Bone harvest and grafting was carried out by one operator (G.P.). Optical density of iliac and tibial grafts measured using a computerized densitometer, was compared at 6 days, 6 weeks, and 3 months. Due to interference from orthodontic appliances, optical density measurements for 16 subjects were not possible, and these patients were excluded from the study. The length of hospital stay postoperatively for both grafting procedures were recorded.

RESULTS

A significant decrease in relative bone density was demonstrated during the 3-month postoperative period in both iliac and tibial bone graft groups (p < .05). The difference in densities between iliac crest and tibial groups were not significantly different at any of the time points (paired t test, p > .05). Subjects undergoing iliac crest grafts stayed an average of 5 days in the hospital postoperatively, compared with subjects with tibial grafts who stayed an average of 3 days postoperatively.

CONCLUSION

Optical density measurements of bone grafted into alveolar clefts, reported here for the first time, provide a valuable objective assessment of graft progress. Tibial and iliac crest grafts gave similar optical densities at recipient sites over the first 3 months. Iliac crest grafts required significantly longer postoperative stay; an important consideration in selecting donor sites for secondary bone grafting.

The outcomes of mandibular third molar removal and non-removal: a study of patients' preferences using a multi-attribute method

The aim was to study patients' preferences about outcomes of mandibular third molar removal and non-removal using multi-attribute utility (MAU) methodology. The study comprised three stages. Stage 1: Elicitation of domains, i.e. main areas of patients' lives which could be affected by third molar removal and non-removal. Stage 2a: Interdomain weighting was obtained by relative weighting of the domains elicited in Stage 1. Stage 2b: Intradomain weighting obtained by patients' designation of values for different health states of each domain. Stage 3: Rating of outcomes. The patients were asked to imagine experiencing a variety of outcomes of mandibular third molar removal and non-removal, described in 19 short vignettes. The numbers of patients interviewed for the three stages were 30, 78, and 55, respectively. Five domains were identified. The mean relative weightings were approximately equal for the domains "Home and social life" and "General health and well-being", followed in order of importance by 'Job and studies" and "Health and comfort of mouth, teeth and gums". "Your appearance" received the lowest mean relative weighting. The vignette, which described the presence of a fluid-filled sac and suggested that this tooth must be removed, received the highest mean preference (least effect on patients' lives). The lowest mean preference (most effect on patients' lives) was generated by the vignette, which stated that the jaw was broken and that the teeth must be wired together for 6 weeks. We conclude that, from the patient's perspective, outcomes of non-removal were preferable to outcomes of mandibular third molar removal.

A controlled trial of three referral methods for patients with third molars

AIM

To evaluate the accuracy, sensitivity and specificity of three primary to secondary care referral strategies.

METHOD

Thirty two primary care dental practitioners (GDPs) were randomly allocated one of three referral strategies: current practice (control strategy); a neural network embedded within a computer program and a paper-based clinical algorithm. One hundred and seven patients were assessed for lower third molar treatment: 47, 30 and 30 in each group, respectively. Clinical details were assessed by a panel of experts against a gold standard for third molar removal (the National Institutes of Health criteria). The accuracy, sensitivity, specificity, positive and negative predictive values were calculated for each strategy.

RESULTS

The referral decisions made by the GDPs in the control group displayed greater accuracy and sensitivity but poorer specificity (0.83; 0.97; 0.22) compared with the neural network (0.67; 0.56; 0.79) and clinical algorithm (0.73; 0.56; 0.93).

CONCLUSIONS

It was concluded that incorporation of the clinical algorithm into primary care was the most appropriate option. The computer neural network performed less well than either current practice or the clinical algorithm.

The minor oral surgery outcome scale: a multi-attribute patient-derived outcome measure

PURPOSE

The purpose of this study was to produce a clinically useful, patient-derived, minor oral surgery outcome scale.

PATIENTS AND METHODS

Seventy-seven consecutive patients scheduled for minor oral surgery were interviewed using semistructured interview techniques to identify those areas of life (domains) that patients believed will be affected by minor oral surgery. These interviews were analyzed by a multidisciplinary panel and a scale based on 5 domains, each with 4 outcome statements was constructed. The domains and outcome statements were weighted in terms of importance by a further consecutive sample of 100 patients using resource allocation and visual analog tasks. An additive mathematical formula was applied to the mean weights for each domain and outcome states to produce the final weighted scale.

