IDEA tool: Establishing a prioritisation matrix for oral health improvement interventions

Initial impetus for action: Oral health is not equitably distributed. More deprived areas experience appreciably worse oral health outcomes. Oral health improvement programmes in Local Authorities (LA) seek to reduce these inequalities but have diminished in recent years following the COVID-19 pandemic. LAs have also endured funding cuts to public health budgets, placing a greater emphasis on the need for establishing a clear prioritisation matrix for oral health improvement interventions. Solution: A prioritisation matrix that considered both the importance and do-ability of oral health improvement interventions was developed. Both are composite measures. The importance comprised evidence of benefit, impact on inequalities, alignment with national/local priorities and cost-effectiveness of the intervention. The do-ability considered the available support from stakeholders, building/equipment requirements, workforce issues and investment funding. A working group was necessary to inform the do-ability aspect of the prioritisation matrix. Scores were assigned to each criterion, the sum of the scores informed whether the intervention was eliminated, aspirational or implemented based on predetermined thresholds. Outcome: The prioritisation matrix ensured a transparent and systematic approach for intervention selection, which reflected local resources and priorities. Moreover, this tool should help ensure the most effective, equitable, practical and sustainable interventions are chosen having the greatest impact on improving oral health outcomes.

Living With Endometriosis: A Reflexive Thematic Analysis Examining Women's Experiences With the Irish Healthcare Services

Endometriosis is an incurable chronic condition associated with debilitating pain and subfertility, affecting 1 in 10 women. The current study aims to explore the perceptions and experiences of women with endometriosis regarding the diagnosis, support and treatment options available in Ireland. It will further determine whether additional supports or improvements are needed to care well and effectively for women with this disease in the Irish healthcare system. A qualitative study design was deemed most suitable. Twenty participants, women aged 18 and over with a diagnosis of endometriosis and experience of the Irish healthcare system, were recruited through purposeful sampling to complete semi-structured, one-to-one online interviews. Data was analysed using reflexive thematic analysis, and five themes were identified: 'dismissive attitudes normalising severe pain', 'inadequate health system', 'the impact of delayed diagnoses', 'lack of education and awareness' and 'navigating ignorance, taboo and societal views'. Insights into the experiences and needs of women diagnosed with endometriosis in Ireland were gained, and we discuss the implications of our findings for Irish healthcare services with reference to feminist health equity and recent national action plans. We propose a series of recommendations for patient-centred care models including increased access to training and education, as well as support for longer-term chronic pain management.

Supporting family carers in general practice: a scoping review of clinical guidelines and recommendations

BACKGROUND

Increasing numbers of family carers are providing informal care in community settings. This creates a number of challenges because family carers are at risk of poor physical and psychological health outcomes, with consequences both for themselves and those for whom they provide care. General Practitioners (GPs), who play a central role in community-based care, are ideally positioned to identify, assess, and signpost carers to supports. However, there is a significant gap in the literature in respect of appropriate guidance and resources to support them in this role.

METHODS

A scoping review was undertaken to examine clinical guidelines and recommendations for GPs to support them in their role with family carers. This involved a multidisciplinary team, in line with Arksey & O'Malley's framework, and entailed searches of ten peer-reviewed databases and grey literature between September-November 2020.

RESULTS

The searches yielded a total of 4,651 English language papers, 35 of which met the criteria for inclusion after removing duplicates, screening titles and abstracts, and performing full-text readings. Ten papers focused on resources/guidelines for GPs, twenty were research papers, three were review papers, one was a framework of quality markers for carer support, and one was an editorial. Data synthesis indicated that nine (90%) of the guidelines included some elements relating to the identification, assessment, and/or signposting of carers. Key strategies for identifying carers suggest that a whole practice approach is optimal, incorporating a role for the GP, practice staff, and for the use of appropriate supporting documentation. Important knowledge gaps were highlighted in respect of appropriate clinical assessment and evidence-based signposting pathways.

CONCLUSION

Our review addresses a significant gap in the literature by providing an important synthesis of current available evidence on clinical guidelines for GPs in supporting family carers, including strategies for identification, options for assessment and potential referral/signposting routes. However, there is a need for greater transparency of the existing evidence base as well as much more research to evaluate the effectiveness and increase the routine utilisation, of clinical guidelines in primary care.

Detailed analysis of in-hospital transmission of SARS-CoV-2 using whole genome sequencing

BACKGROUND

Hospital transmission of SARS-CoV-2 has proved difficult to control, with healthcare-associated infections troublesome throughout.

AIM

To understand factors contributing to hospital transmission of infections, which is necessary for containing spread.

METHODS

An outbreak of 56 staff and patient cases of COVID-19 over a 31-day period in a tertiary referral unit is presented, with at least a further 29 cases identified outside of the unit and the hospital by whole genome sequencing (WGS).

FINDINGS

Transmission is documented from staff to staff, staff to patients, and patients to staff, showing disruption of a tertiary referral service, despite implementation of nationally recommended control measures, superior ventilation, and use of personal protective equipment. There was extensive spread from the index case, despite this patient spending only 10 h bed bound on the ward in strict cubicle isolation and with an initial single target low level (C_T = 32) polymerase chain reaction test.

