The presenting complaints of low income adults for emergency dental care: an analysis of 35,000 episodes in Victoria, Australia

OBJECTIVE

This study examined the mix of presenting problems faced by a large diverse dental service treating low-income Australian adults and provides a basis for communities to understand and manage demand for dental services.

DESIGN

A retrospective analysis in a state-wide multi-centre dental health service. Data for all patients (in all public adult dental clinics in the state of Victoria during May-Aug 2005) who used the emergency services in a 12 week period were recorded and analysed. A triage question tree was developed and embedded into a neural network based computer triage tool.

RESULTS

Approximately 52% of low income adults presenting for emergency treatment required treatment on the day of triage. The main problem was with natural teeth (89.6%). Of those with natural teeth problems, 41.3% had pain disturbing their sleep patterns and 14.7% had experienced a swelling. Metropolitan patients accessed the services 2.3 times more than rural patients.

CONCLUSION

These data clearly highlight that there is significant opportunity to reduce nearly 48% of on-day demand for emergency dental care through the application of appropriately clinical based triage.

Length of hospitalisation for people with severe mental illness

BACKGROUND

In high income countries, over the last three decades, the length of hospital stays for people with serious mental illness has reduced drastically. Some argue that this reduction has led to revolving door admissions and worsening mental health outcomes despite apparent cost savings, whilst others suggest longer stays may be more harmful by institutionalising people to hospital care.

OBJECTIVES

To determine the clinical and service outcomes of planned short stay admission policies versus a long or standard stay for people with serious mental illnesses.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's register of trials (July 2007).

SELECTION CRITERIA

We included all randomised trials comparing planned short with long/standard hospital stays for people with serious mental illnesses.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based on a fixed effects model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated fixed effects weighted mean differences (WMD).

MAIN RESULTS

We included six relevant trials. We found no significant difference in hospital readmissions between planned short stays and standard care at one year (n=651, 4 RCTs, RR 1.26 CI 1.0 to 1.6). Short hospital stay did not confer any benefit in terms of 'loss to follow up compared with standard care (n=453, 3 RCTs, RR 0.87 CI 0.7 to 1.1). There were no significant differences for the outcome of 'leaving hospital prematurely' (n=229, 2 RCTs, RR 0.77 CI 0.3 to 1.8). More post-discharge day care was given to participants in the short stay group (n=247, 1 RCT, RR 4.52 CI 2.7 to 7.5, NNH 3 CI 2 to 6) and people from the short stay groups were more likely to be employed at two years (n=330, 2 RCTs, RR 0.61 CI 0.5 to 0.8, NNT 5 CI 4 to 8). Economic data were few but, once discharged, costs may be more for those allocated to an initial short stay.

AUTHORS' CONCLUSIONS

The effects of hospital care and the length of stay is important for mental health policy. We found limited data, although outcomes do suggest that a planned short stay policy does not encourage a 'revolving door' pattern of admission and disjointed care for people with serious mental illness. More large, well-designed and reported trials are justified.

Interventions for treating scabies

BACKGROUND

Scabies is an intensely itchy parasitic infection of the skin caused by the Sarcoptes scabiei mite. It is a common public health problem with an estimated global prevalence of 300 million cases. Serious adverse effects have been reported for some drugs used to treat scabies.

OBJECTIVES

To evaluate topical and systemic drugs for treating scabies.

SEARCH STRATEGY

In February 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2006, Issue 1), MEDLINE, EMBASE, LILACS, and INDMED. In March 2007, we also searched the grey literature and sources for registered trials. We also checked the reference lists of retrieved studies.

SELECTION CRITERIA

Randomized controlled trials of drug treatments for scabies.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Results were presented as relative risks with 95% confidence intervals and data combined where appropriate.

