Is it time to reconsider the use of vital teeth bleaching in children and adolescents in Europe?

PURPOSE

The aim of this study was to determine whether carbamide peroxide is effective in bleaching vital permanent teeth in children.

METHODS

A literature search was conducted using all keywords relevant to the research subject. The outcome measures were identified as colour change, tooth sensitivity, oral irritation and patient satisfaction. The certainty of evidence for each outcome was assessed using the current GRADE guidelines.

RESULTS

Of 115 potentially relevant articles, 112 were excluded, as they did not exclusively involve children, intervention involved additional treatment such as microabrasion or restorative work, or case studies. Patient satisfaction was not assessed in the three articles so no analysis could be made with regards to this outcome. The GRADE assessment showed that all of the three articles demonstrated very low certainty of evidence for the other assessed outcomes. The overall findings from the studies suggest that a 10% carbamide peroxide overnight tray system is effective at bleaching vital permanent teeth in children and associated tooth sensitivity and oral irritation are found to be in a similar range compared to those reported in adult studies. However, due to the very low certainty of the evidence, it is not possible to draw these conclusions.

CONCLUSION

Better quality randomised controlled trials are needed to investigate the indication, short and long term effectiveness and side effects of carbamide teeth in vital permanent teeth in children.

Decision-making around admission to intensive care in the UK pre-COVID-19: a multicentre ethnographic study

Predicting who will benefit from admission to an intensive care unit is not straightforward and admission processes vary. Our aim was to understand how decisions to admit or not are made. We observed 55 decision-making events in six NHS hospitals. We interviewed 30 referring and 43 intensive care doctors about these events. We describe the nature and context of the decision-making and analysed how doctors make intensive care admission decisions. Such decisions are complex with intrinsic uncertainty, often urgent and made with incomplete information. While doctors aspire to make patient-centred decisions, key challenges include: being overworked with lack of time; limited support from senior staff; and a lack of adequate staffing in other parts of the hospital that may be compromising patient safety. To reduce decision complexity, heuristic rules based on experience are often used to help think through the problem; for example, the patient's functional status or clinical gestalt. The intensive care doctors actively managed relationships with referring doctors; acted as the hospital generalist for acutely ill patients; and brought calm to crisis situations. However, they frequently failed to elicit values and preferences from patients or family members. They were rarely explicit in balancing burdens and benefits of intensive care for patients, so consistency and equity cannot be judged. The use of a framework for intensive care admission decisions that reminds doctors to seek patient or family views and encourages explicit balancing of burdens and benefits could improve decision-making. However, a supportive, adequately resourced context is also needed.

A process evaluation of the WHiTE Two trial comparing total hip arthroplasty with and without dual mobility component in the treatment of displaced intracapsular fractures of the proximal femur: Can a trial investigating total hip arthroplasty for hip fracture be delivered in the NHS?

Objectives

The annual incidence of hip fracture is 620 000 in the European Union. The cost of this clinical problem has been estimated at 1.75 million disability-adjusted life years lost, equating to 1.4% of the total healthcare burden in established market economies. Recent guidance from The National Institute for Health and Clinical Excellence (NICE) states that research into the clinical and cost effectiveness of total hip arthroplasty (THA) as a treatment for hip fracture is a priority. We asked the question: can a trial investigating THA for hip fracture currently be delivered in the NHS?

Methods

We performed a contemporaneous process evaluation that provides a context for the interpretation of the findings of WHiTE Two – a randomised study of THA for hip fracture. We developed a mixed methods approach to situate the trial centre within the context of wider United Kingdom clinical practice. We focused on fidelity, implementation, acceptability and feasibility of both the trial processes and interventions to stakeholder groups, such as healthcare providers and patients.

Results

We have shown that patients are willing to participate in this type of research and that surgeons value being part of a team that has a strong research ethos. However, surgical practice does not currently reflect NICE guidance. Current models of service delivery for hip fractures are unlikely to be able to provide timely total hip arthroplasty for suitable patients.

Conclusions

Further observational research should be conducted to define the population of interest before future interventional studies are performed.