CONCLUSION

This investigation highlights how effectively and rapidly SARS-CoV-2 can spread in certain circumstances. It raises questions about infection control measures in place at the time and calls into question the premise that transmissibility can be reliably detected by using lower sensitivity rapid antigen lateral flow tests. We also highlight the value of early intervention in reducing impact as well as the value of WGS in understanding outbreaks.

Supporting family carers in Ireland: the role of the general practitioner

BACKGROUND

Ireland has over half a million family carers who provide care to a family member or loved one. Internationally, it is recognised that general practitioners (GPs) have a critical role to play in the identification and support of family carers, but, to date, no guidelines exist in Ireland to support GPs in this role.

AIMS

The aim of this study was to examine how carers are currently supported (or not) by healthcare professionals in Ireland, with a particular focus on the role of the GP.

METHODS

A mixed method design was used, involving a national online survey (N = 132) of family carers in Ireland and one-to-one interviews with 10 stakeholders (4 GPs; 6 carers). The quantitative data were analysed using a series of descriptive and inferential statistics; the interview data were analysed using framework analysis.

RESULTS

Sixty-one per cent of the carer sample reported experiencing psychological distress, more than two-thirds of whom (69%) reported 'rarely' or 'never' being asked about their own health and wellbeing. Sixty-one per cent also felt misunderstood in terms of the challenges they face in their caring role. Three key themes were identified from the interview data including (1) GP role ambiguity; (2) navigating informal processes and (3) changing needs along the care trajectory.

CONCLUSIONS

The findings suggest important gaps in terms of the role of GPs vis-à-vis their support of family carers. GPs themselves indicated that they need both greater clarity regarding their role with family carers and more training and resources in this regard. A requirement for more streamlined communication and information provision was also highlighted by both GPs and carers. Carers reported a need for more information on the role of GPs in supporting carers as well as more support in addressing, in particular, the psychological complexities of carer identity and help seeking.

Impact of Reducing Water Fluoride on Dental Caries and Fluorosis

Guidance intended to reduce fluoride toothpaste ingestion in early childhood was introduced in Ireland in 2002. In 2007, water fluoride concentration was adjusted from 0.8-1.0 to 0.6-0.8 ppm. The objective of this study was to determine the difference in caries and fluorosis levels following introduction of these 2 policy measures. A before-and-after study compared caries and fluorosis in random samples of 8-y-olds in Dublin (n = 707) and Cork-Kerry (n = 1148) in 2017 with 8-y-olds in Dublin (n = 679) and Cork-Kerry (n = 565) in 2002. Dentinal caries experience (primary teeth, d_3vcmft(cde)) and fluorosis (permanent teeth, Dean's index of very mild or higher) were clinically measured. Lifetime exposure to community water fluoridation (CWF) was classified as "full CWF"/"no CWF." Effect of examination year on caries prevalence and severity and fluorosis prevalence was assessed using multivariate regression adjusting for other explanatory variables. There was little change in commencement of fluoride toothpaste use at ≤24 mo following introduction of toothbrushing guidance. Among children with full CWF, there was no statistically significant difference in caries prevalence or severity between 2017 and 2002. In 2017, caries prevalence was 55% in Dublin (full CWF) and 56% in Cork-Kerry (full CWF), and mean d_3vcmft(cde) among children with caries was 3.4 and 3.7, respectively. Caries severity was less in 2017 (mean 4.2) than 2002 (mean 4.9) among children with no CWF (P = 0.039). The difference in caries severity between children with full CWF and no CWF was less in 2017 than in 2002 (interaction P = 0.013), suggesting a reduced benefit for CWF in 2017. In 2017, fluorosis prevalence was 18% in Dublin (full CWF) and 12% in Cork-Kerry (full CWF). Fluorosis was predominantly "very mild" with no statistically significant difference between 2017 and 2002. CWF at 0.6 to 0.8 ppm is an effective caries-preventive measure. Results suggested low uptake of toothbrushing guidance, a reduced caries-preventive effect for CWF in primary teeth, and no reduction in fluorosis following introduction of the policy measures.

An RCT of atraumatic restorative treatment for older adults: 5 year results

OBJECTIVES

to compare the survival of ART and a conventional restorative technique (CT) for restoring carious lesions in older adults after 5 years.

METHODS

In this parallel randomised controlled clinical trial, 219 independently-living adults were recruited from a dental hospital/community and a geriatric day hospital. Ninety-nine patients who met the inclusion criteria and presented with carious lesions were randomly allocated to receive either ART or conventional restorations (anaesthesia, rotary instruments and resin-modified glass ionomer). The status of restorations was assessed 6 months, 1, 2 and 5 years after restoration placement. Estimates of cumulative survival were calculated for each interval between assessments and a Cox Proportional Hazards (PH) model was fitted to the interval-censored survival time.

RESULTS

Three hundred restorations (ART n=142; CT n=158) were placed on 99 patients, 46 males and 53 females, with a mean age of 73.2, SD: 6.8 (65-90 yrs). After 5 years, ART and CT presented cumulative probability of survival of 85% and 79% (p=0.8095), respectively.

CONCLUSIONS

ART presents survival rates comparable to a conventional technique, when treating older adults after 5 years. The ART approach could be a useful tool to provide dental care for older adults particularly in the nonclinical setting. (Trial Registration number: ISRCTN 76299321).

