International Survey of Pediatric Oncologists' Beliefs and Communication Practices Regarding Symptom Self-Monitoring by Childhood Cancer Survivors

PURPOSE

Childhood cancer survivors report self-monitoring for and worrying about symptoms of disease recurrence and secondary cancers, although symptom-related worry is associated with poorer health-related quality of life. This survey captured pediatric oncologists' beliefs and communication practices regarding symptom self-monitoring for childhood cancer survivors.

METHODS

Using a closed-loop snowball sampling technique, pediatric oncologists completed an online survey regarding the importance of symptom self-monitoring for off-therapy patients, the degree to which symptom self-monitoring was perceived to cause stress and worry, and communication practices.

RESULTS

196 pediatric oncologists (White [78%]; female [64%]; M_age = 47 years) from every continent except Antarctica participated. Oncologists believed it is important for off-therapy patients to self-monitor for symptoms of cancer recurrence (90%) and treatment late effects (94%), although some noted that recurrence (30%) and late effects (55%) are typically detected by routine surveillance before symptoms appear. Oncologists varied in their beliefs that off-therapy patients do (31%) or do not (31%) worry unnecessarily about symptoms of recurrence. Two thirds (62%) of oncologists reported often/always discussing with off-therapy patients which symptoms could indicate cancer recurrence, whereas fewer than half (43%) often/always discussed which symptoms were unlikely to indicate recurrence. Oncologists identified a need for education regarding how to communicate around symptom self-monitoring and the potential utility of a screening tool to identify those who worry excessively.

CONCLUSION

Despite nearly universal belief that their off-therapy patients should self-monitor for symptoms of disease recurrence and late effects, a substantial proportion of pediatric oncologists do not counsel patients on symptom self-monitoring. Since nearly one-third believe that off-therapy patients worry unnecessarily about symptoms of recurrence, improving patient education regarding which symptoms are and are not medically concerning could decrease stress and improve health-related quality of life for pediatric cancer survivors.

Is self always prioritised? Attenuating the ownership self-reference effect in memory

The current study demonstrates the abolishment of the Ownership Self Reference Effect (OSRE) when elaborate details of a distant other-referent are provided. In a 2 (High versus Low information) × 2 (Self versus Other) experimental design, we tested the capacity for the SRE to be modulated with social saliency. Using a well-established ownership paradigm (Collard et al., 2020; Cunningham et al., 2008; Sparks et al., 2016), when the other was made socially salient (i.e. details and characteristics about the other were provided to the participant prior to encoding), no SRE emerged, such that self-owned and other-owned items were recalled with comparable accuracy. In contrast, when the other was not salient (i.e., no details about them were provided), participants accurately recalled a higher proportion of self-owned items, demonstrating a typical SRE in source memory. The degree of self- or other- referencing was not related to measured variables of closeness, similarity or shared traits with the other. Although the SRE is an established and robust effect, the findings of the current study illustrate critical circumstances in which the self is no longer prioritised above the other. In line with our predictions, we suggest that the self has automatic attributed social salience (e.g. through ownership) and that enhancing social salience by elaborating details of the other, prioritisation can expand to encapsulate an other beyond the self and influence incidental memory.

Smartphone-based Ecological Momentary Assessment to study "scanxiety" among Adolescent and Young Adult survivors of childhood cancer: A feasibility study

OBJECTIVE

Scan-related anxiety ("scanxiety") refers to the fear, stress, and anxiety in anticipation of tests and scans in follow-up cancer care. This study assessed the feasibility of Ecological Momentary Assessment (EMA) for real-world, real-time capture of scanxiety using patients' personal smartphone.

METHODS

Adolescent and Young Adult survivors of childhood cancer were prompted to complete EMA surveys on a smartphone app three times per day for 11 days (33 surveys total) around their routine surveillance scans. Participants provided structured feedback on the EMA protocol.

RESULTS

Thirty out of 46 contacted survivors (65%) enrolled, exceeding the preregistered feasibility cutoff of 55%. The survey completion rate (83%) greatly exceeded the preregistered feasibility cutoff of 65%. Participants generally found the smartphone app easy and enjoyable to use and reported low levels of distress from answering surveys. Participants reported significantly more daily fear of cancer recurrence (FCR) and negative affect in the days before compared to the days after surveillance scans, aligning with the expected trajectory of scanxiety. Participants who reported greater FCR and scanxiety using comprehensive measures at baseline also reported significantly more daily FCR around their surveillance scans, indicating validity of EMA items. Bodily threat monitoring was prospectively and concurrently associated with daily FCR, thus warranting further investigation as a risk factor for scanxiety.

CONCLUSIONS

Findings indicate the feasibility, acceptability, and validity of EMA as a research tool to capture the dynamics and potential risk factors for scanxiety.

Worry about somatic symptoms as a sign of cancer recurrence: prevalence and associations with fear of recurrence and quality of life in survivors of childhood cancer

OBJECTIVE

Somatic symptoms (e.g., pain, fatigue) are common after childhood cancer and are associated with greater fear of cancer recurrence and poorer health-related quality of life (HRQoL). Qualitative studies indicate that survivors of childhood cancer (SCCs) worry about somatic symptoms as indicating cancer recurrence, which could in part explain associations between symptoms and poorer psychosocial outcomes. However, the prevalence, characteristics, and impact of symptom worry has not been quantitatively studied.

METHODS

SCCs (N = 111; 52% female; Mage at study = 17.67 years, range = 8-25 years; Mage at diagnosis = 6.70 years) across a variety of diagnoses were recruited from a pediatric cancer center in Canada and completed self-report measures of symptom worry, symptom frequency, general anxiety, fear of cancer recurrence, and HRQoL.