Cite this article: C. Huxley, J. Achten, M. L. Costa, F. Griffiths, X. L. Griffin. A process evaluation of the WHiTE Two trial comparing total hip arthroplasty with and without dual mobility component in the treatment of displaced intracapsular fractures of the proximal femur: Can a trial investigating total hip arthroplasty for hip fracture be delivered in the NHS? Bone Joint Res 2016;5:444–452. DOI: 10.1302/2046-3758.510.BJR-2015-0008.R1.

Evaluation of recruitment methods for a trial targeting childhood obesity: Families for Health randomised controlled trial

BACKGROUND

Recruitment to trials evaluating the effectiveness of childhood obesity management interventions is challenging. We report our experience of recruitment to the Families for Health study, a randomised controlled trial evaluating the effectiveness of a family-based community programme for children aged 6-11 years, versus usual care. We evaluated the effectiveness of active recruitment (contacting eligible families directly) versus passive recruitment (informing the community through flyers, public events, media).

METHODS

Initial approaches included passive recruitment via the media (newspapers and radio) and two active recruitment methods: National Child Measurement Programme (letters to families with overweight children) and referrals from health-care professionals. With slow initial recruitment, further strategies were employed, including active (e.g. targeted letters from general practices) and passive (e.g. flyers, posters and public events) methods. At first enquiry from a potential participant, families were asked where they heard about the study. Further quantitative (questionnaire) and qualitative data (one-to-one interviews with parents/carers), were collected from recruited families at baseline and 3-month follow-up and included questions about recruitment.

RESULTS

In total, 194 families enquired about Families for Health, and 115 (59.3 %) were recruited and randomised. Active recruitment yielded 85 enquiries, with 43 families recruited (50.6 %); passive recruitment yielded 99 enquiries with 72 families recruited (72.7 %). Information seen at schools or GP surgeries accounted for over a quarter of enquiries (28.4 %) and over a third (37.4 %) of final recruitment. Eight out of ten families who enquired this way were recruited. Media-led enquiries were low (5 %), but all were recruited. Children of families recruited actively were more likely to be Asian or mixed race. Despite extensive recruitment methods, the trial did not recruit as planned, and was awarded a no-cost extension to complete the 12-month follow-up.

CONCLUSIONS

The higher number of participants recruited through passive methods may be due to the large number of potential participants these methods reached and because participants may see the information more than once. Recruiting to a child obesity treatment study is complex and it is advisable to use multiple recruitment strategies, some aiming at blanket coverage and some targeted at families with children who are overweight.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN45032201 (Date: 18 August 2011).

Characterisation of linear predictability and non-stationarity of subcutaneous glucose profiles

Continuous glucose monitoring is increasingly used in the management of diabetes. Subcutaneous glucose profiles are characterised by a strong non-stationarity, which limits the application of correlation-spectral analysis. We derived an index of linear predictability by calculating the autocorrelation function of time series increments and applied detrended fluctuation analysis to assess the non-stationarity of the profiles. Time series from volunteers with both type 1 and type 2 diabetes and from control subjects were analysed. The results suggest that in control subjects, blood glucose variation is relatively uncorrelated, and this variation could be modelled as a random walk with no retention of 'memory' of previous values. In diabetes, variation is both greater and smoother, with retention of inter-dependence between neighbouring values. Essential components for adequate longer term prediction were identified via a decomposition of time series into a slow trend and responses to external stimuli. Implications for diabetes management are discussed.

The Warwick Hip Trauma Evaluation - an abridged protocol for the WHiTE Study: A multiple embedded randomised controlled trial cohort study

Fractures of the proximal femur are one of the greatest challenges facing the medical community, constituting a heavy socioeconomic burden worldwide. The National Hip Fracture Audit currently provides a framework for service evaluation. This evaluation is based upon the assessment of process rather than assessment of patient-centred outcome and therefore it fails to provide meaningful data regarding the clinical effectiveness of treatments. This study aims to capture data from the cohort of patients who present with a fracture of the proximal femur at a single United Kingdom Major Trauma Centre. Patient-centred outcomes will be recorded and provide a baseline cohort within which to test the clinical effectiveness of experimental interventions.

A multicentred randomised controlled trial of a primary care-based cognitive behavioural programme for low back pain. The Back Skills Training (BeST) trial

OBJECTIVES

To estimate the clinical effectiveness of active management (AM) in general practice versus AM plus a group-based, professionally led cognitive behavioural approach (CBA) for subacute and chronic low back pain (LBP) and to measure the cost of each strategy over a period of 12 months and estimate cost-effectiveness.

