Caries control in health service practice

It is suggested that it makes sense for dentists providing care for individual patients to take account of caries risk (as assessed by presentation of active, non-cavitated lesions) when deciding how to allocate time and effort of themselves and their staff. However, there is a question as to how realistic it is to ask the dental team to provide a full diagnostic assessment and all the preventive treatment required for a patient for the payment provided by 1 UDA. It is to be hoped that one or more of the Steele pilots will come up with a practical solution for controlling caries in NHS practice.

Incomplete synapsis and chiasma localization: the chicken or the egg?

In the present study, and as a sincere tribute from the Cytogenetics teams from Madrid to Professor Máximo Drets on his 80th birthday, we have analyzed and compared 3 different grasshopper species with different synaptic patterns, a standard pattern, a second pattern with synapsis restricted to the proximal regions, and a third pattern with synapsis restricted to the distal regions. In the 3 species we have thoroughly analyzed the relationships among cohesin axis morphogenesis, formation of double strand breaks (DSBs) and recombination initiation. Our results demonstrate that in every case recombination initiation precedes synapsis, and that there is a direct relationship between the absence of meiotic recombination and the existence of particular unsynapsed chromosomal regions during prophase I. Based on our results we propose and discuss the mechanisms underlying the existence of incomplete synapsis and the localization of chiasma in wild species.

A comparison of treatment outcomes for moxifloxacin versus ofloxacin/metronidazole for first-line treatment of uncomplicated non-gonococcal pelvic inflammatory disease

Large randomized controlled trials support the efficacy of moxifloxacin for the treatment of uncomplicated pelvic inflammatory disease (PID). This study compares the clinical outcome and tolerability of treatment with moxifloxacin 400 mg once a day or ofloxacin 400 mg plus metronidazole 400 mg both twice daily in patients diagnosed with PID. A retrospective case-notes review was performed on patients diagnosed clinically with PID before and after local guidelines were changed to recommend moxifloxacin as first-line treatment for uncomplicated PID. Before the guidelines changed, 114/134 (85%) patients received the recommended first-line therapy versus 206/257 (80%) after the change, P = 0.3. There was no difference in the clinical outcomes between the two groups; significant improvement/resolved 77% versus 70%; marginal improvement 3% versus 11%; no change/worse 20% versus 18%, P = 0.14. Moxifloxacin is confirmed to be an effective alternative to ofloxacin/metronidazole for the treatment of PID in a large urban genitourinary clinic setting.

A graphic framework for teaching critical appraisal of randomised controlled trials

Students of evidence-based medicine often try unsuccessfully to commit to memory a particular critical appraisal framework (often lengthy), or they have to depend on pocket cards and are lost without them. We have described a pedagogic aid: a flow diagram of an RCT, which has been developed over years of teaching residents. This diagram focuses on the steps in an RCT, and by drawing arrows, it highlights the biases possible at each step. This diagram serves as a framework on which the list of critical appraisal questions can be hung and is easy to remember.

Inverted meiosis: the true bugs as a model to study

Most of the meiotic literature is based on species with monocentric chromosomes, however meiosis in protoctist, plant and animal species with holocentric chromosomes is less characterized. In some cases, an inverted meiotic sequence is claimed to occur, in which segregation of homologs is postponed until the second meiotic division. Additionally, other features also deserve interest, namely: (i) the different behavior of sex chromosomes if compared to that of the autosomes; (ii) the absence of a canonical kinetochore structure; (iii) the restriction of the kinetic activity to the chromosomal ends; (iv) the variations in the orientation of bivalents at the division plate, and (v) the possible occurrence of chiasma terminalization. Here we summarize the current knowledge on these topics in the meiosis of Hemiptera (Heteroptera) and present novel results that illustrate some of the special features mentioned above. We also point out the necessity of reviewing the term 'inverted meiosis' and propose some future prospects to study this peculiar meiosis.