RESULTS

A majority (62%) of SCCs worried about at least one symptom as a sign of recurrence. Pain was the most worrisome symptom, but SCCs also reported worrying about symptoms that are rarely associated with cancer recurrence such as hunger, dizziness, and feeling cold. Symptom worry was more strongly associated with fear of cancer recurrence than the mere frequency of those symptoms, and this relationship held while controlling for treatment factors and general anxiety. Symptom worry and frequency each explained unique variance in HRQoL.

CONCLUSIONS

Worry about somatic symptoms as a sign of cancer recurrence is common and may be impactful after childhood cancer. Excessive worry about somatic symptoms could be an important target to reduce fear of recurrence and increase HRQoL in SCCs.

Cretaceous origins of the vibrotactile bill-tip organ in birds

Some probe-foraging birds locate their buried prey by detecting mechanical vibrations in the substrate using a specialized tactile bill-tip organ comprising mechanoreceptors embedded in densely clustered pits in the bone at the tip of their beak. This remarkable sensory modality is known as 'remote touch', and the associated bill-tip organ is found in probe-foraging taxa belonging to both the palaeognathous (in kiwi) and neognathous (in ibises and shorebirds) clades of modern birds. Intriguingly, a structurally similar bill-tip organ is also present in the beaks of extant, non-probing palaeognathous birds (e.g. emu and ostriches) that do not use remote touch. By comparison with our comprehensive sample representing all orders of extant modern birds (Neornithes), we provide evidence that the lithornithids (the most basal known palaeognathous birds which evolved in the Cretaceous period) had the ability to use remote touch. This finding suggests that the occurrence of the vestigial bony bill-tip organ in all modern non-probing palaeognathous birds represents a plesiomorphic condition. Furthermore, our results show that remote-touch probe foraging evolved very early among the Neornithes and it may even have predated the palaeognathous-neognathous divergence. We postulate that the tactile bony bill-tip organ in Neornithes may have originated from other snout tactile specializations of their non-avian theropod ancestors.

Perfluorobutane sulfonate exposure disrupted human placental cytotrophoblast cell proliferation and invasion involving in dysregulating preeclampsia related genes

We reported that maternal PFBS, an emerging pollutant, exposure is positively associated with preeclampsia which can result from aberrant trophoblasts invasion and subsequent placental ischemia. In this study, we investigated the effects of PFBS on trophoblasts proliferation/invasion and signaling pathways. We exposed a human trophoblast line, HTR8/SVneo, to PFBS. Cell viability, proliferation, and cell cycle were evaluated by the MTS assay, Ki-67 staining, and flow cytometry, respectively. We assessed cell migration and invasion with live-cell imaging-based migration assay and matrigel invasion assay, respectively. Signaling pathways were examined by Western blot, RNA-seq, and qPCR. PFBS exposure interrupted cell proliferation and invasion in a dose-dependent manner. PFBS (100 μM) did not cause cell death but instead significant cell proliferation without cell cycle disruption. PFBS (10 and 100 μM) decreased cell migration and invasion, while PFBS (0.1 μM) significantly increased cell invasion but not migration. Further, RNA-seq analysis identified dysregulated HIF-1α target genes that are relevant to cell proliferation/invasion and preeclampsia, while Western Blot data showed the activation of HIF-1α, but not Notch, ERK1/2, (PI3K)AKT, and P38 pathways. PBFS exposure altered trophoblast cell proliferation/invasion which might be mediated by preeclampsia-related genes, suggesting a possible association between prenatal PFBS exposure and adverse placentation.

Functional Genomics of Healthy and Pathological Fetal Membranes

Premature preterm rupture of membranes (PPROM), rupture of fetal membranes before 37 weeks of gestation, is the leading identifiable cause of spontaneous preterm births. Often there is no obvious cause that is identified in a patient who presents with PPROM. Identifying the upstream molecular events that lead to fetal membrane weakening presents potentially actionable mechanisms which could lead to the identification of at-risk patients and to the development of new therapeutic interventions. Functional genomic studies have transformed understanding of the role of gene regulation in diverse cells and tissues involved health and disease. Here, we review the results of those studies in the context of fetal membranes. We will highlight relevant results from major coordinated functional genomics efforts and from targeted studies focused on individual cell or tissue models. Studies comparing gene expression and DNA methylation between healthy and pathological fetal membranes have found differential regulation between labor and quiescent tissue as well as in preterm births, preeclampsia, and recurrent pregnancy loss. Whole genome and exome sequencing studies have identified common and rare fetal variants associated with preterm births. However, few fetal membrane tissue studies have modeled the response to stimuli relevant to pregnancy. Fetal membranes are readily adaptable to cell culture and relevant cellular phenotypes are readily observable. For these reasons, this is now an unrealized opportunity for genomic studies isolating the effect of cell signaling cascades and mapping the fetal membrane responses that lead to PPROM and other pregnancy complications.