CLINICAL RELEVANCE

This study shows that ART presents survival rates comparable to conventional techniques to treat carious lesions in older patients after 5 years. It is well accepted by this age cohort, and therefore could be an alternative to treat the elderly, especially those who are homebound or cannot attend the dentist.

Involving young people in cyberbullying research: The implementation and evaluation of a rights-based approach

Background

Cyberbullying is an international Public Health concern. Efforts to understand and address it can be enhanced by involving young people. This paper describes a rights‐based collaboration with young people in a qualitative exploration of cyberbullying. It describes the establishment, implementation and evaluation of a Young Person's Advisory Group as well as identifying the impact on the research process and the young people involved.

Methods

Sixteen postprimary school students met with researchers on five occasions in a youth centre. Sessions focused on building the young people's capacity to engage with the research, designing the qualitative study, interpreting study findings and evaluating the collaboration process.

Results

The Advisory Group highlighted a lack of understanding and appropriate action with regard to cyberbullying but believed that their involvement would ultimately help adults to understand their perspective. Evaluation findings indicate that members were supported to form as well as express their views on the design, conduct and interpretation of the research and that these views were acted upon by adult researchers. Their involvement helped to ensure that the research was relevant and reflective of the experiences, interests, values and norms of young people.

Conclusion

Young people can contribute a unique perspective to the research process that is otherwise not accessible to adult researchers. The approach described in this study is a feasible and effective way of operationalizing young people's involvement in health research and could be adapted to explore other topics of relevance to young people.

A Retrospective Audit of In-Hospital 30-day Mortality from Acute Myocardial Infarction in Connolly Hospital Blanchardstown

In 2015, The Department of Health published the first annual report of the "National Healthcare Quality Reporting System." Connolly Hospital was reported to a mortality rate within 30 days post-Acute Myocardial Infarction (AMI) of 9.87 per 100 cases which was statistically significantly higher than the national rate. We carried out a retrospective audit of patients who were HIPE-coded as having died within 30 days of AMI from 2011-2013 and identified 42 patients. On review, only 23 patients (54.8%) were confirmed as having had an AMI. We identified 12 patients who had AMI included on death certificate without any evidence for same. If the 22 patients incorrectly coded were excluded, the mortality rate within 30 days post-AMI in CHB would fall to 4.14 deaths per 100 cases, well below the national average. Inaccuracies of data collection can lead to erroneous conclusions when examining healthcare data.

Alcohol consumption among university students: a typology of consumption to aid the tailoring of effective public health policy

OBJECTIVE

Elevated levels of alcohol consumption among university students are well documented. Policymakers have attempted to combat this issue at a university, national and international level. Tailoring public health policy to effectively tackle alcohol use is crucial. Using Q-methodology, the current study aims to develop a typology of alcohol consumption in the Irish university student population.

SETTING

A large Irish university.

PARTICIPANTS

Hundreds of possible statements on types of consumption were generated from a systematic review and a set of one-on-one interviews. These were reduced to 36 statements, 6 statements which define each of the 6 previously defined consumption types. Participants were advised to scan through the 36 statements and fill the statements into a 'forced choice, standardised distribution'. Following this, a 45-90 min interview was conducted with students to illuminate subjectivity surrounding alcohol consumption. Analysis was conducted using PQ Method and NVivo software. Principal component analysis, followed by varimax rotation, was conducted to uncover the final factor information.

RESULTS

In total, 43 students completed the Q-study: 19 men and 24 women. A typology describing 4 distinct groupings of alcohol consumer was uncovered: the guarded drinker, the calculated hedonist, the peer-influenced drinker and the inevitable binger. Factor loadings of each of the consumer groupings were noted for type description.

CONCLUSIONS

This is the first study to propose ideal types of alcohol consumption among a university student population. Further research is required to investigate the degree to which each of these ideal types is subscribed. However, this typology, in addition to informing public policy and strategies, will be a valuable analytic tool in future research.

Spatial Overlap of Grey Seals and Fisheries in Irish Waters, Some New Insights Using Telemetry Technology and VMS

Seals and humans often target the same food resource, leading to competition. This is of mounting concern with fish stocks in global decline. Grey seals were tracked from southeast Ireland, an area of mixed demersal and pelagic fisheries, and overlap with fisheries on the Celtic Shelf and Irish Sea was assessed. Overall, there was low overlap between the tagged seals and fisheries. However, when we separate active (e.g. trawls) and passive gear (e.g. nets, lines) fisheries, a different picture emerged. Overlap with active fisheries was no different from that expected under a random distribution, but overlap with passive fisheries was significantly higher. This suggests that grey seals may be targeting the same areas as passive fisheries and/or specifically targeting passive gear. There was variation in foraging areas between individual seals suggesting habitat partitioning to reduce intra-specific competition or potential individual specialisation in foraging behaviour. Our findings support other recent assertions that seal/fisheries interactions in Irish waters are an issue in inshore passive fisheries, most likely at the operational and individual level. This suggests that seal population management measures would be unjustifiable, and mitigation is best focused on minimizing interactions at nets.

