Sociodemographic disparities and potential biases in persistent pain estimates: Findings from 5 waves of the Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

Pain is a prevalent, debilitating condition among older adults. Much evidence on this topic comes from cohort studies, which may be affected by attrition and measurement bias. Little is known about the impact of these biases on pain estimates for European older adults. Additionally, there is a lack of longitudinal research on pain and sociodemographic disparities in Irish older adults.

METHODS

We analysed data from 8171 participants (aged ≥50 at baseline) across five waves of the Irish Longitudinal Study on Ageing. Longitudinal pain severity and sociodemographic disparities in pain were explored visually and using a latent growth curve model. Using multivariate logistic regression, we examined bias due to attrition at later waves associated with reported pain at Wave 1. Measurement biases due to reporting heterogeneity were assessed by investigating associations between sociodemographic factors and pain-related disability for given pain levels.

RESULTS

Wave 1 severe pain was associated with increased odds of attrition due to death by Wave 5 (AOR: 1.63, 95% CI: 1.20, 2.19). Not having private health insurance was associated with increased odds of pain-related disability at Wave 1, controlling for pain severity (AOR: 1.37, 95% CI: 1.15, 1.64). These results suggested mortality bias and reporting heterogeneity measurement bias, respectively. Sex, education level, and private health insurance status disparities in pain were observed longitudinally.

CONCLUSIONS

Mortality bias and reporting heterogeneity measurement bias must be accounted for to improve older adult pain estimates. There is a need for policymakers to address sociodemographic disparities in older adult pain levels.

SIGNIFICANCE

This study highlights a need to address bias in the estimation of pain in observational studies of older adults. Understanding the sources and extent of these biases is important so that health practices and policies to address pain disparities can be guided by accurate estimates. Women, those with lower educational attainment, and those without private health insurance were found to have the highest pain burden longitudinally, suggesting a need for targeted interventions for these groups in Ireland and internationally.

Posttraumatic stress disorder (PTSD) and complex PTSD in eating disorder treatment-seekers: Prevalence and associations with symptom severity

Although childhood trauma and posttraumatic stress disorder (PTSD) have been well-researched in eating disorder epidemiology, prevalence rates are unavailable for complex PTSD (CPTSD). Under recently introduced ICD-11 criteria, individuals with CPTSD have both PTSD symptoms and additional disturbances in self-organization (DSO). Using ICD-11 criteria, this study aimed to determine the prevalence of PTSD and DSO symptoms, diagnostic rates of PTSD and CPTSD, and childhood trauma exposure in eating disorder treatment-seekers. Participants (N = 217) were individuals attending residential, partial hospitalization, and outpatient services who completed measures of eating disorder- and trauma-related symptoms and childhood adverse experiences. One third of participants reported PTSD symptoms, and over half reported DSO symptoms, with probable ICD-11 diagnostic rates of 3.8% for PTSD and 28.4% for CPTSD. CPTSD was significantly more prevalent than PTSD and more common in higher levels of care. Both PTSD and DSO symptom severity were positively correlated with eating disorder symptoms and impairment, rs = .285-.642. DSO symptom severity was a significant and unique explanatory factor of eating disorder severity and impairment. The findings highlight the prevalence of CPTSD in eating disorder populations and the association between DSO symptoms and eating psychopathology independent of PTSD symptoms. Implications are discussed for adjunct treatment approaches for individuals with comorbid eating disorders and PTSD or CPTSD.

Perineal fibroadenoma masquerading as a soft-tissue sarcoma: a case report

We report a case of a perineal fibroadenoma initially diagnosed on ultrasound and magnetic resonance imaging as a soft tissue sarcoma in a 35-year-old female. Following wide local excision, histopathology revealed the lesion as a vulval fibroadenoma. We provide an overview of the literature and highlight the need to consider fibroadenoma, arising from ectopic breast tissue, as an important differential for general surgeons and gynaecologists caring for patients with perineal masses.

Hand hygiene compliance by direct observation in physicians and nurses: a systematic review and meta-analysis

BACKGROUND

Direct observation of hand hygiene compliance is the "gold standard" despite limitations and potential for bias. Previous literature highlights poorer hand hygiene compliance amongst physicians than nurses and suggests that covert monitoring may give better compliance estimates than overt monitoring.

AIM

This review aimed to explore differences in compliance between physicians and nurses further, and to analyse if compliance estimates differed when observations were covert rather than overt.

METHODS

A systematic search of databases PubMed, EMBASE, CENTRAL and CINAHL was performed. Experimental or observational studies in hospital settings in high-income countries published in English from 2010 onwards were included if estimates for both physicians and nurses using direct observation were reported. The search yielded 4814 studies, of which 105 were included.