The costs of keeping cool: behavioural trade-offs between foraging and thermoregulation are associated with significant mass losses in an arid-zone bird

Avian responses to high environmental temperatures include retreating to cooler microsites and/or increasing rates of evaporative heat dissipation via panting, both of which may affect foraging success. We hypothesized that behavioural trade-offs constrain the maintenance of avian body condition in hot environments, and tested predictions arising from this hypothesis for male Southern Yellow-billed Hornbills (Tockus leucomelas) breeding in the Kalahari Desert. Operative temperatures experienced by the hornbills varied by up to 13 °C among four microsite categories used by foraging males. Lower prey capture rates while panting and reductions associated with the occupancy of off-ground microsites, resulted in sharp declines in foraging efficiency during hot weather. Consequently, male body mass (M_b) gain between sunrise and sunset decreased with increasing daily maximum air temperature (T_max), from ~ 5% when T_max < 25 °C to zero when T_max = 38.4 °C. Overnight M_b loss averaged ~ 4.5% irrespective of T_max, creating a situation where nett 24-h M_b loss approached 5% on extremely hot days. These findings support the notion that temperature is a major determinant of body condition for arid-zone birds. Moreover, the strong temperature dependence of foraging success and body condition among male hornbills provisioning nests raises the possibility that male behavioural trade-offs translate into equally strong effects of hot weather on female condition and nest success. Our results also reveal how rapid anthropogenic climate change is likely to substantially decrease the probability of arid-zone birds like hornbills being able to successfully provision nests while maintaining their own condition.

Bayesian estimation of genetic regulatory effects in high-throughput reporter assays

MOTIVATION

High-throughput reporter assays dramatically improve our ability to assign function to noncoding genetic variants, by measuring allelic effects on gene expression in the controlled setting of a reporter gene. Unlike genetic association tests, such assays are not confounded by linkage disequilibrium when loci are independently assayed. These methods can thus improve the identification of causal disease mutations. While work continues on improving experimental aspects of these assays, less effort has gone into developing methods for assessing the statistical significance of assay results, particularly in the case of rare variants captured from patient DNA.

RESULTS

We describe a Bayesian hierarchical model, called Bayesian Inference of Regulatory Differences, which integrates prior information and explicitly accounts for variability between experimental replicates. The model produces substantially more accurate predictions than existing methods when allele frequencies are low, which is of clear advantage in the search for disease-causing variants in DNA captured from patient cohorts. Using the model, we demonstrate a clear tradeoff between variant sequencing coverage and numbers of biological replicates, and we show that the use of additional biological replicates decreases variance in estimates of effect size, due to the properties of the Poisson-binomial distribution. We also provide a power and sample size calculator, which facilitates decision making in experimental design parameters.

AVAILABILITY AND IMPLEMENTATION

The software is freely available from www.geneprediction.org/bird. The experimental design web tool can be accessed at http://67.159.92.22:8080.

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

Career satisfaction and work-life balance of specialist orthodontists within the UK/ROI

Objectives To investigate factors affecting career satisfaction and work-life balance in specialist orthodontists in the UK/ROI.Design and setting Prospective questionnaire-based study.Subjects and methods The questionnaire was sent to specialist orthodontists who were members of the British Orthodontic Society.Results Orthodontists reported high levels of career satisfaction (median score 90/100). Career satisfaction was significantly higher in those who exhibited: i) satisfaction with working hours; ii) satisfaction with the level of control over their working day; iii) ability to manage unexpected home events; and iv) confidence in how readily they managed patient expectations. The work-life balance score was lower than the career satisfaction score but the median score was 75/100. Work-life balance scores were significantly affected by the same four factors, but additionally were higher in those who worked part-time.Conclusions Orthodontists in this study were highly satisfied with their career and the majority responded that they would choose orthodontics again. Work-life balance scores were lower than career satisfaction scores but still relatively high. It is important for the profession to consider ways of maintaining, or improving, career satisfaction and work-life balance; including maintaining flexibility of working hours and ensuring that all clinicians have ready access to appropriate training courses throughout their careers (for example, management of patient expectations).

Social anxiety in orthognathic patients

There is evidence that patients seeking orthognathic treatment may be motivated by social anxiety disorder (SAD). The aim of this study was to investigate SAD in orthognathic patients using the Brief Fear of Negative Evaluation Scale (BFNES) and to compare these findings with those of the general population. This was a cross-sectional, questionnaire study conducted in two parts. Firstly, a national survey was conducted to yield data for the BFNES from a large, random sample of the UK general population. Secondly, orthognathic patients completed the BFNES. The BFNES scores are reported in two formats: the original 12-item scale (O-BFNES) and a shorter eight-item version (S-BFNES). With regards to the national survey, 1196 individuals participated. The mean O-BFNES score was 29.72 (standard deviation (SD) 9.39) and S-BFNES score was 15.59 (SD 7.67). With regards to the orthognathic sample, 61 patients participated. The mean O-BFNES score was 39.56 (SD 10.35) and the mean S-BFNES score was 24.21 (SD 8.41). Orthognathic patients had significantly higher scores than the general UK population (P<0.001), and multiple linear regression revealed that age, gender, and patient status were all independent predictors of BFNES scores. From the results of this study, orthognathic patients experience significantly higher levels of social anxiety than the general population.

Psychological support for orthognathic patients – what do orthodontists want?

AIMS

(1) To evaluate consultant orthodontist opinion on referral of orthognathic patients to a liaison psychiatrist or psychologist and (2) To investigate the value of training orthodontic specialists in recognition of patients with psychological profiles that might affect orthognathic outcome.

DESIGN

Questionnaire-based study.

SUBJECTS AND METHODS

A structured questionnaire was distributed to all consultant orthodontists in the UK.

RESULTS

Approximately 40% of consultants thought that up to 10% of their orthognathic patients would benefit from psychological assessment by appropriately trained personnel. Twenty per cent of consultants were not certain what proportion of their patients would benefit from referral and over half the respondents said they do not refer any orthognathic patients for assessment. The most common reasons for referral were past/current psychiatric history (36%), unrealistic expectations (32%), 'gut instinct' (14%), no significant clinical problem (13%). Reasons not to refer were: nobody to refer to (30.5%), fear of patient reacting badly (15.8%), not sure who to refer to (14.7%), response from mental health team not useful (12.4%), waiting list too long (9.6%). The majority of clinicians felt they would benefit from training in this field (84.7%), as over 80% reported no teaching or training in psychological assessment/management.