Audience Recall of News Stories Presented by Newspaper, Computer, Television and Radio

This study reports results of a large-scale experiment in which subjects were exposed to news stories presented by one of four media. The goal was to provide both baseline data and a reasonably definitive answer as to the relative level of recall resulting from presentations by newspapers, computer screen, television and radio while controlling for other factors. Facts from news stories presented by newspaper or computer screen were recalled at a significantly higher level than were facts from the same stories when presented via radio or television. Somewhat surprisingly, results from computer screens were closer to newspapers than to television.

The true financial impact of hospital readmissions

Hospital executives working to reduce the cost of readmissions should note that: The penalty imposed by the Centers for Medicare & Medicaid Services (CMS) for excess readmissions can be disproportionately high The true cost of readmissions goes beyond the CMS penalty Even small reductions in readmissions can substantially reduce penalties Changes to healthcare reimbursement, such as bundled payments, will also incentivize hospitals to reduce readmissions.

Bacterial-mediated DNA delivery to tumour associated phagocytic cells

Phagocytic cells including macrophages, dendritic cells and neutrophils are now recognised as playing a negative role in many disease settings including cancer. In particular, macrophages are known to play a pathophysiological role in multiple diseases and present a valid and ubiquitous therapeutic target. The technology to target these phagocytic cells in situ, both selectively and efficiently, is required in order to translate novel therapeutic modalities into clinical reality. We present a novel delivery strategy using non-pathogenic bacteria to effect gene delivery specifically to tumour-associated phagocytic cells. Non-invasive bacteria lack the ability to actively enter host cells, except for phagocytic cells. We exploit this natural property to effect 'passive transfection' of tumour-associated phagocytic cells following direct administration of transgene-loaded bacteria to tumour regions. Using an in vitro-differentiated human monocyte cell line and two in vivo mouse models (an ovarian cancer ascites and a solid colon tumour model) proof of delivery is demonstrated with bacteria carrying reporter constructs. The results confirm that the delivery strategy is specific for phagocytic cells and that the bacterial vector itself recruits more phagocytic cells to the tumour. While proof of delivery to phagocytic cells is demonstrated in vivo for solid and ascites tumour models, this strategy may be applied to other settings, including non-cancer related disease.

Abstract PD02-07: Next-generation sequencing of FFPE breast cancers demonstrates high concordance with FISH in calling HER2 amplifications and commonly detects other clinically relevant genomic alterations

Background: As more therapies targeting genomic alterations become available, next-generation sequencing (NGS) is increasingly performed in tumor types where mutational status may drive treatment choice. In addition to its ability to identify base substitutions, insertions and deletions across entire exons, NGS can detect relevant copy number changes such as amplification of HER2 in breast tumors. However, for NGS to be clinically applicable, it must reliably analyze FFPE tumor samples and show concordance with the best current diagnostic methods.

Methods: To confirm a clinical role for NGS in detecting copy number alterations, we identified 35 FFPE invasive breast carcinomas previously tested for HER2 status by FISH, including 15 HER2 positives (≥7 copies) and 20 HER2 negatives (<4 copies) and sequenced 3,230 exons of 182 cancer genes including HER2, in a CLIA certified lab (Foundation Medicine). Average coverage depth of >900X uniquely-mapping reads was obtained. Sequence data were analyzed for HER2 copy number (blinded to FISH results) based on a statistical model using allele frequencies and coverage depth of HER2 exons versus a process-matched normal control, classifying cases as HER2 positive (≥6 average copies), HER2 negative (<4 copies), intermediate (4–5 copies) or unknown (<20% tumor purity). The data were also analyzed for additional clinically relevant genomic alterations.

Results: High concordance was noted between HER2 copy number status determined by FISH and NGS: 30 of the 35 samples were classified as positive or negative by NGS, 1 was classified as intermediate and 4 as unknown due to low purity. Using FISH as a gold standard, NGS HER2 calls demonstrated an accuracy of 97% (29/30, 95% CI 83–99%), 93% sensitivity (13/14, 95% CI 69–99%) and 100% specificity (16/16, 95% CI 81–100%). One discordant case was noted (FISH positive, NGS negative). Furthermore, NGS revealed 70 additional alterations (38 base substitutions, 10 insertions/deletions, 22 copy number alterations) in 23 cancer genes (an average of 2.0 alterations per sample). Genomic alterations that predict sensitivity or resistance to approved or experimental targeted therapies and thus plausibly guide treatment decisions were found in 69% of patients. These include PIK3CA (16 cases, PI3 kinase/mTOR inhibitors), PTEN (3 cases, PI3K/AKT/mTOR inhibitors), KRAS (1 case, resistance to cetuximab and panitumumab), and NF1 (1 case, mTOR/MAPK inhibitors) plus amplifications of CCND1 (4 cases, CDK4 inhibitors), FGFR1 (3 cases, FGF inhibitors) and MCL1 (3 cases, BCL-2 inhibitors, resistance to anti-tubulin therapies). Four cases included co-amplification of RARA with HER2.

Conclusions: We conclude that HER2 status can be reliably determined by NGS on FFPE breast cancers and that NGS uncovers additional actionable genomic alterations that could impact disease management in a high proportion of patients. Further evaluation of NGS as a guide to therapy in breast cancer is warranted.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD02-07.