FINDINGS

The weighted pooled compliance rate for nurses was 52% (95% CI 47% to 57%) and for doctors was 45% (95% CI 40% to 49%). Heterogeneity was considerable (I²=99%). The majority of studies were at moderate or high risk of bias. Random-effects meta-analysis of low risk of bias studies suggests higher compliance for nurses than physicians for both overt (difference of 7%, 95% CI for the difference 0.8% to 13.5%, p=0.027) and covert (difference of 7%, 95% CI 3% to 11%, p=0.0002) observation. Considerable heterogeneity was found in all analyses.

CONCLUSION

Wide variability in compliance estimates and differences in the methodological quality of hand hygiene studies were identified. Further research with meta-regression should explore sources of heterogeneity and improve the conduct and reporting of hand hygiene studies.

Evaluation of a model of online, facilitated, peer group supervision for dietitians working in eating disorders

BACKGROUND

The recently published Australia and New Zealand Academy of Eating Disorders (ANZAED) practice and training standards for dietitians providing eating disorder treatment recommended dietitians working in eating disorders (EDs) seek further clinical experience, training, and supervision to provide effective evidence-informed treatment. Access to dietetic clinical supervision is problematic, secondary to limited trained supervisors, location, cost, and lack of organizational support. Demand for clinical supervision increased with the 2022 introduction of ANZAED credentialing for eating disorder (ED) clinicians in Australia and addition of the Eating Disorder Management Plan to the Medicare Benefits Scheme. In 2018, QuEDS piloted a model of online peer group supervision with the goal of increasing service capacity to provide ED-specific clinical supervision to dietitians. Positive evaluation of the pilot led to the rollout of QuEDS Facilitated Peer Supervision (QuEDS FPS) program which was evaluated for utility and acceptability.

METHODS

By August 2021 five QuEDS FPS groups were established each with a maximum of 10 Queensland-based dietitians from public hospital, community, or private practice plus an additional Facilitator and Co-facilitator. A total of 76 participants enrolled in the program over the study period in addition to the 10 participants from the pilot program. Participant experience was evaluated with anonymous, voluntary surveys at baseline (59 responses), 6 months follow-up (37 responses), plus a one-off survey in August 2021 (50 responses). Pilot participant's Baseline and Follow-up surveys were not included in this evaluation.

RESULTS

Survey responses were positive across the four Kirkpatrick training evaluation domains of reaction, learning, behavior, and results. Respondents reported positive change to clinical practice (98%), including increased confidence to implement evidence-informed guidelines, and improved engagement with, and advocacy for, ED clients. Service capacity to provide supervision was increased by high participant to Facilitator ratios (10 participants to one Facilitator and one Co-facilitator) and recruitment of external Facilitators. Respondents indicated they would recommend QuEDS FPS to other dietitians and 96% planned to continue with the program.

CONCLUSIONS

QuEDS FPS program increases capacity to provide supervision with demonstrated positive impacts on dietitians' confidence and ability to deliver dietetic interventions in the ED arena and, by inference, the dietetic care of people with an ED.

Screening, assessment and diagnosis in the eating disorders: findings from a rapid review

BACKGROUND

Limited screening practices, minimal eating disorder training in the healthcare professions, and barriers related to help-seeking contribute to persistent low rates of eating disorder detection, significant unmet treatment need, and appreciable associated disease burden. The current review sought to broadly summarise the literature and identify gaps relating to the screening, assessment, and diagnosis of eating disorders within Western healthcare systems.

METHODS

This paper forms part of a Rapid Review series scoping the evidence base for the field of eating disorders, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for studies published between 2009 and mid 2021 in English. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised through purposive sampling. Data from selected studies relating to Screening, Assessment and Diagnosis of eating disorders were synthesised and are disseminated in the current review.

RESULTS

Eighty seven studies were identified, 38% relating to screening and 62% to assessment and diagnosis. The majority of screening studies were conducted in university student samples, showing high prevalence but only modest improvements in help-seeking in those studies that followed up post-screen. In healthcare settings, clinicians continue to have difficulty identifying eating disorder presentations, particularly Binge Eating Disorder, Other Specified Feeding or Eating Disorders, and sub-threshold eating disorders. This is preceded by inadequate and frequently homogenous screening mechanisms and exacerbated by considerable personal and health-system barriers, including self-stigma and lack of resourcing. While all groups are at risk of delayed or no diagnosis, those at particular risk include LGBTQ+ and gender diverse individuals, individuals living in larger bodies, and males.