CONCLUSIONS

Although we have no evidence to prove that interdisciplinary care is better for patients, clinical experience and reports from clinicians working in large centres, tells us there are probable advantages. The development of a training programme for both orthodontists and mental health teams would seem to be beneficial for both clinicians and patients.

Implementation of the virtual learning environment into a UK orthodontic training programme: the postgraduate and lecturer perspective

The virtual learning environment (VLE) was formally introduced into the orthodontic postgraduate teaching programme at the UCL Eastman Dental Institute in October 2006 with the main role to support the existing didactic teaching. The aim of this study was to establish the programme co-ordinator, lecturer and postgraduate perspective on the introduction of the VLE as an adjunct to other teaching methods. All participants were interviewed utilising open-ended questions to ascertain their response. The interviews were semi-structured and were continued until no new information was elicited. The interviews suggested that the programme co-ordinator, lecturers and the majority of the postgraduates were confident that the VLE could produce a better learning experience. The VLE has a number of advantages and disadvantages, however, there is great potential for the VLE to encourage a constructivist approach to teaching and learning. Moves have been made to align aspects, such as assessment, with the VLE and the rest of the curriculum.

A national review of mandibular orthognathic surgery activity in the National Health Service in England over a nine year period: part 1--service factors

We aimed to investigate the changing provision of mandibular orthognathic surgery in England for the period 1 April 1997-30 March 2006. Data on hospital inpatient activity were extracted from the NHS Hospital Episode Statistics (HES) database for all mandibular orthognathic surgical procedures between these dates. We investigated provider factors (in which units providing services were classified as undertaking either high or low volumes of activity) and temporal changes. There was a steady increase in the number of procedures over time, and a decrease in the mean time spent in hospital (p<0.001). Provider units with high volumes of activity had shorter inpatient stays than those that provided low volume (p<0.001) and exhibited a greater reduction in the duration of inpatient stays (p=0.02). Patterns of care are changing, and increasing numbers of treatments are being done as day-cases (p<0.001). Units with high volumes seem to be more efficient in terms of duration of hospital stay than low volume units. However, our data do not allow an insight into the quality of care provided, and further research is needed to address this issue.

Orthodontic treatment for deep bite and retroclined upper front teeth in children

BACKGROUND

Correction of the type of dental problem where the bite is deep and the upper front teeth are retroclined (Class II division 2 malocclusion) may be carried out using different types of orthodontic treatment. However, in severe cases, surgery to the jaws in combination with orthodontics may be required. In growing children, treatment may sometimes be carried out using special upper and lower dental braces (functional appliances) that can be removed from the mouth. In many cases this treatment does not involve taking out any permanent teeth. Often, however, further treatment is needed with fixed braces to get the best result. In other cases, treatment aims to move the upper first permanent molars backwards to provide space for the correction of the front teeth. This may be carried out by applying a force to the teeth and jaws from the back of the head using a head brace (headgear) and transmitting this force to a part of a fixed or removable dental brace. This treatment may or may not involve the removal of permanent teeth. In some cases, neither functional appliances nor headgear are required and treatment may be carried out without extraction of any permanent teeth. Instead of using a headgear, in certain cases, the back teeth are held back in other ways such as with an arch across or in contact with the front of the roof of the mouth which links two bands glued to the back teeth. Often in these cases, two permanent teeth are taken out from the middle of the upper arch (one on each side) to provide room to correct the upper front teeth. It is important for orthodontists to find out whether orthodontic treatment only, carried out without the removal of permanent teeth, in children with a Class II division 2 malocclusion produces a result which is any different from no orthodontic treatment or orthodontic treatment only involving extraction of permanent teeth.

OBJECTIVES

To establish whether orthodontic treatment, carried out without the removal of permanent teeth, in children with a Class II division 2 malocclusion, produces a result which is any different from no orthodontic treatment or orthodontic treatment involving removal of permanent teeth.

SEARCH STRATEGY

The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched. The handsearching of the main international orthodontic journals was updated to April 2006. There were no restrictions with regard to publication status or language of publication. International researchers, likely to be involved in Class II division 2 clinical trials, were contacted to identify any unpublished or ongoing trials.

SELECTION CRITERIA

Trials were selected if they met the following criteria: randomised controlled trials (RCTs) and controlled clinical trials (CCTs) of orthodontic treatments to correct deep bite and retroclined upper front teeth in children.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were to be conducted in duplicate and independently by two review authors. Results were to be expressed as random-effects models using mean differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals. Heterogeneity was to be investigated including both clinical and methodological factors.

MAIN RESULTS

No RCTs or CCTs were identified that assessed the treatment of Class II division 2 malocclusion in children.

AUTHORS' CONCLUSIONS

It is not possible to provide any evidence-based guidance to recommend or discourage any type of orthodontic treatment to correct Class II division 2 malocclusion in children.

Which factors influence willingness-to-pay for orthognathic treatment?