Costs of treatment of Swiss patients with HIV on antiretroviral therapy in hospital-based and general practice-based care: a prospective cohort study

Some ambulant people with HIV are cared for primarily by their general practitioner and some in an outpatient clinic. Costs and patterns of care in these settings were studied in 65 such patients based in Zürich, from a limited societal perspective (excluding patient costs) based on medical resource use. Antiretroviral therapy (ART), other medications and patient variables were collected prospectively, and non-medication resources (professional time and investigations) and treatment history data were collected from medical records and by record linkage to the Swiss HIV Cohort Study database. Cost differences between the settings were estimated using multiple regression, controlling for differences in case-mix. ART comprised 80% of the total cost, non-medication costs 15% and non-ART medications 5%. Total costs were higher in the outpatient clinic (estimated additional cost after controlling for case-mix = 3489 Swiss Francs per year at 1999 prices, 95% confidence interval 742 to 6236, p=0.017). The difference was accounted for by higher ART costs in the outpatient clinic, not through a tendency to use more expensive drugs or higher doses but rather through the use of more drugs concurrently. Differences in ART prescribing patterns between the doctors in the outpatient clinic and the general practitioners were considerable and appear worthy of further investigation.

Genomewide linkage scan for obsessive-compulsive disorder: evidence for susceptibility loci on chromosomes 3q, 7p, 1q, 15q, and 6q

Obsessive-compulsive disorder (OCD) is the tenth most disabling medical condition worldwide. Twin and family studies implicate a genetic etiology for this disorder, although specific genes have yet to be identified. Here, we present the first large-scale model-free linkage analysis of both extended and nuclear families using both 'broad' (definite and probable diagnoses) and 'narrow' (definite only) definitions of OCD. We conducted a genome-scan analysis of 219 families collected as part of the OCD Collaborative Genetics Study. Suggestive linkage signals were revealed by multipoint analysis on chromosomes 3q27-28 (P=0.0003), 6q (P=0.003), 7p (P=0.001), 1q (P=0.003), and 15q (P=0.006). Using the 'broad' OCD definition, we observed the strongest evidence for linkage on chromosome 3q27-28. The maximum overall Kong and Cox LODall score (2.67) occurred at D3S1262 and D3S2398, and simulation based P-values for these two signals were 0.0003 and 0.0004, respectively, although for both signals, the simulation-based genome-wide significance levels were 0.055. Covariate-linkage analyses implicated a possible role of gene(s) on chromosome 1 in increasing the risk for an earlier onset form of OCD. We are currently pursuing fine mapping in the five regions giving suggestive signals, with a particular focus on 3q27-28. Given probable etiologic heterogeneity in OCD, mapping gene(s) involved in the disorder may be enhanced by replication studies, large-scale family-based linkage studies, and the application of novel statistical methods.

X and B chromosomes display similar meiotic characteristics in male grasshoppers

We have analysed the chromosome organisation and the location and temporal appearance of different proteins in X and B chromosomes in the grasshopper Eyprepocnemis plorans throughout the first meiotic prophase. We have used adult males that carry a B chromosome collected in natural Spanish populations. The scaffold organisation has been analysed by means of silver stained chromatid cores. In addition, we have detected by immunolabelling the presence of phosphoepitopes, the ensemble of cohesin axes, the location of histone gamma-H2AX, and recombinase Rad51. Our observations demonstrate that X and B chromosomes share similarities in chromatin organisation and in the expression of the tested proteins, which strongly differ from those of the autosomes. These results could be interpreted either as a support to the hypothesis that the Bs analysed here originated from the X chromosome, and/or that their chromatin composition and precocious condensation could determine their meiotic behaviour.

Is HSV serology useful for the management of first episode genital herpes?

BACKGROUND

First episode genital herpes simplex virus (HSV) infections can be classified into three groups, primary genital herpes (no previous exposure to HSV), non-primary first episode (IgG antibody to HSV of the non-presenting type), and first episode with pre-existing IgG HSV antibodies. The use of IgM to classify first episode genital herpes has not been evaluated.

OBJECTIVE

To evaluate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of HSV-1 and HSV-2 IgM antibodies for the diagnosis of first episode genital herpes, when compared with clinical diagnosis.

METHODS

Patients with a first clinical episode of genital herpes were recruited. Sera were tested for IgG antibodies to HSV-2 using an indirect enzyme linked immunosorbent assay (ELISA). Equivocal results were resolved by western blot. HSV-1 IgG and IgM and HSV-2 IgM antibodies were detected using western blot.

RESULTS

157 patients were recruited. 31 were excluded (missing data or no detectable antibodies and negative viral isolation). Therefore, 126 patients were included in the analysis. 23 (18.3%) had primary genital herpes, 34 (27.0%) non-primary first episode, and 69 (54.8%) had pre-existing genital herpes. The specificity and PPV of HSV IgM was 100%; the sensitivity was 79% and the NPV 85%.