CONCLUSIONS

A majority of individuals with eating disorders remain undiagnosed and untreated despite a high prevalence of these conditions and increased advocacy in recent years. Research into improving detection and clinician diagnostic skill is extremely limited. Innovative empirical research is strongly recommended to address significant individual and health-system barriers currently preventing appropriate and timely intervention for many. Limited screening in healthcare settings and low rates of eating disorder training in the healthcare professions are just some of the barriers to help-seeking which may contribute to delayed intervention and diagnosis in the eating disorders. This has significant impacts, prolonging treatment when it is finally received, and increasing healthcare costs for both the individual and the healthcare system. The current review is part of a larger Rapid Review series conducted to inform the development of Australia's National Eating Disorders Research and Translation Strategy 2021-2031. A Rapid Review is designed to comprehensively summarise a body of literature in a short timeframe, often to guide policy-making and address urgent health concerns. The Rapid Review synthesises the current evidence-base and identifies gaps in eating disorder research and care, in order to guide decision making and address urgent health concerns. This paper gives a critical overview of the scientific literature relating to the current state of screening, assessment, and diagnosis of eating disorders within Western healthcare systems that may inform health policy and research in an Australian context. It covers screening initiatives in both general and high-risk populations; personal, clinician and healthcare system challenges relating to help-seeking; and obstacles to accurate and timely clinical diagnosis across the eating disorders.

E-learning for chest x-ray interpretation improves medical student skills and confidence levels

BACKGROUND

Radiology is an important aspect of medicine to which medical students often do not receive sufficient exposure. The aim of this project was to determine whether the integration of an innovative e-learning module on chest x-ray interpretation of the heart would enhance the radiological interpretive skills, and improve the confidence, of first year graduate entry medical students.

METHODS

All first-year graduate entry (all students had a prior university degree) medical students at the University of Limerick (n = 152) during academic year 2015-16 were invited to participate in this study. An assessment instrument was developed which consisted of 5 radiological cases to be interpreted over a designated and supervised 15-min time period. Students underwent a pre-, mid- and post-intervention assessment of their radiology interpretative skills. An online e-module was provided following the pre-test and additional practice cases were provided following the mid-intervention test. Assessment scores and confidence levels were compared pre-, mid- and post-intervention.

RESULTS

The overall performance (out of a total score of 25) for the 87 students who completed all three assessments increased from 13.2 (SD 3.36) pre-intervention to 14.3 (SD 2.97) mid-intervention to 15.8 (SD 3.40) post-intervention. This change over time was statistically significant (p < 0.001) with a medium effect size (eta-squared = 0.35). Increases from pre- to post-intervention were observed in each of the five areas assessed, although performance remained poor in diagnosis post-intervention. Of the 118 students who provided feedback after the intervention, 102 (86.4%) stated that they would recommend the resource to a colleague to improve their interpretative skills.

CONCLUSIONS

This study suggests that early exposure to e-learning radiology modules is beneficial in undergraduate medical school curricula. Further studies are encouraged to assess how long the improvement may last before attrition.

Comparing cardiovascular risk factors, disease and treatment in participants with rheumatoid arthritis and without arthritis in a population based stud

Rheumatoid Arthritis (RA) is associated with a significant increase in mortality compared to the general population, with cardiovascular disease (CVD) the leading cause of death. The aim of this study is to compare the prevalence and treatment of modifiable CV risk factors and history of CVD in those with RA and those without arthritis in Ireland. Data from the Irish Longitudinal Study on Ageing (TILDA), a population-representative cohort study of people in Ireland aged 50 or over, was used. Participants with RA (n=457) were twice as likely to be obese (OR 2.02, 95% CI 1.99 to 2.06) compared to those without arthritis (n=4,063). Participants with RA were also more likely to be physically inactive (OR 1.73, 95% CI 1.69 to 1.76) and taking antihypertensive medication than those without arthritis. Exercise can have a beneficial impact on CVD and specific interventions to increase physical activity in those with RA may be warranted.

Nurse Triage in an Irish Out-of-hours General Practice Co-Operative

Specially trained triage nurses play a crucial role in the operation of out-of-hours GP co-operatives. This study aimed to establish the proportion of all patient contacts with the out-of-hours GP co-operative based in the Mid-West of Ireland (Shannondoc), which were managed by triage nurses. A retrospective, descriptive analysis was conducted on the database of contacts to the Shannondoc urgent, out-of-hours primary care co-operative. Of the 110,039 contacts to the service in 2013, 19,147 (17.4%) were classified as being managed by nurses and 14.2% were managed by nurse telephone triage alone. Twenty-four percent of the 19,147 calls managed by nurses involved children under six years. Triage nurses play an important role in administering safe medical advice over the phone. This has implications for the training of triage nurses and the future planning of urgent out-of-hours primary care services.

Development and implementation of a 'Mental Health Finder' software tool within an electronic medical record system

BACKGROUND

In Ireland, as in many other healthcare systems, mental health service provision is being reconfigured with a move toward more care in the community, and particularly primary care. Recording and surveillance systems for mental health information and activities in primary care are needed for service planning and quality improvement.