RESULTS

Five domains were identified from the interviews and weighted according to their order of importance (0 to 100 scale; 0 = least important). These were general health and well-being (24.6); impact on home/social life (20.8); health and comfort of the mouth, teeth, and gums (20.0); appearance (18.8); and impact on job/studies (15.8).

CONCLUSION

A clinically applicable, multi-attribute outcome scale has been produced that takes into account all determinants of health outcome as perceived by the patient in the context of minor oral surgery. It is completed by selecting a weighted statement from each domain, the sum of which constitutes the patient's health state utility score. The scale has potentially extensive application to both clinical care and research.

The development of an assault patient questionnaire to allow accident and emergency departments to contribute to Crime and Disorder Act local crime audits

OBJECTIVE

To evaluate and refine an assault patient questionnaire to facilitate the contribution of accident and emergency (A&E) departments to Crime and Disorder Act local crime audits.

METHOD

A brief nine item questionnaire was devised in collaboration with the authors of the Home Office British Crime Survey. A prospective sample of 46 consecutive assault patients who attended Cardiff Royal Infirmary A&E department were interviewed by either reception staff or triage nurses. The questionnaire was revised appropriately.

RESULTS

The collection of information in A&E departments about the circumstances of violence was straightforward. Questions about motive for violence and about relationships between the injured and their assailants were problematic.

CONCLUSION

The collection of information relevant to Crime and Disorder Act crime audits was possible without extra resource. Receptionists were found to be the most appropriate staff to record information.

Posttraumatic stress reactions after injury

BACKGROUND

Many individuals experience psychological distress after injury. It is unclear whether poor psychological outcome reflects pretrauma variables.

METHODS

In a prospective, cross-sectional study, 152 accident and emergency department patients with physical injuries and an acute stress reaction completed trauma and psychometric questionnaires, including the Impact of Event Scale and the Hospital Anxiety and Depression Scale.

RESULTS

Although levels of pretrauma social, occupational, and familial functioning were high, and the modal Abbreviated Injury Scale score was 1, there were high levels of psychological distress at 3 weeks. Mean Hospital Anxiety and Depression Scale anxiety and depression scores were 11.8 (SD, 4.4) and 8.7 (SD, 4.4), respectively. The mean total Impact of Event Scale score was 46.0 (SD, 16.1). Stepwise linear regression analysis found unemployment and previous history of trauma to be associated with increased symptoms of traumatic stress.

CONCLUSION

Trauma patients with high levels of pretrauma functioning may develop acute psychological distress. Unemployment and previous trauma increase risk. Psychological wellbeing should be considered in routine injury assessments.

Effectiveness of toughened glassware in terms of reducing injury in bars: a randomised controlled trial

OBJECTIVE

To evaluate the effectiveness, in terms of injury prevention, of toughened pint glassware in bars.

DESIGN

Randomised controlled trial.

SETTING

A random sample of 57 bars in South Wales, West Midlands, and West of England.

SUBJECTS

A total of 1229 bar workers.

INTERVENTION

Complete replacement of pint glasses with annealed (control) or toughened (intervention) glassware.

MAIN OUTCOME MEASURES

Bar staff injuries recorded monthly: number, site, and severity (lifestyle impact; treatment need) of injuries.

RESULTS

Ninety eight bar staff experienced 115 injuries: 43 in the control group, 72 in the intervention group. Adjusting for people at risk gave a relative risk (RR) of 1.48 (confidence interval (CI) 1.02 to 2.15). Similarly, adjusting for hours worked gave RR 1.57 (CI 1.08 to 2.29). Thus, injury rate was 60% higher in the intervention group (p<0.05), with no significant difference in severity. Most were hand injuries requiring first aid. Injuries tended to occur simultaneously in more than one body part in the intervention group, reportedly caused by spontaneous disintegration of toughened glassware. Impact resistance testing showed the energy required to break annealed glass (1.8 +/- 0.2 J) was greater than that for toughened glass (1.4 +/- 0.2 J), though the difference was not significant.

CONCLUSIONS

Glass with lower impact resistance caused more injuries. "Toughened" glassware had lower impact resistance. Standards for toughening need to be developed.

Perceived risk of future pathology associated with pathology-free third molars: a comparison of oral and maxillofacial surgeons and family dentists

OBJECTIVE

To examine and compare practitioners' judgements of risk of future pathology associated with pathology-free disease asymptomatic third molars.

SUBJECTS

10 oral and maxillofacial surgeons and 18 family dentists (90% male) with experience ranging from 5-28 years.