MAIN RESULTS

Twenty small trials involving 2392 people were included. One trial was placebo controlled, 16 compared two or more drug treatments, two compared treatment regimens, and one compared different drug vehicles.Fewer treatment failures occurred by day seven with oral ivermectin in one small trial (55 participants). Topical permethrin appeared more effective than oral ivermectin (85 participants, 1 trial), topical crotamiton (194 participants, 2 trials), and topical lindane (753 participants, 5 trials). Permethrin also appeared more effective in reducing itch persistence than either crotamiton (94 participants, 1 trial) or lindane (490 participants, 2 trials). One small trial did not detect a difference between permethrin (a synthetic pyrethroid) and a natural pyrethrin-based topical treatment (40 participants). No significant difference was detected in the number of treatment failures between crotamiton and lindane (100 participants, 1 trial), lindane and sulfur (68 participants, 1 trial), benzyl benzoate and sulfur (158 participants, 1 trial), and benzyl benzoate and natural synergized pyrethrins (240 participants, 1 trial); all were topical treatments. No trials of malathion were identified. No serious adverse events were reported. A number of trials reported skin reactions in participants randomized to topical treatments. There were occasional reports of headache, abdominal pain, diarrhoea, vomiting, and hypotension.

AUTHORS' CONCLUSIONS

Topical permethrin appears to be the most effective treatment for scabies. Ivermectin appears to be an effective oral treatment. More research is needed on the effectiveness of malathion, particularly when compared to permethrin, and on the management of scabies in an institutional setting and at a community level.

Oxidative Stress Induces ADAM9 Protein Expression in Human Prostate Cancer Cells

The ADAM (a disintegrin and metalloprotease) family is a group of transmembrane proteins containing cell adhesive and proteolytic functional domains. Microarray analysis detected elevated ADAM9 during the transition of human LNCaP prostate cancer cells from an androgen-dependent to an androgen-independent and metastatic state. Using a prostate tissue array (N = 200), the levels of ADAM9 protein expression were also elevated in malignant as compared with benign prostate tissues. ADAM9 protein expression was found in 43% of benign glands with light staining and 87% of malignant glands with increasing intensity of staining. We found that ADAM9 mRNA and protein expressions were elevated on exposure of human prostate cancer cells to stress conditions such as cell crowding, hypoxia, and hydrogen peroxide. We uncovered an ADAM9-like protein, which is predominantly induced together with the ADAM9 protein by a brief exposure of prostate cancer cells to hydrogen peroxide. Induction of ADAM9 protein in LNCaP or C4-2 cells can be completely abrogated by the administration of an antioxidant, ebselen, or genetic transfer of a hydrogen peroxide degradative enzyme, catalase, suggesting that reactive oxygen species (ROS) are a common mediator. The induction of ADAM9 by stress can be inhibited by both actinomycin D and cycloheximide through increased gene transcription and protein synthesis. In conclusion, intracellular ROS and/or hydrogen peroxide, generated by cell stress, regulate ADAM9 expression. ADAM9 could be responsible for supporting prostate cancer cell survival and progression. By decreasing ADAM9 expression, we observed apoptotic cell death in prostate cancer cells.

Performance evaluation of an automated image registration algorithm using an integrated kilovoltage imaging and guidance system

Image-guided radiation therapy delivery may be used to assess the position of the tumor and anatomical structures within the body as opposed to relying on external marks. The purpose of this manuscript is to evaluate the performance of the image registration software for automatically detecting and repositioning a 3D offset of a phantom using a kilovoltage onboard imaging system. Verification tests were performed on both a geometric rigid phantom and an anthropomorphic head phantom containing a humanoid skeleton to assess the precision and accuracy of the automated positioning system. From the translation only studies, the average deviation between the detected and known offset was less than 0.75 mm for each of the three principal directions, and the shifts did not show any directional sensitivity. The results are given as the measurement with standard deviation in parentheses. The combined translations and rotations had the greatest average deviation in the lateral, longitudinal, and vertical directions. For all dimensions, the magnitude of the deviation does not appear to be correlated with the magnitude of the actual translation introduced. The On-Board Imager (OBI) system has been successfully integrated into a feasible online radiotherapy treatment guidance procedure. Evaluation of each patient's resulting automatch should be performed by therapists before each treatment session for adequate clinical oversight.