AIMS

We describe the development and initial implementation of a software tool ('mental health finder') within a widely used primary care electronic medical record system (EMR) in Ireland to enable large-scale data collection on the epidemiology and management of mental health and substance use problems among patients attending general practice.

METHODS

In collaboration with the Irish Primary Care Research Network (IPCRN), we developed the 'Mental Health Finder' as a software plug-in to a commonly used primary care EMR system to facilitate data collection on mental health diagnoses and pharmacological treatments among patients. The finder searches for and identifies patients based on diagnostic coding and/or prescribed medicines. It was initially implemented among a convenience sample of six GP practices.

RESULTS

Prevalence of mental health and substance use problems across the six practices, as identified by the finder, was 9.4% (range 6.9-12.7%). 61.9% of identified patients were female; 25.8% were private patients. One-third (33.4%) of identified patients were prescribed more than one class of psychotropic medication. Of the patients identified by the finder, 89.9% were identifiable via prescribing data, 23.7% via diagnostic coding.

CONCLUSIONS

The finder is a feasible and promising methodology for large-scale data collection on mental health problems in primary care.

Cocaine use in Young Adults: Correlation with Early Onset Cannabis, Alcohol and Tobacco Use

There is ongoing debate regarding the relationship between early tobacco, alcohol and cannabis use and later cocaine abuse. We utilised data from two Irish national general population surveys. Of the 1,897 young adult participants, the prevalence of lifetime use was as follows: tobacco 62%, alcohol 96%, cannabis 31% and cocaine 7.0%. Logistic regression analysis indicated that being single, earlier age of first alcohol use, and history of cannabis use were significant independent predictors of lifetime use of cocaine. The substance use route to cocaine use in this Irish sample is quite typical of that seen internationally. Those who commence alcohol use in the early teenage years are more likely to use cocaine subsequently, even after controlling for early onset cannabis use and other socio-demographic characteristics. This suggests that policies which delay age of first drinking may possibly also curtail cocaine use.

ViEWS from the prehospital perspective: a comparison with a prehospital score to triage categorisation in the emergency department

This aim of this observ estigate how the recently introduced National Early Warning Score (ViEWS) applied in the prehospital setting (Ph-ViEWS) compares with the Manchester Triage System (MTS) used in most Emergency Departments (ED) in Ireland. 386 patients fitted the inclusion criteria of which 272 (69%) had a complete set of values. Of 272 MTS 1 and 2 patients, only 114 (42%) had a Ph-ViEWS ⋝7. This study found that a substantial number of patients deemed urgent at the time of triage do not have elevated Ph-ViEWS.

Plasma fibrinogen associates independently with total and cardiovascular mortality among subjects with normal and reduced kidney function in the general population

BACKGROUND

The contribution of novel risk factors to mortality in chronic kidney disease remains controversial.

AIM

To explore the association of plasma fibrinogen with mortality among individuals with normal and reduced kidney function.

METHODS

We identified 9184 subjects, age 40 and over from the Third National Health and Nutrition Examination Survey (1988-94) with vital status assessed through 2006. Plasma fibrinogen was modeled as continuous variable and in quartile groups (0 to <7.7, 7.7 to <9.0, 9.0 to <10.5 and ≥ 10.5 µmol/l) with total and cardiovascular mortality across categories of glomerular filtration rate (eGFR); <60, 60-90, >90 ml/min/1.73 m(2) using Cox regression.

RESULTS

In multivariate analysis, the adjusted hazard ratio (HR) per 1 µmol/l (34 mg/dl) increase in fibrinogen was 1.07 [95% confidence interval (CI) 1.04-1.09] for total mortality and 1.06 (95% CI 1.03-1.09) for cardiovascular mortality. The adjusted HR for total mortality was 1.05 (1.01-1.09) for subjects with eGFR 60-90 ml/min/1.73 m(2) and 1.06 (1.02-1.10) for subjects with eGFR <60 ml/min/1.73 m(2). Subjects in the highest quartiles within each eGFR category; >90, 60-90 and <60 ml/min/1.73 m(2) experienced HRs of 1.45 (95% CI 1.03-2.03), 1.35 (95% CI 1.00-1.83) and 1.72 (95% CI 1.14-2.58), respectively, compared with subjects in the lowest quartile group. The patterns were similar for cardiovascular mortality.

CONCLUSIONS

Plasma fibrinogen associates with mortality among subjects with mild to moderate kidney impairment as it does in subjects with normal kidney function and should be considered a therapeutic target for cardiovascular risk reduction.

Prevalence of depression in patients with type 2 diabetes mellitus in Irish primary care and the impact of depression on the control of diabetes

BACKGROUND

As the Irish population ages, the management of chronic conditions in primary care is emerging as a challenge. The presence of co-morbid depression is common among such patients and may affect their response to treatment.