Bacterial vectors for imaging and cancer gene therapy: a review

The significant burden of resistance to conventional anticancer treatments in patients with advanced disease has prompted the need to explore alternative therapeutic strategies. The challenge for oncology researchers is to identify a therapy which is selective for tumors with limited toxicity to normal tissue. Engineered bacteria have the unique potential to overcome traditional therapies' limitations by specifically targeting tumors. It has been shown that bacteria are naturally capable of homing to tumors when systemically administered resulting in high levels of replication locally, either external to (non-invasive species) or within tumor cells (pathogens). Pre-clinical and clinical investigations involving bacterial vectors require relevant means of monitoring vector trafficking and levels over time, and development of bacterial-specific real-time imaging modalities are key for successful development of clinical bacterial gene delivery. This review discusses the currently available imaging technologies and the progress to date exploiting these for monitoring of bacterial gene delivery in vivo.

The effect of increased overjet on the magnitude and reproducibility of smiling in adult females

The objective of this study was to determine if increased overjet (greater than 6 mm) influences the magnitude and reproducibility of natural smile and maximal smile in Caucasian adult females. Twenty adult females with an increased overjet (6-10 mm) and 20 control adult females (overjet 2-4 mm) with no history of orthodontic treatment volunteered to participate. The mean age in the control group was 30.1 ± 6.4 years and the mean age in the test group was 31.9 ± 10.8 years. Three-dimensional stereophotogrammetric images were captured of each subject for three expressions: at rest, natural smile, and maximal smile. The images were recorded twice on two separate occasions, 6 weeks apart. Images were landmarked and a partial ordinary Procrustes superimposition was used to adjust for the differences in head posture between the same expressions. The magnitude of movement relative to the rest position, averaged over all the landmarks, was calculated and compared between the groups using analysis of variance (linear mixed-effects model); the intra- and inter-session reproducibility of both expressions was assessed. There was greater mean movement, averaged over all the landmarks, in the control group than in the increased overjet group for both natural smile and maximal smile (P = 0.0068). For these expressions, there were no statistically significant differences in reproducibility within sessions (P = 0.5403) or between sessions (P = 0.3665). Increased overjet had a statistically significant effect on the magnitude of smiling but did not influence the reproducibility of natural or maximal smile relative to controls.

Intra- and postoperative very low dose intravenous ketamine infusion does not increase pain relief after major spine surgery in patients with preoperative narcotic analgesic intake

OBJECTIVE

This study aims to demonstrate the analgesic efficacy and opioid-sparing effect of low dose ketamine in patients with preoperative narcotic intake undergoing major spine surgery.

DESIGN

The study used a prospective, randomized, double-blinded, and placebo-controlled clinical trial.

SETTINGS AND PATIENTS

We evaluated the analgesic efficacy and safety of low dose IV ketamine infusion after major spine surgery in patients with preoperative narcotic analgesic intake. Ketamine group received IV ketamine infusion (2 µg/kg/min) and saline group received saline intraoperatively and the first 24 hours postoperatively. In addition, all patients received IV patient-controlled hydromorphone and epidural bupivacaine.

OUTCOME MEASURES

Pain scores, narcotic requirement, and side effects were compared between the groups for 48 hours postoperatively.

RESULTS

Thirty patients completed the study (N = 15 in each group). No difference in pain scores at rest and movement was noted between the groups (P > 0.05). Patients in ketamine group received 40.42 ± 32.86 mg IV hydromorphone at 48 hours compared with 38.24 ± 26.19 mg in saline group (P = 0.84). Central nervous system side effects were observed in five (33%) ketamine group patients compared with nine (60%) in saline group (P = 0.29).

CONCLUSION

The addition of IV very low dose ketamine infusion regimen did not improve postoperative analgesia. Side effects were not increased with low dose ketamine.

Safety implications of the Boyle-Davis mouth gag and tracheal tube position in tonsillectomy

BACKGROUND

The risk of death after tonsillectomy is extremely small, and is mostly caused by the direct or indirect effects of haemorrhage or anaesthetic complications. These complications include aspiration, accidental dislodgement of the tracheal tube (TT), and pneumothorax or pneumomediastinum. The Boyle-Davis mouth gag (BDG) is a device used to visualize the oropharynx and stabilize the TT during tonsillectomy. We postulate that a deployed BDG may influence the position of the TT, and potentially result in silent aspiration, accidental extubation, and unilateral pulmonary ventilation. This has not, to our knowledge, been evaluated before. The aim of this prospective, pilot study was to evaluate the displacement of the TT upon opening and closing the BDG, in an objective manner.

METHODS

Patients undergoing tonsillectomy with/without adenoidectomy at a regional department underwent flexible bronchoscopy to evaluate the changes in position of the TT tip with the BDG in an open and closed position, relative to the position of the carina.

RESULTS

Twenty-three patients were enrolled into the study. Deploying the BDG resulted in TT displacement in 96% of patients. The mean displacement was 9.5 mm (range -10 to +27 mm).

CONCLUSIONS

We believe that this study raises concerns not previously highlighted, on how manipulating a BDG may influence the TT position. It may serve to explain additional mechanisms of potentially fatal anaesthetic complications such as TT dislodgement, unilateral ventilation, and pneumothorax, particularly in paediatric patients, after tonsillectomy.