CONCLUSION

IgM HSV serology may be useful in the management of some patients with first episode genital herpes and provide an indication of the source of infection. Drawbacks include the low sensitivity and NPV, lack of availability, IgM antibodies may occasionally be produced in response to recurrent infection and, finally, IgM antibodies may take up to 10 days to develop and last 7-10 days.

Quality of generalist vs. specialty care for people with HIV on antiretroviral treatment: a prospective cohort study

OBJECTIVES

To describe health-care use by persons with HIV in an urban area of Switzerland (Zurich). Further, to compare the different health-care settings.

DESIGN

A 1-year prospective cohort study recruiting 60 patients at general practices and 60 patients at a specialized university outpatient clinic.

METHODS

Patients and their treating physicians were interviewed or answered questionnaires, respectively, at baseline, month 6 and 12.

RESULTS

During the study period, five patient groups were identified among the 106 enrolled patients, of whom (i) 42% saw a general practitioner exclusively, (ii) 31% were treated at the specialized outpatient clinic, (iii) 8% were in shared care, (iv) 10% changed health-care model, and (v) 9% were lost to follow-up. Baseline demographic, psychosocial and clinical data were similar among patient groups. At study end, the proportion of patients with HIV-1 RNA < 400 copies/mL was 72%, 74%, 88%, 55% among groups (i) to (iv), respectively (ns), and 22% at month 6 among those lost to follow-up. Indicators for quality of care were similarly good among all patient groups.

CONCLUSIONS

A well-working system offers high-quality healthcare to persons living with HIV, where existing teams of specialty and primary health-care professionals efficiently and effectively co-operate.

[Structures of co-operation between an HIV-outpatient clinic and private care physicians]

OBJECTIVES OF THE STUDY

This qualitative study looks at structures of co-operation between the two major HIV-care settings in the region of Zurich (Switzerland), i.e. a HIV-specialised outpatient clinic at the University hospital and private practitioners. Hypothesizing that good co-operation between the institutions increases the quality and effectiveness of care for patients living with HIV and treated with highly active antiretroviral therapy (HAART), the structures of co-operation are investigated.

METHODS

Qualitative data were collected by means of three focus-group discussions with physicians from both settings. By means of a structured interview guide, different aspects of co-operation were assessed (e. g. current status, deficits, degree of satisfaction). Contents analysis of the data revealed consensus versus dissonance pertaining to different areas of co-operation.

RESULTS

Results show that co-operation has been implemented effectively on three different planes (case-related, knowledge-related, training-related) and generally has been perceived by the participants to function well. Institutions have different emphasis on care (specialists vs. generalists). They formulate different concepts of co-operation, which result in diverse degrees of satisfaction.

CONCLUSIONS

On the basis of the results obtained, suggestions for improved co-operation as recommended by the participants are discussed, which could further increase the quality of HIV-related care.

Navy hearing conservation program: hearing threshold comparisons to Navy SEALS and divers

The study examined hearing threshold for Navy special operations personnel (SEALS (Sea-Air-Land): N = 212; divers: N = 165). Hearing threshold values were obtained and age adjusted using Mantel Haenzel Weighted odds ratio (MHOR) to compare with information in the Navy Hearing Conservation Database. For any threshold above 20 dB in the 500 through 3000 Hz range, the SEALS were significantly less at risk (MHOR = 0.54, p = 0.022) in the right ear, while the divers were significantly less at risk in the left ear (MHOR = 0.61, p = 0.047). For hearing thresholds at 4000 Hz above 40 dB, SEALS were significantly more at risk in both left ear (MHOR = 2.03, p = 0.0043) and right ear (MHOR = 2.58, p = 0.000089), while divers were not different. Risk assessment based on these findings must consider the multiple exposure hazards and critical mission profiles for the Navy special operations personnel. Requirements for mission accomplishment in hazardous environments may deem these risks acceptable.

Impact numbers in health policy decisions

OBJECTIVE

To outline the major methodological issues appropriate to the use of the population impact number (PIN) and the disease impact number (DIN) in health policy decision making.

DESIGN

Review of literature and calculation of PIN and DIN statistics in different settings.

SETTING

Previously proposed extensions to the number needed to treat (NNT): the DIN and the PIN, which give a population perspective to this measure.