Behavioural and heart rate responses to velvet antler removal in red deer

Heart rate and behaviour during and following velvet antler removal were monitored in yearling red deer stags to determine the extent to which this procedure was perceived by the deer to be aversive. Nine stags normally kept at pasture were habituated over 5 weeks to the following daily handling procedure. Each deer was fitted with a harness containing a heart rate monitor. It was then allowed to run through a fixed course in a deer yard, restrained for 40 s in a mechanical deer crush, and then confined for 3.5 h with the remainder of the group of stags in an indoor pen containing food and water. In Week 6, the deer were subjected to either restraint for 6 minutes (the control treatment) or removal of one velvet antler under local anaesthesia. Each velvet antler was removed on separate occasions, either on Days 1 and 2 (five deer) or Days 3 and 4 (four deer). The control treatment was applied to all deer when velvet antler was not being removed, and on Day 5. Heart rate and behaviour (time taken to enter the treatment area, and number of struggles made during restraint) were measured before and during treatment, and post-treatment activities were recorded at 0, 1 and 3 h (indoors), and at 6 and 9 h (at pasture). Heart rate was higher during the second velvet antler removal treatment than during the first, but lower during the second control treatment than the first (P<0.05). During velvet antler removal, stags struggled more, and after the treatment flicked their ears, shook their heads, and groomed themselves more than control stags (P<0.05). Stags whose velvet antler had been removed spent less time eating than control stags, and spent progressively more time sitting during the 3.5 h of confinement (P<0.05). However, during the paddock observation at 9 h post-treatment, stags which had had their velvet antler removed grazed more than control stags (P<0.05). The increase in heart rate over the two velvet antler removal treatments and the greater amount of struggling during velvet antler removal indicated that it was more aversive than the control treatment. Post-treatment differences in behaviour may have been due to pain following velvet antler removal.

Normalization of microarray data using a spatial mixed model analysis which includes splines

MOTIVATION

Microarray experiments with thousands of genes on a slide and multiple slides used in any experimental set represent a large body of data with many sources of variation. The identification of such sources of variation within microarray experimental sets is critical for correct deciphering of desired gene expression differences.

RESULTS

We describe new methods for the normalization using spatial mixed models which include splines and analysis of two-colour spotted microarrays for within slide variation and for a series of slides. The model typically explains 45-85% of the variation on a slide with only approximately 1% of the total degrees of freedom. The results from our methods compare favourably with those from intensity dependent normalization loess methods where we accounted for twice as much uncontrolled and unwanted variation on the slides. We have also developed an index for each EST that combines the various measures of the differential response into a single value that researchers can use to rapidly assess the genes of interest.

Essential oils from New Zealand manuka: triketone and other chemotypes of Leptospermum scoparium

The triketone chemotype of manuka, Leptospermum scoparium (Myrtaceae), is commercially important because of its antimicrobial activity. Oils from 36 individual plants on the East Cape of New Zealand all showed similar high triketone contents (>20% total triketones) with little seasonal variation. Analyses of oils from 261 individual manuka plants collected from 87 sites throughout New Zealand showed that the high triketone chemotype was localised on the East Cape, although oils with triketone levels up to 20% were found in the Marlborough Sounds area of the South Island. Cluster analysis revealed other chemotypes localised on other areas. Ten further chemotypes are described: alpha-pinene; sesquiterpene-rich with high myrcene; sesquiterpene-rich with elevated caryophyllene and humulene; sesquiterpene-rich with an unidentified sesquiterpene hydrocarbon; high geranyl acetate; sesquiterpene-rich with high gamma-ylangene + alpha-copaene and elevated triketones; sesquiterpene-rich with no distinctive components; sesquiterpene-rich with high trans-methyl cinnamate; high linalol; and sesquiterpene-rich with elevated elemene and selinene. Some of the chemotypes contained aroma compounds at relatively high levels, with a geranyl acetate-rich oil being most notable. Possible origins for this complex array of chemotypes are proposed.

Dietary advice for treatment of type 2 diabetes mellitus in adults

BACKGROUND

While initial dietary management immediately after formal diagnosis is an 'accepted' cornerstone of treatment of type 2 diabetes mellitus, a formal and systematic overview of its efficacy and method of delivery is not currently available.

OBJECTIVES

To assess the effect of type and frequency of different types of dietary advice to all adults with type 2 diabetes on weight, measures of diabetic control, morbidity, total mortality and quality of life.

SEARCH STRATEGY

We carried out a comprehensive search of The Cochrane Library (The Cochrane Library Issue 3, 2003), MEDLINE (1966 to October Week 1, 2003), EMBASE (1980 to Week 40, 2003), CINAHL (1982 to October Week 1, 2003), AMED (1985 to October 2003), bibliographies and contacted relevant experts.

SELECTION CRITERIA

All randomised controlled trials, of six months or longer, in which dietary advice was the main intervention in adults with type 2 diabetes mellitus.