AIMS

This study sought to determine whether the prevalence of depression is higher in patients with type 2 diabetes mellitus than in the population aged >50 in the West of Ireland, and whether depression is an independent predictor of diabetes control.

METHODS

We used a cross-sectional design to examine an anonymized database of 9,698 patients aged >50 years whose medical data were collected as part of NUI Galway's CLARITY study. Glycosylated HbA1c levels were used to estimate type 2 DM control; depression was assessed using the Hospital Anxiety and Depression Scale.

RESULTS

We found that while there is a higher prevalence of severe depression in patients with type 2 DM, there is no association between their diabetes control and depression after controlling for age, gender, comorbidity and GMS status. Multimorbidity is a significant predictor of depression in both diabetic and non-diabetic populations, with the odds of depression increasing as the number of co-morbidities increased.

CONCLUSIONS

Patients with type 2 DM are more likely to suffer from severe depression than those without. Depression itself is not an independent predictor of diabetes control. However, it may be that the increased rates of depression observed in patients with type 2 DM are at least partially attributable to the burden of additional illnesses seen in these patients.

Independent and conjoint associations of gout and hyperuricaemia with total and cardiovascular mortality

BACKGROUND

Gout and serum uric acid are associated with mortality but their simultaneous contributions have not been fully evaluated in the general population.

PURPOSE

To explore the independent and conjoint relationships of gout and uric acid with mortality in the US population.

METHODS

Mortality risks of gout and serum uric acid were determined for 15 773 participants, aged 20 years or older, in the Third National Health and Nutrition Examination Survey by linking baseline information collected during 1988-1994 with mortality data up to 2006. Multivariable Cox proportional hazards regression determined adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for each exposure and all analyses were conducted in 2011 and 2012.

RESULTS

Compared with subjects without a history of gout, the multivariable HR for subjects with gout were 1.42 (CI 1.12-1.82) for total and 1.58 (CI 1.13-2.19) for cardiovascular mortality. Adjusted HRs per 59.5 µmol/l (1 mg/dl) increase in uric acid were 1.16 (CI 1.10-1.22) for total and cardiovascular mortality and this pattern was consistent across disease categories. In the conjoint analysis, the adjusted HRs for mortality in the highest two uric acid quartiles were 1.64 (CI 1.08-2.51) and 1.77 (CI 1.23-2.55), respectively, for subjects with gout, and were 1.09 (CI 0.87-1.37) and 1.37 (CI (1.11-1.70), respectively, for subjects without gout, compared with those without gout in the lowest quartile. A similar pattern emerged for cardiovascular mortality.

CONCLUSION

Gout and serum uric acid independently associate with total and cardiovascular mortality. These risks increase with rising uric acid concentrations.

Impact of chronically street homeless tenants in congregate supportive housing

New initiatives to house chronically street homeless (CSH) adults have led to increasing proportions of this population living in congregate supportive housing, but little is known about the impact of this shift on supportive housing programs. The present multisite, mixed-methods study examined service utilization and lease compliance among 52 chronically street homeless and 46 long-term shelter stayer (LTSS) adults during their first 12 months in congregate supportive housing. Quantitative analysis of administrative data revealed that CSH tenants used significantly more service resources than LTSS tenants, including more advocacy, escorting, and psychiatric treatment and more assistance with financial, housing, and mental and physical health issues. The 2 groups did not differ significantly on measures of lease compliance. Qualitative focus groups with CSH tenants, service provider staff, and property management staff all indicated that existing supportive housing services are suitable for this population, although some adjustments, additional resources, or both, may be indicated.

Endodontic treatment completion following emergency pulpectomy

AIM

Emergency pulpectomy is frequently performed to relieve pain experienced by patients following acute episodes of endodontic pain, or to limit the risks of infection or possible root resorption following traumatic pulpal exposures. The aim of this study was to examine subsequent patient attendance for completion of root canal treatment following pulpectomy procedures in a dental emergency unit.

METHODS

The treatment records of 574 patients who had each received an emergency pulpectomy at the Casualty Clinic of the University Dental School and Hospital, Cork, Ireland were reviewed. The influence of age, gender, etiology, tooth type, and month in which the pulpectomy was performed on subsequent completion of endodontic treatment was examined.

RESULTS

Of 574 patients, 39% (n = 224) returned to have endodontic treatment completed, 11% (n = 63) returned to have the tooth extracted, and 50% (n = 287) did not return for completion of the endodontic treatment. Cases were monitored up to five years following pulpectomy. Using a multinomial regression model, tooth type, etiology, and month in which the treatment was performed were found to be statistically significant predictors (p < 0.05) of endodontic treatment completion in the Cork University Dental School and Hospital.

CONCLUSIONS

Proper patient selection and pre-treatment counseling are important considerations when planning emergency pulpectomies to avoid inappropriate use of resources and manpower.