METHOD

Participants were presented with periapical radiographs of 36 asymptomatic, disease-free mandibular third molars and were informed of the age and sex of the patients and the degree of eruption of the third molars. Participants were asked to assess likelihood of future pathology in general, and more specifically, likelihood of root resorption, pericoronitis, periodontitis, cystic change and neoplasia if the third molar was left in situ.

RESULTS

There was significant variation between the 28 raters but not between the two groups. Excepting assessment of future cystic change, there was no evidence that oral and maxillofacial surgeons and family dentists rated the 36 cases in consistently different ways.

CONCLUSIONS

Practitioners varied very considerably in their judgment of the risks of pathology associated with asymptomatic disease-free third molars. Specialisation, did not account for this variation.

Ultrasound-guided needle aspiration of lateral masticator space abscess

Shortly after admission with facial space infection, ultrasound-guided needle aspiration of lateral masticator space abscess was carried out in 2 adult patients. One abscess was associated with pericoronitis and the other with post-extraction infection. Successful aspiration of pus was followed by an instantaneous improvement in the ability to open the mouth for a period of at least 24 hours. This obviated the need for conscious nasoendoscopic intubation and allowed orotracheal intubation for conventional drainage. We concluded that ultrasonography can be beneficial in the management of orofacial infections.

The cost, effectiveness and cost effectiveness of removal and retention of asymptomatic, disease free third molars

PURPOSE OF INVESTIGATION

The study was undertaken to identify the least costly, most effective and most cost-effective management strategy for asymptomatic, disease free mandibular third molars.

METHODS AND PATIENTS

A decision tree model of the outcomes of mandibular third molar retention and removal was constructed. Probability data for possible outcomes were obtained from a comprehensive literature review and entered into the decision tree. The cost to the NHS in treating each outcome was calculated. 100 patients attending the oral surgery clinics, University of Wales Dental Hospital rated the effect of each outcome on their own life. The cost and effectiveness data for each outcome were entered into the decision tree and the analyses were conducted by 'folding back' the decision tree based on the probabilities.

MAIN FINDINGS

Mandibular third molar retention was less costly (170 Pounds), more effective (69.5 effectiveness units on a 100 point scale) and more cost-effective (2.43 Pounds per unit of effectiveness) than removal (226 Pounds, 63.3 and 3.57 Pounds respectively). These findings were sensitive to changes in the probability of pericoronitis, periodontal disease and caries.

PRINCIPAL CONCLUSIONS

Mandibular third molar retention is less costly to the NHS, more effective for the patient and more cost-effective to both parties than removal. However, should the likelihood of developing pericoronitis, periodontal disease and caries increase substantially then removal becomes the more cost-effective strategy.

Effect of closed circuit television on urban violence

OBJECTIVE

To evaluate the effect of city and town centre closed circuit television (CCTV) surveillance on violence in terms of accident and emergency (A&E) department and police assault data.

METHODS

A&E department and local police assault data in three centres in Wales (Cardiff, Swansea, and Rhyl) two years before and two years after the installation of CCTV were studied. British Crime Survey and police crime statistics were used as control data.

RESULTS

A&E records of 24,442 assault patients and 3228 violent offences recorded by the police were studied. Data from two A&E departments (Swansea (+3%) and Rhyl (+45%)) showed increases in recorded assaults after CCTV installation but a decrease (12%) in the largest centre, Cardiff. There was an overall reduction in town/city centre violence from the A&E department perspective of 1% in the two years after CCTV installation. In contrast, police data demonstrated changes in the opposite direction (-44%, -24%, and +20% respectively) contributing to an overall decrease of 9%. British Crime Survey and police statistics for England and Wales demonstrated no overall change and a 16% increase respectively.

CONCLUSIONS

City centre CCTV installation had no obvious influence on levels of assaults recorded in A&E departments. There was a negative relationship between police and A&E recording in all three centres. A&E departments are important and unique sources of information about community violence.

Factors influencing nerve damage during lower third molar surgery

OBJECTIVE

To investigate relationships between pathology, eruption status, age, anaesthetic modality and nerve damage during lower third molar surgery.

DESIGN

Single centre prospective study.

SETTING

Oral surgery out-patient clinics.

SUBJECTS

367 patients unselected for age, gender or social class, scheduled for lower third molar removal. At 1 week, any evidence of iatrogenic nerve damage was recorded. Patients with altered lingual and/or labial sensation were followed up for 6 months.