DESIGN

Pragmatic multicentred randomised controlled trial with investigator-blinded assessment of outcomes.

SETTING

Fifty-six general practices from seven English regions.

PARTICIPANTS

People with subacute and chronic LBP who were experiencing symptoms that were at least moderately troublesome.

INTERVENTIONS

Participants were randomised (in a ratio of 2:1) to receive either AM+CBA or AM alone.

MAIN OUTCOME MEASURES

Primary outcomes were the Roland Morris Disability Questionnaire (RMQ) and the Modified Von Korff Scale (MVK), which measure LBP and disability. Secondary outcomes included mental and physical health-related quality of life (Short Form 12-item health survey), health status, fear avoidance beliefs and pain self-efficacy. Cost-utility of CBA was considered from both the UK NHS perspective and a broader health-care perspective, including both NHS costs and costs of privately purchased goods and services related to LBP. Quality-adjusted life-years (QALYs) were calculated from the five-item EuroQoL.

RESULTS

Between April 2005 and April 2007, 701 participants were randomised: 233 to AM and 468 to AM+CBA. Of these, 420 were female. The mean age of participants was 54 years and mean baseline RMQ was 8.7. Outcome data were obtained for 85% of participants at 12 months. Benefits were seen across a range of outcome measures in favour of CBA with no evidence of group or therapist effects. CBA resulted in at least twice as much improvement as AM. Mean additional improvement in the CBA arm was 1.1 [95% confidence interval (CI) 0.4 to 1.7], 1.4 (95% CI 0.7 to 2.1) and 1.3 (95% CI 0.6 to 2.1) change points in the RMQ at 3, 6 and 12 months respectively. Additional improvement in MVK pain was 6.8 (95% CI 3.5 to 10.2), 8.0 (95% CI 4.3 to 11.7) and 7.0 (95% CI 3.2 to 10.7) points, and in MVK disability was 4.3 (95% CI 0.4 to 8.2), 8.1 (95% CI 4.1 to 12.0) and 8.4 (95% CI 4.4 to 12.4) points at 3, 6 and 12 months respectively. At 12 months, 60% of the AM+CBA arm and 31% of the AM arm reported some or complete recovery. Mean cost of attending a CBA course was 187 pounds per participant with an additional benefit in QALYs of 0.099 and an additional cost of 178.06 pounds. Incremental cost-effectiveness ratio was 1786.00 pounds. Probability of CBA being cost-effective reached 90% at about 3000 pounds and remained at that level or above; at a cost-effectiveness threshold of 20,000 pounds the CBA group had an almost 100% probability of being considered cost-effective. User perspectives on the acceptability of group treatments were sought through semi-structured interviews. Most were familiar with key messages of AM; most who had attended any group sessions had retained key messages from the sessions and two-thirds talked about a reduction in fear avoidance and changes in their behaviour. Group sessions appeared to provide reassurance, lessen isolation and enable participants to learn strategies from each other.

CONCLUSIONS

Long-term effectiveness and cost-effectiveness of CBA in treating subacute and chronic LBP was shown, making this intervention attractive to patients, clinicians and purchasers. Short-term (3-month) clinical effects were similar to those found in high-quality studies of other therapies and benefits were maintained and increased over the long term (12 months). Cost per QALY was about half that of competing interventions for LBP and because the intervention can be delivered by existing NHS staff following brief training, the back skills training programme could be implemented within the NHS with relative ease.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN37807450.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Effects of the Diabetes Manual 1:1 structured education in primary care

AIMS

To determine the effects of the Diabetes Manual on glycaemic control, diabetes-related distress and confidence to self-care of patients with Type 2 diabetes.

METHODS

A cluster randomized, controlled trial of an intervention group vs. a 6-month delayed-intervention control group with a nested qualitative study. Participants were 48 urban general practices in the West Midlands, UK, with high population deprivation levels and 245 adults with Type 2 diabetes with a mean age of 62 years recruited pre-randomization. The Diabetes Manual is 1:1 structured education designed for delivery by practice nurses. Measured outcomes were HbA(1c), cardiovascular risk factors, diabetes-related distress measured by the Problem Areas in Diabetes Scale and confidence to self-care measured by the Diabetes Management Self-Efficacy Scale. Outcomes were assessed at baseline and 26 weeks.