A qualitative study of trends in patient preferences for the management of the partially dentate state

OBJECTIVE

To identify factors influencing attitudes of partially dentate adults towards dental treatment in Ireland.

BACKGROUND

People are retaining more teeth later in life than ever before. Management of partially dentate older adults will be a major requirement for the future and it is important to determine factors which may influence patients' attitudes to care.

METHODS

SUBJECTS

A purposive sample of 22 partially dentate patients was recruited; 12 women and 12 men, ranging in age from 45 to 75 years.

DATA COLLECTION

Semi-structured individual interviews.

RESULTS

Dental patients have increasing expectations in relation to (i) a more sophisticated approach to the management of missing teeth and (ii) their right to actively participate in decision making regarding the management of their tooth loss. There is some evidence of a cohort effect with younger patients (45-64 years) having higher expectations.

CONCLUSIONS

The evidence of a cohort effect within this study in relation to higher patient expectations indicates that both contemporary and future patients are likely to seek a service based on conservation and restoration of missing teeth by fixed prostheses.

An open-label phase II study evaluating the safety and efficacy of PTK787 in patients with progressive metastatic neuroendocrine cancer

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Background: PTK787, an aminophthalazine, is an orally active angiogenesis inhibitor blocking all known vascular endothelial growth factor receptors (VEGFR)- and platelet-derived growth factor receptor (PDGFR)-tyrosine kinases . The majority of metastatic neuroendocrine malignancies express VEGF and PDGF receptors. Since both growth factors have been implicated in tumor-induced angiogenesis, PTK787 offers a novel approach for inhibiting tumor growth. Methods: In a phase II trial, we investigated the safety and antitumor activity of PTK787 in patients who had biopsy-proven metastatic neuroendocrine cancer, such as carcinoid, and had shown evidence of progression on somatosatin analog therapy. Eligible patients had measurable lesions other than bone, a Karnofsky performance status >60 and normal hematologic, renal and hepatic functions. Patients on octreotide therapy were required to be on a stable dose not exceeding 30 mg monthly of the LAR formulation. Initial dosing of PTK787 was 1,250 mg daily. Results: Six patients (4 males) were enrolled between 5/20/05 to 8/09/05. Median age was 61 years (range, 48 to 65). There was 1 withdrawal of consent. The remaining 5 patients continue on treatment as of January 2006. One patient required a 10 day discontinuation for rising SGOT/SGPT and alkaline phosphatase. Resumption of PTK787 at 1,000 mg daily was well tolerated in this patient. Radiographically and scintigraphically, all 5 patients have demonstrated stable disease by CT and OctreoScan, respectively. Recruitment to this trial continues. Conclusions: PTK787 is generally well tolerated in patients with metastatic neuroendocrine cancer and may be effective in controlling somatostatin analog resistant disease though partial radiographic responses have not been observed.

No significant financial relationships to disclose.

Validation of counter propagation neural network models for predictive toxicology according to the OECD principles: a case study

The OECD has proposed five principles for validation of QSAR models used for regulatory purposes. Here we present a case study investigating how these principles can be applied to models based on Kohonen and counter propagation neural networks. The study is based on a counter propagation network model that has been built using toxicity data in fish fathead minnow for 541 compounds. The study demonstrates that most, if not all, of the OECD criteria may be met when modeling using this neural network approach.

Dental caries and enamel fluorosis among the fluoridated population in the Republic of Ireland and non fluoridated population in Northern Ireland in 2002

BACKGROUND

An all Ireland/North South survey of Oral Health was carried out in 2001/2002.

AIMS

To compare levels of dental caries and enamel fluorosis among children and adolescents in the fluoridated Republic of Ireland (RoI) with those in the non fluoridated North of Ireland (NI).

METHODOLOGY

Cross sectional oral health survey of a representative, random, stratified sample of 5-, 8-, 12- and 15-year-olds in Rol and in NI (N = 19,950). WHO examination criteria with the addition of visible, non cavitated dentine caries were used for recording caries. Fluorosis was measured using Dean's Index.

RESULTS

In the RoI, the mean d(3c)mft / D(3c)MFT for 5-, 8-, 12-, and 15-year-olds with full domestic water fluoridation (n = 9,975), was 1.0, 0.3, 1.1 and 2.1 respectively. The corresponding means in non fluoridated NI (n = 1,475) were 1.8, 0.3, 1.5 and 3.6 respectively. (p < 0.0001, NS, p < 0.0005 and p < 0.0001). The prevalence of enamel fluorosis has increased in RoI since 1984, 23% and 36% of 8- and 15-year olds respectively in fluoridated areas had Dean's Index scores at the questionable or greater level in 2002 compared with 6% and 5% respectively in 1984.

CONCLUSIONS

In 2002 apart from 8-year-olds, caries levels were lower amongst children resident in fluoridated communities in RoI than amongst corresponding age groups in non-fluoridated NI. Caries has declined in fluoridated and non fluoridated groups in both jurisdictions since the early 1960s. In RoI fluorosis levels were higher amongst lifetime residents of fluoridated communities and have increased since 1984.