MAIN RESULTS

The PIN and DIN allow us to compare the population impact of different interventions either within the same disease or in different diseases or conditions. The primary studies used for relative risk estimates should have outcomes, time periods and comparison groups that are congruent and relevant to the local setting. These need to be combined with local data on disease rates and population size. Depending on the particular problem, the target may be disease incidence or prevalence and the effects of interest may be either the incremental impact or the total impact of each intervention. For practical application, it will be important to use sensitivity analyses to determine plausible intervals for the impact numbers.

CONCLUSIONS

Attention to various methodological issues will permit the DIN and PIN to be used to assist health policy makers assign a population perspective to measures of risk.

Impact numbers: measures of risk factor impact on the whole population from case-control and cohort studies

OBJECTIVE

To describe new measures of risk from case-control and cohort studies, which are simple to understand and relate to numbers of the population at risk.

DESIGN

Theoretical development of new measures of risk.

SETTING

Review of literature and previously described measures.

MAIN RESULTS

The new measures are: (1) the population impact number (PIN), the number of those in the whole population among whom one case is attributable to the exposure or risk factor (this is equivalent to the reciprocal of the population attributable risk); (2) the case impact number (CIN) the number of people with the disease or outcome for whom one case will be attributable to the exposure or risk factor (this is equivalent to the reciprocal of the population attributable fraction); (3) the exposure impact number (EIN) the number of people with the exposure among whom one excess case is attributable to the exposure (this is equivalent to the reciprocal of the attributable risk); (4) the exposed cases impact number (ECIN) the number of exposed cases among whom one case is attributable to the exposure (this is equivalent to the reciprocal of the aetiological fraction). The impact number reflects the number of people in each population (the whole population, the cases, all those exposed, and the exposed cases) among whom one case is attributable to the particular risk factor.

CONCLUSIONS

These new measures should help communicate the impact on a population, of estimates of risk derived from cohort or case-control studies.

Performance on tests of frontal lobe function reflect general intellectual ability

Recent studies have indicated that performance on tests of frontal lobe function are highly associated with general intellectual ability (g). Some authors have even claimed that the available evidence does not support a more specific account of frontal lobe function than to provide a general intellectual function for the performance of goal directed tasks. We examined the relationship between performance on the WAIS-R (as a measure of g) and performance on standard tests of frontal lobe function in 123 healthy individuals. Our results demonstrate that in healthy individuals (i) performance on the most popular tests of frontal lobe function shares significant variance, and (ii) a large proportion of that shared variance is highly associated with performance on the Wechsler Adult Intelligence Scales-Revised (WAIS-R), so that the tests are similar to the extent that they measure g. Performance on the Modified Card Sorting Test (MCST), however, is not related to g. The results support the claim that many tests of frontal lobe function measure primarily a non-specific intellectual function but also indicate that some tests, like the MCST, may be assessing more specific cognitive operations.

A population perspective to evidence based medicine: "evidence for population health"

We explore the notion that the public health community could learn lessons from the success of evidence based medicine (EBM) and develop a public health counterpart called "Evidence for Population Health". While EBM focuses on individual patients, its public health counterpart would aim to improve the health of communities effectively and efficiently.

Do silicone breast implants cause rheumatologic disorders? A systematic review for a court-appointed national science panel

OBJECTIVE

To assist in evaluating expert testimony and scientific evidence presented in law suits brought against silicone breast implant manufacturers, a US District Court Order established a National Science Panel to assess whether existing studies provide scientific evidence of an association between silicone breast implants and systemic classic/accepted connective disease, atypical connective disease, and certain signs and symptoms identified by plaintiffs in the law suits. Local disorders potentially associated with these implants were not addressed in this review. Therefore, we performed a systematic review of published studies on the association between silicone breast implants and systemic connective tissue disorders.

METHODS

Data from relevant studies (human cohort, case-control, or cross-sectional studies with > or = 10 participants and appropriate controls) were identified through literature searches of Medline, Current Contents, HealthStar, Biological Abstracts, EMBase, Toxline, and Dissertation Abstracts. Two independent reviewers, using standard collection forms, extracted data from the included studies. Adjusted relative risks (RRs) in cohort studies and odds ratios (ORs) in case-control and cross-sectional studies were reported if provided; otherwise, unadjusted RRs and ORs were calculated.

RESULTS

Twenty-four studies meeting inclusion criteria were identified. No association was evident between breast implants and any established or atypical connective tissue disorder. There was discordance among studies in reports of arthralgias, lymphadenopathy, myalgias, sicca symptoms, skin changes, and stiffness.