Effect of pre-heating on the viscosity and microhardness of a resin composite

The effect of pre-heating resin composite on pre-cured viscosity and post-cured surface hardness was evaluated. Groups of uncured specimens were heated to 60 degrees C and compared with control groups (24 degrees C) with respect to viscosity and surface hardness. Mean (SD) viscosities of the pre-heated specimens (n = 15) were in the range of 285 (13)-377 (11) (Pa) compared with 642 (35)-800 (23) (Pa) at ambient temperature. There was a statistically significant difference between the two groups (P < 0.001). Mean (SD) Vickers microhardness (VHN) of the pre-heated group (n = 15) was 68.6 (2.3) for the top surface and 68.7 (1.8) for the bottom surface measured at 24 h post curing (specimen thickness = 1.5 mm). The corresponding values for the room temperature group were 60.6 (1.4) and 59.0 (3.5). There was a statistically significant difference between corresponding measurements taken at the top and bottom for the pre-heated and room temperature groups (P < 0.001). There was no significant difference between top and bottom measurements within each group. Pre-heating resin composite reduces its pre-cured viscosity and enhances its subsequent surface hardness. These effects may translate as easier placement together with an increased degree of polymerization and depth-of-cure.

Quality of written communication and master impressions for fabrication of removable partial prostheses in the Kingdom of Bahrain

The aim of this study was to examine the quality of written instructions and choice of impression trays and materials for removable partial dentures (RPDs) in the Kingdom of Bahrain. All six private dental laboratories in Bahrain were contacted and invited to participate in the study. Five laboratories participated, and submitted written instructions received by them for fabrication of both acrylic (A-RPDs) and cobalt-chromium (CC-RPDs) RPDs. These were examined for evidence of selected design variables. Types of impression trays and materials used were also recorded. One hundred and thirty-one written instructions were examined. Eleven percent (n = 14) were for CC-RPDs, 89% (n = 117) for A-RPDs. All treatments were provided on a private basis. Fifty-seven percent (n =1 8) of CC-RPD instructions requested the technician to design the prosthesis, 43% (n = 6) contained a diagram and 43% (n = 6) mentioned all design variables. Seventy-nine percent (n = 92) of A-RPDs requested the technician to design the denture, and only 1% (n = 1) mentioned all design variables. Alginate impression material was most commonly used for master impressions (83% of impressions (n = 109); 85% (n = 99) of A-RPDs, and 71% (n = 10) of CC-RPDs). Master casts were poured after a minimum of 24 h. Acrylic custom trays were used in 14% (n = 19) of cases (43% (n = 6) of CC-RPDs; 13% (n = 15) of A-RPDs). The quality of written instructions to dental laboratories for the fabrication of RPDs was found to be inadequate in Kingdom of Bahrain. There was widespread use of inappropriate impression trays and materials.

Dental school admissions in Ireland: can current selection criteria predict success?

INTRODUCTION

Entry into university education in Ireland, including dental school, is based solely on academic performance in the Leaving Certificate Examination, held at the end of formal school education. The aim of this investigation was to examine the suitability of this process for the selection of dental students in Ireland.

MATERIALS AND METHODS

Information for all dental students who entered the dental degree programme immediately following completion of the Leaving Certificate Examination at the National University of Ireland, Cork, during the years 1997-1999 was retrieved. Information was collected relating to gender, the number of times the student had attempted the Leaving Certificate Examination, their performance in this examination, the total number of marks awarded to each student at the end of the First and Final Dental Examinations, and their performance in individual modules.

RESULTS

Whilst there was a significant relationship between performance in the Leaving Certificate Examination and the First Dental Examination (correlation coefficient = 0.22, P < 0.05), this relationship could only explain 12% of the variation within the performance of students in this examination. There was no relationship between performance in the Leaving Certificate and the Final Dental Examination (correlation coefficient = 0.09, P > 0.05). There was a significant correlation between performance in the Leaving Certificate Examination and performance in seven of the 55 programme modules, all of which were pre-clinical modules, and of which five were related to basic sciences.

CONCLUSIONS

Based on the limitations of this study, the current selection process for dental students in Ireland seems to be of limited value.