Combined oral contraceptives in women with systemic lupus erythematosus

BACKGROUND

Oral contraceptives are rarely prescribed for women with systemic lupus erythematosus, because of concern about potential negative side effects. In this double-blind, randomized, noninferiority trial, we prospectively evaluated the effect of oral contraceptives on lupus activity in premenopausal women with systemic lupus erythematosus.

METHODS

A total of 183 women with inactive (76 percent) or stable active (24 percent) systemic lupus erythematosus at 15 U.S. sites were randomly assigned to receive either oral contraceptives (triphasic ethinyl estradiol at a dose of 35 microg plus norethindrone at a dose of 0.5 to 1 mg for 12 cycles of 28 days each; 91 women) or placebo (92 women) and were evaluated at months 1, 2, 3, 6, 9, and 12. Subjects were excluded if they had moderate or high levels of anticardiolipin antibodies, lupus anticoagulant, or a history of thrombosis.

RESULTS

The primary end point, a severe lupus flare, occurred in 7 of 91 subjects receiving oral contraceptives (7.7 percent) as compared with 7 of 92 subjects receiving placebo (7.6 percent). The 12-month rates of severe flare were similar: 0.084 for the group receiving oral contraceptives and 0.087 for the placebo group (P=0.95; upper limit of the one-sided 95 percent confidence interval for this difference, 0.069, which is within the prespecified 9 percent margin for noninferiority). Rates of mild or moderate flares were 1.40 flares per person-year for subjects receiving oral contraceptives and 1.44 flares per person-year for subjects receiving placebo (relative risk, 0.98; P=0.86). In the group that was randomized to receive oral contraceptives, there was one deep venous thrombosis and one clotted graft; in the placebo group, there was one deep venous thrombosis, one ocular thrombosis, one superficial thrombophlebitis, and one death (after cessation of the trial).

CONCLUSIONS

Our study indicates that oral contraceptives do not increase the risk of flare among women with systemic lupus erythematosus whose disease is stable.

Use of Dental Service Data to Inform Research and Policy

Data collected routinely in dental care delivery systems could be used to inform research and policy. Projects in which data were collected with the help of general dental practitioners are outlined. In an EU-funded project, six partners collaborated to develop a methodology designed to establish links between characteristics of a health care system and health outcome, and to determine the characteristics of oral health care systems which promote oral health and those which are detrimental to oral health. The results indicated that the data collected in the different systems investigated varied enormously, and they could not be easily adapted to help in developing policy. A theoretical model was developed in which the production of oral health care was considered separately from the production of oral health. In the second example, the longevity of the restorations in a dental care delivery system in Ireland was investigated by routine service data.

Primary tooth fluorosis in 5-year-old schoolchildren in Ireland

AIM

This was to determine the prevalence of primary tooth fluorosis in the dentitions of 5-year-old schoolchildren. A subsidiary aim was to investigate whether an association existed between the presence of primary tooth fluorosis, fluoridation status, infant feeding practices or the oral hygiene practices of the child.

STUDY DESIGN

A cross-sectional and stratified by fluoridation status study.

METHODS

Fluorosis was recorded using a modification of the Tooth Surface Index of Fluorosis (TSIF). Demographic data, information on infant feeding practices and oral hygiene practices were collected via a parental questionnaire.

STATISTICS

Stepwise logistic regression analysis.

RESULTS

Fluorosis prevalence in the fluoridated group (n=208) was 32%; 29.3% (n=61) had a modified TSIF score of 1; 2.4% (n=5) had a modified TSIF score of 2; and 1% (n=1) had a modified TSIF score of 5. In the non-fluoridated group (n=86) one child had a modified TSIF score of 1. Primary tooth prevalence of fluorosis in the entire sample (n=294) was 23%. Factors that were associated with primary tooth fluorosis were: fluoridation status (p= 0.0003, 95% CI = 5-281) and the age at which toothbrushing with toothpaste commenced (p = 0.016, 95% C.I. 1.1 - 3.8). No association with infant feeding practices was identified.

CONCLUSION

The overall prevalence of primary tooth fluorosis was 23%. Lifetime residence in a fluoridated area and commencement of toothbrushing with toothpaste between 12 and 18 months of age were associated with primary tooth fluorosis. No association with infant feeding practices was identified.

The effect of combined estrogen and progesterone hormone replacement therapy on disease activity in systemic lupus erythematosus: a randomized trial

BACKGROUND

There is concern that exogenous female hormones may worsen disease activity in women with systemic lupus erythematosus (SLE).

OBJECTIVE

To evaluate the effect of hormone replacement therapy (HRT) on disease activity in postmenopausal women with SLE.

DESIGN

Randomized, double-blind, placebo-controlled noninferiority trial conducted from March 1996 to June 2002.

SETTING

16 university-affiliated rheumatology clinics or practices in 11 U.S. states.

PATIENTS

351 menopausal patients (mean age, 50 years) with inactive (81.5%) or stable-active (18.5%) SLE.

INTERVENTIONS

12 months of treatment with active drug (0.625 mg of conjugated estrogen daily, plus 5 mg of medroxyprogesterone for 12 days per month) or placebo. The 12-month follow-up rate was 82% for the HRT group and 87% for the placebo group.

MEASUREMENTS

The primary end point was occurrence of a severe flare as defined by Safety of Estrogens in Lupus Erythematosus, National Assessment-Systemic Lupus Erythematosus Disease Activity Index composite.