The aims of this interview-based questionnaire study were to establish which factors influence willingness-to-pay (WTP) for orthognathic treatment and to compare WTP values, from both members of the general public and orthognathic patients, with the actual cost of treatment, the hypothesis being that the more highly valued the intervention, the higher the WTP value. Data were collected from 88 orthognathic patients and a convenience sample of 100 adults using the so-called 'payment card' method. Demographic data were recorded, as well as ability to pay, incisor relationship, occupation, and level of education. In addition, the resources used in orthognathic treatment were estimated for five patients who participated in the study. The results showed that there was a significant difference between the mean WTP values for the public and patient groups. Patients were prepared to pay [see symbol in tex]2750 more than members of the general public. In addition, a significant relationship was found between WTP and incisor relationship in the patient group, with Class II division 1 patients prepared to pay [see symbol in text]3130 more than those with Class III malocclusions. Ability to pay did not significantly affect WTP. The mean total costs estimated for orthognathic treatment were lower than the mean patient WTP value and similar to the mean WTP value for the public group. In terms of cost-benefit, it appears that orthognathic treatment provides 'good value for money'. This study also showed that both patients and the general public were prepared to place a monetary value on the correction of dentofacial deformity and that this form of economic evaluation is a useful tool in monitoring health care in the UK.

How to write a thesis

The prospect of writing a thesis can be intimidating. However, there are certain formats that the writer should follow in order to make life much easier. This article covers a logical approach to presenting research findings. Also included are suggestions for a last minute checklist.

How to...write a paper

Writing a paper may seem like a daunting process for the inexperienced researcher (and sometimes for those who are experienced!). However, this does not need to be the case if the approach is logical and systematic. This article covers some of the most important aspects of writing a scientific paper.

A cost-utility analysis of patients undergoing orthognathic treatment for the management of dentofacial disharmony

INTRODUCTION

Management of dentofacial discrepancies using orthognathic treatment is now a common procedure in the United Kingdom. Although the benefits of orthognathic intervention are often considered, the cost implications have not been investigated to our knowledge. This study is a cost-utility analysis of orthognathic treatment.

PATIENTS AND METHODS

Twenty-one patients were interviewed five times during treatment using the time trade-off (TTO) method to establish utility values. Quality adjusted life years (QALYs) gained as a result of treatment were calculated and discounted. The resource use was calculated for each of the 21 patients individually and the costs subjected to both a sensitivity analysis and discounting. The incremental mean cost per additional QALY was calculated (as compared with a 'no treatment' approach).

RESULTS

The incremental cost for each additional QALY was 561 pounds sterling for the groups combined, based on mean additional costs and QALYs (546 pounds sterling for the bimaxillary group and 617 pounds sterling for the single jaw group).

DISCUSSION

Orthognathic treatment seems to provide good outcomes at relatively low cost. Even allowing for the uncertainty in mean costs and QALYs, there is a high probability of treatment being cost-effective. Cost-utility analysis is still a relatively new technique in dentistry and further studies should be encouraged.

A comparison of parents' and patients' views of orthognathic treatment

The aim of this study was to assess parents' views of orthognathic treatment and compare them with the views of their son or daughter who underwent the treatment. Fifty patients who had undergone orthognathic treatment and one of their parents were recruited over an 8-month period between July 1999 and March 2000. The study was a retrospective, questionnaire-based study. Comparison of parents' and patients' views was undertaken using Cohen's kappa coefficient. This was also used to compare individual parent and patient views pre- and posttreatment. Response rates were 90% (n = 45) for patients and 80% (n = 40) for parents. Parents rated their son or daughter as having a more attractive facial and dental appearance and higher levels of self-confidence both pre- and posttreatment than the patients graded themselves. Parents and patients both felt there was significant improvement in facial and dental appearance and self-confidence following treatment.

Are pre-treatment psychological characteristics influenced by pre-surgical orthodontics?

A number of investigations have looked at psychological changes occurring in association with orthognathic treatment. However, most of these studies have used a pre-surgery questionnaire as the baseline measurement. There is little data relating to the true baseline, i.e. that prior to any active treatment. Until this aspect is investigated, it is not possible to assume that pre-surgery is an acceptable baseline. This questionnaire based study aimed to assess changes in six psychological outcome measures between T1 (prior to any active treatment) and T2 (following pre-surgical orthodontics/prior to surgery). The outcome variables were: state anxiety, trait anxiety, depression, self-esteem, body image, and facial body image. Sixty-two patients (39 females and 23 males) completed both questionnaires. The results showed that intervention, in the form of orthodontic treatment, had a minimal effect on the chosen psychometric outcome variables. There was a significant reduction in satisfaction with body image amongst patients who initially reported mild to moderate dental/facial problems, whilst a moderate increase in satisfaction occurred in those patients reporting severe conditions initially. Also of note were significant increases in state anxiety amongst older patients whilst trait anxiety showed greater increases in females than males.

An introduction to economic evaluation of health care

Economic evaluation is an accepted method for the appraisal of health care programmes. Although it is used widely in medicine, its use in the field of dentistry has achieved popularity more recently. Economic evaluation in dentistry is likely to become increasingly important in the future and this paper introduces readers to some of the basic concepts.

Quality of life and its importance in orthodontics

Over the last 10-15 years, the terms quality of life (QOL) and health-related quality of life (HRQL) have been seen increasingly in medical literature. Much of the orthodontic treatment that is undertaken is justified on the basis of improving health-related quality of life. With this in mind, studying HRQL in orthodontic patients has the potential to provide information about treatment needs and outcomes, and may also facilitate improved care. Clinicians should therefore be aware of some of the ways in which health-related quality of life may be assessed. The first part of this review article looks at the general concepts of health-related quality of life, whilst the second section focuses on dentistry and orthodontics.