DATA COLLECTION AND ANALYSIS

The lead investigator performed all data extraction and quality scoring with duplication being carried out by one of the other six investigators independently with discrepancies resolved by discussion and consensus. Authors were contacted for missing data. For continuous outcomes, endpoint data were preferred to change data.

MAIN RESULTS

Thirty-six articles reporting a total of eighteen trials following 1467 participants were included. Dietary approaches assessed in this review were low-fat/high-carbohydrate diets, high-fat/low-carbohydrate diets, low-calorie (1000 kcal per day) and very-low-calorie (500 kcal per day) diets and modified fat diets. Two trials compared the American Diabetes Association exchange diet with a standard reduced fat diet and five studies assessed low-fat diets versus moderate fat or low-carbohydrate diets. Two studies assessed the effect of a very-low-calorie diet versus a low-calorie diet. Six studies compared dietary advice with dietary advice plus exercise and three other studies assessed dietary advice versus dietary advice plus behavioural approaches. The studies all measured weight and measures of glycaemic control although not all studies reported these in the articles published. Other outcomes which were measured in these studies included mortality, blood pressure, serum cholesterol (including LDL and HDL cholesterol), serum triglycerides, maximal exercise capacity and compliance. The results suggest that adoption of regular exercise is a good way to promote better glycaemic control in type 2 diabetic patients, however all of these studies were at high risk of bias.

REVIEWERS' CONCLUSIONS

There are no high quality data on the efficacy of the dietary treatment of type 2 diabetes, however the data available indicate that the adoption of exercise appears to improve glycated haemoglobin at six and twelve months in people with type 2 diabetes. There is an urgent need for well-designed studies which examine a range of interventions, at various points during follow-up, although there is a promising study currently underway.

Dietary advice for treatment of type 2 diabetes mellitus in adults

BACKGROUND

While initial dietary management immediately after formal diagnosis is an 'accepted' cornerstone of treatment of type 2 diabetes mellitus, a formal and systematic overview of its efficacy and method of delivery is not currently available.

OBJECTIVES

To assess the effect of type and frequency of different types of dietary advice to all adults with type 2 diabetes on weight, measures of diabetic control, morbidity, total mortality and quality of life.

SEARCH STRATEGY

We carried out a comprehensive search of The Cochrane Library (The Cochrane Library Issue 3, 2003), MEDLINE (1966 to October Week 1, 2003), EMBASE (1980 to Week 40, 2003), CINAHL (1982 to October Week 1, 2003), AMED (1985 to October 2003), bibliographies and contacted relevant experts.

SELECTION CRITERIA

All randomised controlled trials, of six months or longer, in which dietary advice was the main intervention in adults with type 2 diabetes mellitus.

DATA COLLECTION AND ANALYSIS

The lead investigator performed all data extraction and quality scoring with duplication being carried out by one of the other six investigators independently with discrepancies resolved by discussion and consensus. Authors were contacted for missing data. For continuous outcomes, endpoint data were preferred to change data.

MAIN RESULTS

Thirty-six articles reporting a total of eighteen trials following 1467 participants were included. Dietary approaches assessed in this review were low-fat/high-carbohydrate diets, high-fat/low-carbohydrate diets, low-calorie (1000 kcal per day) and very-low-calorie (500 kcal per day) diets and modified fat diets. Two trials compared the American Diabetes Association exchange diet with a standard reduced fat diet and five studies assessed low-fat diets versus moderate fat or low-carbohydrate diets. Two studies assessed the effect of a very-low-calorie diet versus a low-calorie diet. Six studies compared dietary advice with dietary advice plus exercise and three other studies assessed dietary advice versus dietary advice plus behavioural approaches. The studies all measured weight and measures of glycaemic control although not all studies reported these in the articles published. Other outcomes which were measured in these studies included mortality, blood pressure, serum cholesterol (including LDL and HDL cholesterol), serum triglycerides, maximal exercise capacity and compliance. The results suggest that adoption of regular exercise is a good way to promote better glycaemic control in type 2 diabetic patients, however all of these studies were at high risk of bias.

REVIEWERS' CONCLUSIONS

There are no high quality data on the efficacy of the dietary treatment of type 2 diabetes, however the data available indicate that the adoption of exercise appears to improve glycated haemoglobin at six and twelve months in people with type 2 diabetes. There is an urgent need for well-designed studies which examine a range of interventions, at various points during follow-up, although there is a promising study currently underway.