RESULTS

Severe flare was rare in both treatment groups: The 12-month severe flare rate was 0.081 for the HRT group and 0.049 for the placebo group, yielding an estimated difference of 0.033 (P = 0.23). The upper limit of the 1-sided 95% CI for the treatment difference was 0.078, within the prespecified margin of 9% for noninferiority. Mild to moderate flares were significantly increased in the HRT group: 1.14 flares/person-year for HRT and 0.86 flare/person-year for placebo (relative risk, 1.34; P = 0.01). The probability of any type of flare by 12 months was 0.64 for the HRT group and 0.51 for the placebo group (P = 0.01). In the HRT group, there were 1 death, 1 stroke, 2 cases of deep venous thrombosis, and 1 case of thrombosis in an arteriovenous graft; in the placebo group, 1 patient developed deep venous thrombosis.

LIMITATIONS

Findings are not generalizable to women with high-titer anticardiolipin antibodies, lupus anticoagulant, or previous thrombosis.

CONCLUSIONS

Adding a short course of HRT is associated with a small risk for increasing the natural flare rate of lupus. Most of these flares are mild to moderate. The benefits of HRT can be balanced against the risk for flare because HRT did not significantly increase the risk for severe flare compared with placebo.

Parents' preference as to whether they would like to accompany their child when receiving dental treatment--results from a national survey

BACKGROUND AND DESIGN

parental accompaniment of children during dental treatment has always been a contentious issue. One of the factors that should be considered is the preference of the parents. The aim of this paper is to report the preference of parents of eight-year-old schoolchildren in Ireland in relation to accompanying their child during dental procedures and is part of the National Survey of Children's Dental Health in Ireland, which was conducted between October 2001 and June 2002. The survey had a cross sectional design and parents of children (average age 8.4 years) selected for dental examination were asked to complete a questionnaire.

RESULTS

3629 completed questionnaires were obtained from parents of eight-year-old children giving a response rate of 68 per cent. Sixty-seven per cent of parents expressed a preference to accompany their child during dental treatment, while nine per cent expressed a preference not to accompany their child. The sex of the child (p = 0.33) or the fact that the parents were holders of a medical card (surrogate for disadvantage) (p = 0.08) did not affect parents' preference. However, parents of a single child had a higher preference (78 per cent) for accompanying their child than did parents with greater than one child in the family unit (66 per cent) (p = 0.0009).

CONCLUSION

If given the choice, the majority of parents would prefer to accompany their child when receiving dental treatment.

The epidemiology of infectious syphilis in the Republic of Ireland

In response to the increasing numbers of syphilis cases reported among men having sex with men (MSM) in Dublin, an Outbreak Control Team (OCT) was set up in late 2000. The outbreak peaked in 2001 and had largely ceased by late 2003. An enhanced syphilis surveillance system was introduced to capture data from January 2000. Between January 2000 and December 2003, 547 cases of infectious syphilis were notified in Ireland (415 were MSM). Four per cent of cases were diagnosed with HIV and 15.4% of cases were diagnosed with at least one other STI (excluding HIV) within the previous 3 months. The mean number of contacts reported by male cases in the 3 months prior to diagnosis was 4 (range 0-8) for bisexual contacts and 6 for homosexual contacts (range 1-90). Thirty one per cent of MSM reported having had recent unprotected oral sex and 15.9% of MSM reported having had recent unprotected anal sex. Sixteen per cent of cases reported having had sex abroad in the three months prior to diagnosis. The results suggest that risky sexual behaviour contributed to the onward transmission of infection in Dublin. The outbreak in Dublin could be seen as part of a European-wide outbreak of syphilis. The rates of co-infection with HIV and syphilis in Ireland are comparable with rates reported from other centres. There is a need to improve surveillance systems in order to allow real time evaluation of interventions and ongoing monitoring of infection trends.

The epidemiology of infectious syphilis in the Republic of Ireland

In response to the increasing numbers of syphilis cases reported among men having sex with men (MSM) in Dublin, an Outbreak Control Team (OCT) was set up in late 2000. The outbreak peaked in 2001 and had largely ceased by late 2003. An enhanced syphilis surveillance system was introduced to capture data from January 2000. Between January 2000 and December 2003, 547 cases of infectious syphilis were notified in Ireland (415 were MSM). Four per cent of cases were diagnosed with HIV and 15.4% of cases were diagnosed with at least one other STI (excluding HIV) within the previous 3 months. The mean number of contacts reported by male cases in the 3 months prior to diagnosis was 4 (range 0-8) for bisexual contacts and 6 for homosexual contacts (range 1-90). Thirty one per cent of MSM reported having had recent unprotected oral sex and 15.9% of MSM reported having had recent unprotected anal sex. Sixteen per cent of cases reported having had sex abroad in the three months prior to diagnosis. The results suggest that risky sexual behaviour contributed to the onward transmission of infection in Dublin. The outbreak in Dublin could be seen as part of a European-wide outbreak of syphilis. The rates of co-infection with HIV and syphilis in Ireland are comparable with rates reported from other centres. There is a need to improve surveillance systems in order to allow real time evaluation of interventions and ongoing monitoring of infection trends.