Chewing side preferences in children

The dentition of 57 children aged 6-8 years old was examined clinically and radiographically. Subjects were divided into groups according to state of the dentition: caries free, no pathology and no pain; caries, no pathology and no pain; caries, pathology and no pain; caries, pathology and pain. The existence of a preferred chewing side (PCS) was determined using a visual spot-checking method. Subjects were instructed to chew gum on their posterior teeth. After 15 s the position of the chewing gum was recorded as right or left. This procedure was carried out seven times consecutively. Subjects had an 'observed preferred chewing side' (OPCS) when they chewed 5/7, 6/7 or 7/7 times on the same side. To determine if children were aware of their chewing side preference each subject's stated PCS was then recorded as left, right or none. 'Coincidence' between stated and OPCSs was said to occur if the stated PCS corresponded to the OPCS. Seventy-seven per cent of children had a PCS. The majority (70%) of caries free children also had a PCS (P < 0.05). The percentage with an OPCS varied from 70% of the caries free group to 92% of the group with caries, pathology and pain. However, there was no statistically significant association between state of the dentition and the presence of a PCS. Coincidence occurred in 56% of children. There was a statistically significant association between state of the dentition and coincidence (P=0.02). Children in pain were most likely to show coincidence (kappa=0.81).

Using survival methodologies in demonstrating caries efficacy

Exploiting recent advances in statistical methods, particularly for correlated intra-subject data, could increase the efficiency of caries clinical trials. Methods of analysis using the tooth surface as the unit should be investigated. Whole-mouth measures such as the DMFS increment ignore the variation in the number of surfaces at risk between subjects and within a subject over time. The use of "survival time" for each surface as the outcome measure--i.e., the time from the start of the trial to when a surface is recorded as decayed or filled--is proposed. Data from caries clinical trials could be described as clustered survival data, where clustering of tooth surfaces exists such that survival times within the same cluster or subject are correlated. Advances in the analysis of clustered survival data, such as the use of marginal models with robust variance estimators, have recently been exploited in the analysis of caries clinical trials. The analysis produced results similar to those achieved by conventional DMFS-based analysis. The results using survival analysis are easily interpreted-for example, the median survival time of tooth surfaces in female subjects using a toothpaste with a higher level of fluoride (1500 ppm F) is 1.07 times the median survival time of surfaces in female subjects using toothpaste with less fluoride (1000 ppm F). Further research is required to investigate if survival analysis is a more sensitive method of analysis, i.e., whether causative factors can be identified with fewer subjects than with the conventional method of analysis.

Soluble Cell Adhesion Molecules in Gingival Crevicular Fluid in Periodontal Health and Disease

BACKGROUND

Cell adhesion molecules (CAMs) are cell surface proteins involved in the binding of cells to each other, to endothelial cells, or to the extracellular matrix. The soluble forms of CAMs (sCAMs) are thought to be produced by proteolytic cleavage from the cell surface and are shed into the gingival crevicular fluid (GCF). The aim of this study was to investigate whether sCAMs, sICAM-1, sVCAM-1, and sE-Selectin were present in GCF in both periodontal health and disease and to examine their relationship with periodontal inflammation.

METHODS

GCF was collected from a clinically healthy, a gingivitis, and a periodontitis site in 29 subjects with chronic periodontitis and from a single clinically healthy site in 22 subjects without chronic periodontitis. The volume of GCF was measured and each sample was analyzed for sCAMs by enzyme-linked immunosorbent assay (ELISA). The effect of treatment (oral hygiene instruction, scaling and root planing) on the levels of sCAMs in each site of the diseased group was also investigated.

RESULTS

Statistically significant differences (P < 0.05) were found between the levels of sVCAM-1 in periodontal health and disease. These results indicate that changes in the levels of sCAMs may be a sensitive indicator to differentiate healthy sites from those with periodontitis. Statistically significant changes in the levels of sICAM-1 were recorded after treatment (P < 0.05).

CONCLUSIONS

Further studies are required to establish if these potential biomarkers will enable the identification of those sites most at risk for disease progression and also evaluate the response to treatment, thereby playing a preventive role in the pathogenesis of periodontal disease.

Randomized clinical trial and economic analysis of four-layer compression bandaging for venous ulcers

BACKGROUND

The aim of this study was to compare the cost-effectiveness of four-layer compression bandaging for venous leg ulcers with that of other available treatments.

METHODS

In this pragmatic trial, 200 patients with a venous leg ulcer were randomized either to four-layer bandaging (intervention group; n = 100) or to continue their usual system of care (control group; n = 100). The follow-up for each patient was 12 weeks. Analysis was by intention to treat; the main outcome measures were time to healing and cost to the health board per leg healed.

RESULTS

Baseline characteristics were well matched in the two groups. The Kaplan-Meier estimate of the healing rate at 3 months was 54 per cent with four-layer bandaging and 34 per cent in the control group. Throughout the 3 months, four-layer bandaging healed leg ulcers significantly earlier (P = 0.006). There was a significant reduction in the median cost per leg healed with four-layer bandaging (euro 210 versus euro 234; P = 0.040).

CONCLUSION

Four-layer bandaging is currently the most effective method of treating venous leg ulcers in a community setting.

Surface hardness of light-activated resin composites cured by two different visible-light sources: an in vitro study

OBJECTIVE

Microhardness values of upper and lower surfaces of disk specimens of 3 commercially available resin composites were compared and cured using both the traditional halogen source and a plasma arc lamp.