A comparison of information retention at an initial orthodontic consultation

The exchange of information is an everyday part of orthodontic treatment. However, the amount of information that is understood and retained, by patients and their parents, is not known. There has been very little research in the area of information retention in dentistry. This has implications with the demands for improved provision of information for patients. This questionnaire-based study, compared the effectiveness of written, verbal, and visual methods of providing orthodontic information. It assessed the retention of this information, by patients and parents, in both the short- and long-term. Twenty-eight patients and their parents, were allocated alternately into one of three groups, receiving written, verbal, or visual information. Short-term retention of knowledge was assessed 10-15 minutes after receiving the information and long-term retention rated by a second questionnaire mailed 8 weeks later. Overall, little difference was found between the three methods. The findings suggested that verbal information should not be given to patients unless supplemented by written and/or visual information, and that parents were more attentive to verbal instructions than their children.

The application of multilevel, multivariate modelling to orthodontic research data

OBJECTIVE

To demonstrate the use of multilevel multivariate modelling in the evaluation of multiple outcome dental data.

BASIC RESEARCH DESIGN

Multiple outcome dental research data are used to illustrate the problems of analysing such complex information structures i.e. several outcomes clustered within subjects. Appropriate and statistically efficient methods of data analysis are proposed and illustrated step-by-step. The data structure is analysed using multilevel multivariate regression techniques and this process is discussed in comparison to conventional single-level multiple regression.

PARTICIPANTS

Questionnaire data were obtained from an orthognathic study of 84 subjects seeking treatment and 106 'non-treatment' controls (full details of which are reported elsewhere).

RESULTS

Multivariate multiple regression analysis demonstrated a number of advantages over separate single-level multiple regression approaches, including a gain in statistical efficiency and greater insight into: a) the role of (significant) explanatory variables and b) outcome variable interactions. Multilevel multivariate analysis reduced the risk of both Tipe I and Type II statistical errors.

CONCLUSIONS

The study demonstrates the benefit of multilevel multivariate modelling over conventional single-level techniques for statistical analysis of multiple outcome data. As a result of ongoing technical developments in the power, speed and memory of modern PCs, multilevel multivariate regression can now be undertaken with relative ease. Consequently, researchers are better equipped to analyse such complex data structures, particularly within dentistry where multivariate data are common.

A comparison of the perception of facial profile by the general public and 3 groups of clinicians

Orthodontists and maxillofacial surgeons frequently plan orthognathic treatment to produce an "ideal" Class I occlusion and skeletal relationship. The aim of this study was to investigate whether the preferred facial profile chosen by orthodontists, maxillofacial surgeons, dental students, and members of the general public conformed to a Class I profile. Photographs were taken of 2 male and 2 female adult subjects with Class I profiles, and by means of a computer program the images were manipulated to produce Class II, Class III, and long face profiles. The orthodontists, surgeons, dental students, and members of the general public ranked each group of 4 photos in order of their attractiveness. Orthodontists and maxillofacial surgeons were found to be significantly more likely to choose a Class I skeletal relationship as the most attractive profile. A significant difference was found between orthodontists and dental students (P < 0.01) and between orthodontists and the general public (P < 0.001) with regard to the assessment of the Class I profile as the most attractive, when all 4 subjects were considered. Similar results were noted for maxillofacial surgeons. Whether the assessor was an orthodontist, maxillofacial surgeon, or a member of the general public was found to be significant when examining subjects 1 (female) and 3 (male). The sex of the assessor was also a significant factor for subject 3 (male), where female assessors were more likely to rank the Class I profile as most attractive (P < 0.05).

Development of a condition-specific quality of life measure for patients with dentofacial deformity: I. Reliability of the instrument

The assessment of quality of life is becoming increasingly important in clinical research. Its importance in dentistry has been realised only relatively recently. Health-related quality of life is concerned with the aspects of quality of life that relate specifically to an individual's health. This may be measured using two groups of instruments: (i) generic measures, which provide a summary of health-related quality of life and sometimes generate a single index measure of health or (ii) condition-specific measures, which focus on a particular condition, disease, population or problem and are potentially more responsive to small, but clinically important, changes in health.

OBJECTIVES

The aim of this study was to develop a condition-specific quality of life measure for those patients with severe dentofacial deformity who were requesting orthognathic treatment and to assess the reliability of this instrument.

METHOD

Instrument content was derived through a literature review and interviews with clinicians and patients. The resulting instrument was tested for internal consistency and test-retest reliability.

RESULTS AND CONCLUSION

The instrument was found to divide into four clinically meaningful domains. Internal consistency and test-retest reliability were good. Patient acceptance of the questionnaire was also encouraging.

A comparison of health state utilities for dentofacial deformity as derived from patients and members of the general public

The cost-utility approach is a method of economic evaluation, which assigns a ratio of cost to benefit, based on utility values of the health state in question. It allows efficient use of health care resources and is a useful method in that it permits comparison of a wide range of medical interventions, including those which are life saving and those that improve quality of life. This study obtained utility values for dentofacial deformity from orthognathic patients and members of the general public using three recognized methods--rating scale (RS), standard gamble (SG), and time trade-off (TTO). There were no significant differences between the utility values for the two groups of respondents. Method agreement between the TTO and the SG (the 'gold standard') was better than that between the RS and SG. In addition, the SG and TTO were found to have greater repeatability than the RS.

Relationship between utility values and willingness to pay in patients undergoing orthognathic treatment

OBJECTIVE

To determine utility and willingness to pay (WTP) values for patients undergoing orthognathic treatment in a National Health Service hospital in the United Kingdom and to establish whether WTP values can be used as a measure of strength of preference.

PARTICIPANTS

Forty patients who were about to start orthognathic treatment were recruited over a 10-month period between January and October 1998.