CONCLUSION

The panel found no evidence to support expert testimony suggesting an association between silicone breast implants and connective diseases. Discordance for symptoms may reflect differences in symptoms included in various categories, the small number of cases, and the effect of having single subjects with > 1 symptom represented in analyses of each symptom reported. The process presented here is an early example of the use of independent scientific panels to help courts clarify scientific evidence in legal proceedings.

Audiometric abnormalities in children with Gaucher disease type 3

Exogenous enzyme replacement therapy achieves satisfactory biomedical correction in Gaucher type 1 disease and may halt or reverse neurological progression in type 3, while it does not appear to influence the outcome in type 2. In view of the therapeutic possibilities, early detection and monitoring of type 3 Gaucher disease, as well as evaluation of the effectiveness of enzyme therapy on neuronopathic involvement is necessary. The objective of this study was to evaluate the extent of brainstem disease in children with proven Gaucher type 3, by means of an audiological test battery. We studied 9 patients with Gaucher type 3 disease. The tests included baseline audiometric tests, as well as auditory brainstem evoked responses (ABR), acoustic reflexes and medial olivo-cochlear suppression by contralateral noise tests, that involve overlapping but not identical efferent and afferent pathways and brainstem structures. We found a constellation of abnormalities including bilaterally raised acoustic reflexes, poor medial olivo-cochlear suppression, and very poor brainstem evoked potentials. These abnormalities could be due to a single lesion in the dorsomedial brainstem, or to multiple lesions, and further study is needed to clarify this issue. Combined audiological tests may provide information on the severity of the neurological involvement and should therefore be part of a standard assessment for the diagnosis as well as for long term neurological monitoring of Gaucher type 3 patients.

A graphic framework for teaching critical appraisal of randomized controlled trials

Students of evidence-based medicine often try unsuccessfully to commit to memory a particular critical appraisal framework (often lengthy), or they have to depend on pocket cards and are lost without them. We have described a pedagogic aid: a flow diagram of an RCT, which has been developed over years of teaching residents. This diagram focuses on the steps in an RCT, and by drawing arrows, it highlights the biases possible at each step. This diagram serves as a framework on which the list of critical appraisal questions can be hung and is easy to remember.

Meiotic sister chromatid cohesion in holocentric sex chromosomes of three heteropteran species is maintained in absence of axial elements

It has been suggested that in species with monocentric chromosomes axial element (AE) components may be responsible for sister chromatid cohesion during meiosis. To test this hypothesis in species with holocentric chromosomes we selected three heteropteran species with different sex-determining mechanisms. We observed in surface-spreads and sections using transmission electron microscopy that the univalent sex chromosomes form neither AEs nor synaptonemal complexes (SCs) during pachytene. We also found that a polyclonal antibody recognizing SCP3/Cor1, a protein present at AEs and SC lateral elements of rodents, labels the autosomal SCs but not AEs or SC stretches corresponding to the sex chromosomes. Cytological analysis of the segregational behaviour of the sex univalents demonstrates that although these chromosomes segregate equationally during anaphase I they never show precocious separation of sister chromatids during late prophase I or metaphase I. These results suggest that AEs are not responsible for sister cohesion in sex chromosomes. The segregational behaviour of these chromosomes during both meiotic divisions also indicates that different achiasmate modes of chromosome association exist in heteropteran species.

Diagnosing PID--getting the balance right

The objective of the study was to determine the clinical manifestations and diagnostic criteria used to diagnose presumptive pelvic inflammatory disease (PID) at the Sydney Sexual Health Centre (SSHC). The study was a retrospective, case-note review of all women diagnosed with presumptive PID between April 1991 and December 1997. Seven hundred and thirteen women were included. The commonest recorded symptoms were vaginal discharge (68%), lower abdominal pain (65%) and dyspareunia (57%), while adnexal tenderness (83%), cervical motion tenderness (75%) and cervicitis (56%) were the most frequently recorded examination findings. Sixty-two per cent were prescribed doxycycline and metronidazole. The recording of signs and symptoms in women with presumptive PID was poor and only 22% met the current Centers for Disease Control (CDC) diagnostic criteria. It is likely that PID is over diagnosed in this group of women. This may lead to under diagnosis of other conditions causing pelvic pain and may be detrimental to reproductive health.