RESULTS

There was no significant difference in HbA(1c) between the intervention group and the control group [difference -0.08%, 95% confidence interval (CI) -0.28, 0.11]. Diabetes-related distress scores were lower in the intervention group compared with the control group (difference -4.5, 95% CI -8.1, -1.0). Confidence to self-care Scores were 11.2 points higher (95% CI 4.4, 18.0) in the intervention group compared with the control group. The patient response rate was 18.5%.

CONCLUSIONS

In this population, the Diabetes Manual achieved a small improvement in patient diabetes-related distress and confidence to self-care over 26 weeks, without a change in glycaemic control. Further study is needed to optimize the intervention and characterize those for whom it is more clinically and psychologically effective to support its use in primary care.

Health professionals, their medical interventions and uncertainty: A study focusing on women at midlife

Health professionals face a tension between focusing on the individual and attending to health issues for the population as a whole. This tension is intrinsic to medicine and gives rise to medical uncertainty, which here is explored through accounts of three medical interventions focused on women at midlife: breast screening, hormone replacement therapy and bone densitometry. The accounts come from interviews with UK health professionals using these medical interventions in their daily work. Drawing on the analysis of Fox [(2002). Health and Healing: The public/private divide (pp. 236-253). London: Routledge] we distinguish three aspects of medical uncertainty and explore each one of them in relation to one of the interventions. First is uncertainty about the balance between the individual and distributive ethic of medicine, explored in relation to breast screening. Second is the dilemma faced by health professionals when using medical evidence generated through studies of populations and applying this to individuals. We explore this dilemma for hormone replacement therapy. Thirdly there is uncertainty because of the lack of a conceptual framework for understanding how new micro knowledge, such as human genetic information, can be combined with knowledge of other biological and social dimensions of health. The accounts from the bone denistometry clinic indicate the beginnings of an understanding of the need for such a framework, which would acknowledge complexity, recognising that factors from many different levels of analysis, from heredity through to social factors, interact with each other and influence the individual and their health. However, our analysis suggests biomedicine continues to be dominated by an individualised, context free, concept of health and health risk with individuals alone responsible for their own health and for the health of the population. This may continue to dominate how we perceive responsibilities for health until we establish a conceptual framework that recognises the complex interaction of many factors at macro and micro level affecting health.

Setting priorities and identifying barriers for general practice research in Europe. Results from an EGPRW meeting

BACKGROUND

In spring 2002, WONCA Europe, the European Society of General Practice/Family Medicine and its Network organizations reached consensus on a 'new' European definition of general practice. Subsequently, the European General Practice Research Workshop (EGPRW) started working on a European General Practice Research Agenda. This topic was addressed during the 2002 EGPRW autumn meeting.

OBJECTIVE

Our aim was to explore the views of European general practice researchers on needs and priorities as well as barriers for general practice research in Europe.

METHODS

In seven discussion groups, 43 general practice researchers from 18 European countries had to answer the following questions. (i) What major topics should be included in a research agenda for general practice in your country? (ii) What are the barriers to adequate implementation of general practice research in your country? Group answers were listed and subsequently categorized by two authors.

RESULTS

Research on 'clinical issues' (common diseases, chronic diseases, etc.), including diagnostic strategies, was considered to be the core content of general practice research, with primary care-based morbidity registration essential for surveillance of disease, clinical research and teaching in general practice. There was also consensus on the need for research on education and teaching. 'Insufficient funding opportunities' was perceived to be the major barrier to the development of general practice research.

CONCLUSIONS

These findings could be used as a basis for national checklists of 'content of' and 'conditions for' general practice research. European general practice research training programmes should be developed further.

Reflections from organization science on the development of primary health care research networks

In the UK, policy changes in primary health care research and development have led to the establishment of primary care research networks. These organizations aim to increase research culture, capacity and evidence base in primary care. As publicly funded bodies, these networks need to be accountable. Organizational science has studied network organizations including why and how they develop and how they function most effectively. This paper draws on organizational science to reflect on why primary care research networks appear to be appropriate for primary care research and how their structures and processes can best enable the achievement of their aims.