OUTCOME MEASURES

Utility values were obtained using the standard gamble method and WTP values were determined using a payment card method. The relationship between the two was assessed.

RESULTS

The mean utility value was 0.73 and the mean WTP was 6,833 pounds. The correlation between these two measures was -0.46 (P<0.01).

CONCLUSIONS

The correlation between the utility and WTP values was in the expected direction thus suggesting that WTP may be used as a measure of strength of preference. Therefore, willingness to pay may be a useful technique to combine with cost utility analysis.

Are orthognathic patients different?

This questionnaire-based study investigated the psychological profile of orthognathic patients prior to starting treatment and compared the findings with a control group of non-patients. Comparison of the data used multivariate multiple regression analysis where outcome variables and independent variables were studied simultaneously. Some differences were found in the psychological profile of the orthognathic patient. They displayed higher levels of state anxiety (P < 0.001), higher numbers of individuals in their social support network (P < 0.05), and lower body image and facial body image (P < 0.001). Self-esteem was also found to be lower, but only at borderline levels of significance (P = 0.052).

Economic evaluation of healthcare--is it important to us?

Economic evaluation is now an accepted method for the appraisal of healthcare programmes. Although it is used widely in medicine, its use in the field of dentistry is only just beginning to achieve popularity. Economic evaluation in dentistry is likely to become increasingly important in the future and this paper aims to introduce the basics of the technique as well as describing some of the dental settings in which it is currently being used.

Soft tissue changes associated with incisor decompensation prior to orthognathic surgery

A retrospective cephalometric study employing angular and linear measurements was undertaken to examine soft tissue changes associated with incisor decompensation prior to orthognathic surgery. Subjects were divided into 3 groups based on the presenting malocclusion, and radiographs for each subject were traced and subsequently digitized. The results showed that incisor decompensation was achieved more markedly in Class II division 2 and Class III patients. In Class II division 1 subjects, changes in the mandibular incisor inclination were contrary to what was anticipated. The soft tissue change/dental change ratio following incisor decompensation showed that the soft tissues were least affected in the Class II division 2 group. This may be due to the increased tone of the soft tissues in this group, which resisted the effects of the incisor change. Alternatively, it may indicate that the soft tissue "drape" is not in close approximation to the dentition and therefore dental changes are not transmitted to the soft tissues.

The psychology of facial appearance

Facial attractiveness is now recognized as being important in situations as diverse as education, relationships and employment. An individual's facial appearance is one of their most obvious characteristics and facial disfigurements are judged to be among the least desirable 'handicaps'. A face which deviates from the norm becomes a stigma. This paper looks at the complex area of facial appearance and its importance in the field of dentistry. The relationship between facial attractiveness and varying forms of dental and surgical intervention are discussed, as well as some of the problems which may be encountered during treatment.

An investigation into the effects of polishing on surface hardness and corrosion of orthodontic archwires

The purpose of this study was to investigate the effect of surface roughness on the relative corrosion rates of wires of four alloys-stainless steel, nickel titanium, cobalt chromium, and beta titanium. Batches of wire were divided into two groups. Wires in one group were industrially polished to provide a uniform surface finish; wires in the other group were left for comparison "as received." Wire diameter, hardness, and relative corrosion rates were compared within groups before and after polishing. Comparisons were also made across the four groups of alloys. The samples of as-received wires showed variations in surface finish, with beta titanium having the roughest appearance and cobalt chromium the smoothest. Nickel titanium and stainless steel surfaces were similar. Polishing provided a more uniform finish, but significantly reduced the diameter of the wires. Microhardness testing of wire surfaces of each alloy indicated that no significant work-hardening occurred as a result of polishing. The relative corrosion rates (expressed in terms of corrosion current density) in a 0.9% sodium chloride solution were estimated using the electrochemical technique of polarization resistance. Nickel titanium wires exhibited the greatest corrosion current density in the as-received state. Polishing significantly reduced the corrosion rate of nickel titanium, such that comparison between the four alloys in the polished state revealed no significant difference in their relative corrosion rate/corrosion current density.

Providing immunizations in a pediatric emergency department: underimmunization rates and parental acceptance

OBJECTIVES

To assess the vaccination status and vaccinate eligible children with age-appropriate antigens.

DESIGN

Intervention.

SETTING

Pediatric emergency department in an urban, public hospital.

PATIENTS

Convenience sample of children, aged birth through 72 months.

INTERVENTIONS

Immunization of eligible children.

MAIN OUTCOME MEASURES

1) Immunization coverage rates in the sample population, 2) Acceptance rates of immunization.

RESULTS

A total of 9321 children were enrolled over a 2-year period. Fifty-nine percent were documented to be underimmunized. Overall, 2514 children received a total of 6482 immunizations. Parents who carried portable immunization cards documenting that their child was underimmunized were almost five times more likely to accept immunization for their child than parents who lacked documentation (71% vs 15%, P < 0.0001). The estimated cost of providing immunizations in the emergency department was $47.15 per child immunized, or $18.56 per immunization given.

CONCLUSIONS

The majority of children with documentation of immunization status were underimmunized. When documentation of underimmunization was available, parents were significantly more likely to accept vaccination. These data suggest that vaccinating children in nontraditional settings is feasible and support the creation of an accessible vaccine registry.

Psychological assessment of patients requesting orthognathic surgery and the relevance of body dysmorphic disorder

The psychological assessment of patients requesting orthognathic treatment is a vital and integral part of the overall assessment procedure. It allows identification of potential problems at an early stage before irreversible decisions have been made. This paper aims to highlight some of the aspects of psychological assessment which are particularly important. It also discusses current concepts in the diagnosis and treatment of those patients suffering from body dysmorphic disorder (BDD). This is the term applied to those individuals with a normal appearance who present requesting treatment because they believe that they have a 'defect'.