RESULTS

718 lower third molars were removed from 250 males and 117 females. 96 removals (13.4%) were associated with altered lingual, labial or buccal sensation. There were no significant associations between nerve damage and eruption status, age and pre-operative pathology. There was a highly significant difference in the incidence of nerve damage between LA removal (3%) and GA removal (18%) (chi-squared = 17.18; f = 2; P < 0.01) but no significant associations between surgical difficulty and nerve damage within each of the two groups.

CONCLUSIONS

Lingual and inferior alveolar nerve damage was five times more frequent when lower third molars were removed under general anaesthesia rather than local anaesthesia. This could not be explained in terms of surgical difficulty, pre-operative pathology, age or anatomical position.

The circumstances and scope for prevention of maxillofacial injuries in cyclists

A prospective study of cyclists with maxillofacial injuries attending Accident and Emergency departments in South Wales was carried out over a 12 month period. 65% of the 104 accident victims were aged under 14 years, and 81% were male. Only 14% were wearing helmets. Injuries were mapped to 9 facial zones. Nearly half the victims sustained injury to the central facial zone. There was an association between head injury (HI) and the location of impact on the face (p < 0.0001 Chi-square = 41 df = 8), the nature of the accident (p < 0.012 Chi-square = 10.9 df = 3), and type of injury in the impact zone (p < 0.007 Chi-square = 13.4 df = 4). More patients with facial injuries but without facial bone fractures sustained HIs than those with fractures. The facial skeleton may protect the brain by absorbing impact. The high incidence of midface injuries could be reduced by incorporating a facebar in helmet design.

Impact of third molar removal on demands for postoperative care and job disruption: does anaesthetic choice make a difference?

A prospective cohort study was undertaken to investigate the influences of anaesthetic modality and surgical difficulty on social reintegration and demands on health services after third molar removal. The study was undertaken at the Oral and Maxillofacial Surgery Department, Cardiff Dental Hospital. Of 444 patients, 266 (60%) had their third molars removed. The main outcome measures included anaesthetic modality, surgical difficulty (WHARFE scores), utilisation of health services, effects on work, school and home life. In all, 101 (40%) patients were treated under local anaesthesia (LA) +/- intravenous (i.v.) sedation and 165 (60%) under general anaesthesia (GA); 81 (49%) as inpatients and 84 (51%) as day cases. Of these patients, 38 (14%) returned to the hospital and 74 (28%) utilised primary care services postoperatively in addition to a standard review appointment. Patients treated under GA made more demands on primary care services (chi 2 = 6.41, df = 2, P < 0.05) and took more time away from work (P < 0.05). Patients underestimated the time they needed to recover. There was similar disruption to job, college and home life. There were no links between disruption and particular anaesthetic modalities and surgical difficulty. Surgery under GA was linked to increased postoperative demands on primary care, but not secondary care, and to longer job disruption. This could not fully be attributed to surgical difficulty.

Brief interventions for patients with alcohol-related trauma

Patients who have sustained alcohol-related injuries are frequently treated in departments of oral and maxillofacial surgery. Often, an alcohol intervention will not be possible in accident and emergency departments due to intoxication but, when attending out-patient clinics for follow-up, patients are usually sober. This presents a unique opportunity for encouraging patients to review their alcohol consumption at a time when their facial injury may make them more receptive to advice. This article reviews the convincing evidence of the effectiveness of advice and brief interventions designed to be incorporated into standard out-patient consultations and describes practical screening of patients for harmful drinking, the Stages of Change Model of behaviour change and motivational interviewing for facilitating behavioural change.

Choice of anaesthetic and healthcare facility for third molar surgery

A prospective investigation was carried out to find out which factors affected the choice of anaesthetic for 444 consecutive patients (153 male, 291 female, age range 15-85) listed for extraction of third molars. Two hundred and seventy-two were listed for treatment under general anaesthesia, 120 (44%) as inpatients and 152 (60%) as day cases. The remaining 144 (32%) patients were to be treated under local anaesthesia and 28 (6%) with additional intravenous sedation. Logistic regression analysis showed that difficulty of surgery, patients' anxiety, patients' preferences, medical history, and number of teeth to be removed were important predictors of choice of anaesthetic. From an anaesthetist's perspective, many more patients should have been treated under local anaesthesia with intravenous sedation and fewer should have been listed for inpatient extraction under general anaesthesia.