The productivity of primary care research networks

Primary care research networks are being publicly funded in the United Kingdom to promote a culture of research and development in primary care. This paper discusses the organisational form of these networks and how their productivity can be evaluated, drawing on evidence from management science. An evaluation of a research network has to take account of the complexity of the organisation, the influence of its local context, and its stage of development. Output measures, such as number of research papers, and process measures, such as number of research meetings, may contribute to an evaluation. However, as networking relies on the development of informal, trust-based relationships, the quality of interactions within a network is of paramount importance for its success. Networks can audit and reflect on their success in promoting such relationships and a more formal qualitative evaluation by an independent observer can document their success to those responsible for funding.

Women's control and choice regarding HRT

The promotion and use of hormone replacement therapy (HRT) is the focus of much medical activity and a social phenomenon studied by sociology. The decision to prescribe HRT by a doctor may be a response to a woman's distress and is a decision involving uncertainty about risks and benefits. Sociological analysis has seen the promotion and use of HRT as medicalisation of the menopause. Through individual interviews and focus groups, this study hears from women how they approach the decision to take HRT or not, and what influences them. The interviews reveal how women who dislike medication in general may consider HRT, influenced by fear of ill health which may be enhanced by the experience of illness in the family and by medical advice. For the women the media and their social contacts were the major sources of information about HRT. In the focus groups the women explored the control they had over the choice to take HRT and what limited this control and they explored the uncertainties and complexities of the decision to take HRT or not. This study brings lay women's voices to the debate about the use and promotion of HRT. The results are also used to test the limits of the theory of medicalisation and to inform doctors of the issues women may bring to a consultation about HRT.

General practice and the new science emerging from the theories of 'chaos' and complexity

This paper outlines the general practice world view and introduces the main features of the theories of 'chaos' and complexity. From this, analogies are drawn between general practice and the theories, which suggest a different way of understanding general practice and point to future developments in general practice research. A conceptual and practical link between qualitative and quantitative methods of research is suggested. Methods of combining data about social context with data about individuals and about biomedical factors are discussed. The paper emphasizes the importance of data collected over time and of considering the multiplicative interactions between variables. Finally, the paper suggests that to develop this type of research, general practice many need to reassess systems of categorizing and recording appropriate data.

Women doctors' use of hormone replacement therapy. May be to enable them to cope with demands of their job

Images

Women's decisions about whether or not to take hormone replacement therapy: influence of social and medical factors

BACKGROUND

General practitioners have been described as reluctant to prescribe hormone replacement therapy although its use is widely discussed and advocated in the popular media.

AIM

This study set out to identify women's perceptions of media coverage of hormone replacement therapy; the people influencing women's decisions about therapy and women's sources of information; their general practitioners' attitudes to therapy; and women's experiences of the primary health care team in relation to hormone replacement therapy.

METHOD

In 1993, a postal questionnaire survey was undertaken of 1649 women aged between 20 and 69 years registered with eight general practices in Stockton-on-Tees.

RESULTS

A total of 1225 women (74%) returned questionnaires. Women considered that the media portrayed mainly positive images of hormone replacement therapy. A substantial minority of women found the media information unhelpful (30%) or felt that it was incorrect (17%). General practitioners and practice nurses were most frequently considered to be the most important people in helping women decide about taking therapy, but relatives and friends were also important; 41% of women named no one. The media, friends and relatives were most commonly cited as the main sources of information about therapy. Of the women who had discussed hormone replacement therapy with their general practitioner, 65% felt that their general practitioner was in favour of its use for relieving menopausal symptoms. Two thirds of women felt they had had enough time and information when discussing hormone replacement therapy with their general practitioner and/or practice nurse.

CONCLUSION

Women did not seem to perceive any resistance from their general practitioner to the prescribing of hormone replacement therapy. Although women gathered information about therapy from sources other than their doctor, doctors have an important role, as providers of the therapy, in listening to women and helping them to make their own decision about whether or not to take hormone replacement therapy.