The effect of two alternative methods of canine exposure upon subsequent duration of orthodontic treatment

OBJECTIVES

The aim of this study was to compare the effectiveness, in terms of orthodontic treatment duration, of two methods of canine exposure.

DESIGN

This was a retrospective study using patients' records and lateral cephalometric radiographs.

SAMPLE AND METHODS

50 patients were selected, 25 in each group. In all subjects the impaction was categorized as being 'intermediate'. The methods of canine exposure were: (i) simple surgical exposure; (ii) surgical exposure and placement of an orthodontic attachment, followed by flap replacement.

RESULTS

The treatment duration until the canine was in the line of the arch was 17.7 months in the simple exposure group and 19.3 months in the bonded attachment group. The mean treatment duration (from exposure to debond) was 28.8 months for both groups.

CONCLUSIONS

In terms of treatment duration, no significant difference could be demonstrated between the two methods of surgical exposure to palatally impacted canines.

The use of kinesiography to assess mandibular rest positions following corrective orthognathic surgery

This study utilized the kinesiograph to assess the effect of orthognathic surgery on mandibular rest positions in a group of 27 patients exhibiting vertical facial deformities (14 long faced and 13 short faced patients). Two distinct rest positions were confirmed--clinical and physiological. Following surgery to alter the vertical dimensions, the clinical freeway space was found to adapt immediately whereas the physiological rest position partially adapted in the immediate postoperative period and continued to do so over the following year.

Parental perceptions of access to care and quality of care for inner-city children with asthma

The objective of this study was to describe perceptions of asthma care, morbidity, and health service utilization by parents of children with asthma presenting to an inner-city emergency department (ED). A cross-sectional survey was conducted in an urban pediatric ED, with a convenience sample of 466 parents of children receiving asthma treatment during a consecutive 6-week period in late fall 1995. Parents completed a 30-item survey including sociodemographic data, source of primary medical care and asthma care for their child, selected measures of access to care, and medications used by their child in the week prior to the ED visit. Perceived quality of asthma care was measured by six items (summary score = 0-6) reported to have been performed by the child's asthma doctor: discussion of home peak flow monitoring, child-specific triggers, dogs/cats, smoke, postexacerbation calling instructions, and provision of a written asthma management plan. Functional morbidity was measured by nights of poor sleep, days of cough, and school days missed due to asthma in the previous month. Among 325 patients with previously diagnosed asthma, 308 (97%) were reported to have a source of primary medical care. Of these, 126 respondents identified their primary care provider as the child's usual source of asthma care, while 158 identified the ED as the usual source. The groups did not differ by insurance status, ethnicity, or mean age of the child. Thirty-nine percent of children with the same provider for primary and asthma care compared with 15% of children reported to receive their asthma care predominantly in the ED had used inhaled steroids or cromolyn in the week prior to the ED visit (p < .0001). Children with the same provider for primary and asthma care had a higher mean quality score than children receiving asthma care in the ED (3.7 vs. 2.8, p < 0.0001), but there was no relationship between source of asthma care and functional morbidity. The ED remains the usual source of asthma care for many inner-city children. Among parents surveyed in the ED, there was a significant relationship between source of usual asthma care and quality of care, but a relationship between usual source of asthma care and functional morbidity could not be identified.

Stability of mandibular incisor decompensation in orthognathic patients

This retrospective cephalometric study examined the stability of mandibular incisor decompensation following orthognathic treatment. It also studied the relationship between the mandibular incisor-mandibular plane angle (LIMnp) and the maxillary-mandibular planes angle (MMA). Two groups of 22 subjects each underwent either mandibular advancement only or bimaxillary surgery with mandibular setback. Serial radiographs of each subject were digitized. Twenty-seven Class I subjects who were part of the Leighton Growth Study served as the control. The control group showed a significant association between LIMnp and MMA. For the surgical groups, the only significant relationship between LIMnp and MMA was seen in the mandibular advancement group at debond. No definite indicator was found to suggest that the final MMA dictates the amount of mandibular incisor relapse following debond. Only the bimaxillary group showed an association between changes in LIMnp and changes in MMA during the review period.

The influence of orthognathic surgery on occlusal force in patients with vertical facial deformities

This study utilized bite-force measurements to determine the effect of various orthognathic surgery procedures on occlusal force generation in 42 patients with vertical facial deformities. The results showed that orthognathic surgery produced marked alterations in occlusal force levels which continued to occur up to a year after surgery. Measurements indicated that advancement of the mandible may result in weaker force levels, while bimaxillary surgery for the treatment of a "long face" brings the previously weaker bite force to a more "normal" level.

Gorlin's syndrome: main features and recent advances

Gorlin's syndrome embraces a constellation of cranial, maxillofacial and systemic disorders, which may have a serious effect on both the morbidity and mortality of the patients. Recent work has identified that the disorder is caused by a mutation within a tumour suppressor gene.

Dysmorphophobia: recent developments of interest to the maxillofacial surgeon

Recent changes in the classification of psychiatric illnesses have resulted in the term dysmorphophobia being replaced by that of body dysmorphic disorder (BDD). This paper attempts to alert the clinician to the presenting features of the condition and discusses its management, with particular emphasis on the role of surgery and current concepts of pharmacological treatment. A number of case reports are included to illustrate the diversity of this interesting disorder and the difficulties involved in treatment.