Women's use of hormone replacement therapy for relief of menopausal symptoms, for prevention of osteoporosis, and after hysterectomy

BACKGROUND

Hormone replacement therapy is used for the relief of menopausal symptoms. In the United Kingdom, guidelines have been developed for the use of hormone replacement therapy in the prevention of osteoporosis, and in the United States of America its use has also been recommended for cardiovascular disease prevention. However, compliance has been found to be a problem, and rates of prescribing vary between general practitioners.

AIM

This study set out to describe the prescribing of hormone replacement therapy in one general practice, to enable doctors to plan future prescribing and promotion of hormone replacement therapy, taking into account constraints on its use.

METHOD

The patient records of users of hormone replacement therapy were examined to collect data on menopausal status, reason for use, length of use, breaks from therapy and reasons for stopping therapy. Women with a history of hysterectomy and with risk factors for osteoporosis were identified from the practice morbidity register. Their use of hormone replacement therapy was recorded.

RESULTS

Of women aged 40-59 years on the practice list, 348 were taking hormone replacement therapy (20%). Of 107 women aged under 52 years who had had a hysterectomy and bilateral oophorectomy 76 were taking therapy (71%). Of 158 women under the age of 52 years who had had a hysterectomy with preservation of the ovaries 39 were taking therapy (25%). Among women taking hormone replacement therapy for the relief of menopausal symptoms, the highest rate of use was among those aged 50-54 years where 93 were on therapy (24% of women in that age group in the practice). Twenty out of 47 women with a recorded risk factor for osteoporosis were taking therapy. More than three quarters of women using hormone replacement therapy appeared to be taking it continuously.

CONCLUSION

The uptake of hormone replacement therapy was found to be high for women with a surgical menopause, the group most easily identifiable as at risk of osteoporosis. Women who decided to take therapy appeared to take it continuously, and therefore effectively for prevention. Rate of uptake, rather than compliance, is more likely to constrain its use in prevention.

The use of hormone replacement therapy; results of a community survey

Hormone replacement therapy is used for both menopausal symptoms and in prevention, but for the latter to be effective there may be a need to promote its use. Suitable strategies need to be informed by current practice. A postal questionnaire was therefore sent to 1649 women aged 20-69 years in Stockton-on-Tees to assess which women consider and take hormone replacement therapy. The response rate was 74%. Therapy had been considered by 346 (28%) women of whom 164 (47%) were premenopausal. It was taken by 20% of women aged 45-65 years. Users were more likely to have taken the contraceptive pill. Use of therapy by women with osteoporosis or cardiovascular disease, or with a family history of these, was low. As women used to the idea of taking hormone replacement therapy and accustomed to taking the contraceptive pill reach menopausal age there is likely to be an increase in uptake of therapy. By targeting the 'at risk' groups of women, the primary care team may be able to make most effective use of the therapy and their own resources for the prevention of osteoporosis and cardiovascular disease.

Women's health concerns. Is the promotion of hormone replacement therapy for prevention important to women?

The objectives of this study were to find out women's health concerns for the community and for themselves as they age and whether the promotion of hormone replacement therapy for prevention is important to them. A postal questionnaire was sent to 1649 women aged 20-69 years. The sample was random but stratified for age and taken from the lists of eight general practices in the town of Stockton-on-Tees in north east England. The questionnaire included questions on priorities for health care, fears for personal health with ageing, knowledge about osteoporosis, cardiovascular disease and hormone replacement therapy. A 74.3% response rate was achieved. Cancer was named as deserving highest priority for health care in Britain today by 40.7% of respondents. The promotion of long term hormone replacement therapy was given a relatively low priority. The health problem women named as the one they most fear will affect them as they age was, for 30.2% of women, cancer; for 18.8% of women, dementia; for 11.6% of women, arthritis; for 8.8% of women, heart disease. The role of oestrogen in preventing osteoporosis was known by 74.9% of respondents and its role in prevention of cardiovascular disease by 6.6%. Lack of exercise as a risk factor for osteoporosis was known by 29.0% and as a risk factor for cardiovascular disease by 84.6%. Arthritis-like pain was thought to be a warning sign of osteoporosis by by 55.8% of respondents. The promotion of hormone replacement therapy for prevention does not appear to be a high priority for women.(ABSTRACT TRUNCATED AT 250 WORDS)