METHOD AND MATERIALS

Twenty samples of each of the resin composites were cured in nylon washers. Ten samples of each composite were cured using the appropriate halogen lamp protocol, and 10 samples of each were cured using the plasma lamp protocol. Surface microhardness measurements were carried out using a calibrated Vickers indenter on both top and bottom surfaces after 7 days of storage in air at 20 degrees C. Statistical analysis of the data was carried out using a commercial statistical package. The data for top and bottom surfaces were analyzed separately using a repeated measures analysis of variance (ANOVA).

RESULTS

Lamp, composite, and the interaction between lamp and composite were significant in determining the results for both top and bottom surfaces of the disk-shaped specimens. The plasma lamp yielded lower hardness values for all surfaces compared with the halogen source, but the size of the difference depended on the composite.

CONCLUSION

Caution must be exercised in the plasma irradiation of resin composites as a curing method due to the possibility of reduced surface microhardness values that may reflect a reduced percent conversion of monomer to polymer.

A re-analysis of a caries clinical trial by survival analysis

The decline in caries prevalence, the increases in the level of fluoride exposure, and the lack of placebo control subjects have complicated caries clinical trials in recent times. There has been a substantial increase in the numbers of subjects required for the detection of statistically significant differences between dental products, and hence, the cost of these trials has grown enormously. This study uses a new statistical approach to the analysis of the data from these trials with the ultimate aim of providing a more sensitive method of analysis. The new approach uses survival analysis, where the outcome measure is the survival time of an individual tooth surface. It exploits recent developments in the analysis of clustered survival data where survival times within the same cluster or subject are correlated. To illustrate, the new method of analysis was used for the North Wales, UK, caries clinical trial. It is concluded that survival analysis uses most of the data available in a caries clinical trial, an outcome measure that is easily understood and may lead to a more sensitive method of analysis.

Reasons for choosing dentistry as a career--a survey of dental students attending a dental school in Ireland during 1998-99

The motivations for choosing dentistry as a career in the Republic of Ireland are not clearly defined. To better understand why students choose this occupation, 150 undergraduate dental students of all grades at a University Dental School were surveyed during the academic year 1998-99. Candidates were asked to score the influence of certain factors on their decision to choose dentistry as a career, and were given the opportunity to add commentary. The overall response rate was 80.6%. About 2/3 indicated dentistry was their 1st career choice, with medicine being the primary alternative. Reasons for choosing dentistry included perceived ease of employment, being self-employed, working regular hours, followed by an opportunity of good income, and the opportunity to help people. Having relatives or friends in the profession and lifelong ambition were the least important factors for this sample. Extrinsic factors relating to employment conditions had a strong positive correlation (p<0.0001) with each other, while lifelong ambition had a strong negative correlation (p=0.004) with significant financial reward. No significant differences were found in most responses when analysed by gender or year in school. It is concluded that this sample of students is attracted to dentistry primarily due to a positive perception of working conditions, followed by the altruistic motivations of helping people and improving their appearance.

Tenure in supportive housing for homeless persons with severe mental illness

OBJECTIVE

The study examined the long-term effectiveness of approaches to housing homeless persons with serious mental illness.

METHODS

A total of 2,937 persons placed in high-, moderate, -and low-intensity housing were followed for up to five years. Intensity reflected on the amount of structure and degree of clients' independence. The outcome variable was tenure in housing. Cox stepwise regression was used to calculate risk ratios of becoming discontinuously housed.

RESULTS

Thirty percent of the sample were initially placed in high-intensity settings, 18 percent in moderate-intensity settings, and 52 percent in low-intensity settings. Those in high-intensity settings tended to be younger, to be referred from hospitals, and to have a history or diagnosis of substance abuse. Individuals in moderate-intensity settings were more likely to be female and were least likely to have substance abuse problems. Individuals in low-intensity settings were more likely to be referred by municipal shelters and to have lived in municipal shelters for four or more months. After one, two, and five years, 75 percent, 64 percent, and 50 percent, respectively, of the sample were continuously housed. Older age was associated with longer tenure, and having a history of substance abuse was associated with shorter tenure. Individuals referred from a state psychiatric center had a greater risk of shorter tenure than other types of referrals.

CONCLUSIONS

Results show that homeless persons with serious mental illness can remain in stable housing for periods of up to five years, supporting the premise that long-term residential stability can be enhanced by providing access to safe and affordable supportive housing.

A caries susceptibility classification of tooth surfaces by survival time

Individual tooth surfaces have vastly different susceptibilities to caries and this susceptibility also varies over time. The aim of this study was to develop a method of grouping tooth surfaces into a caries susceptibility classification based on their survival experience. The data used in the study were from a 3-year caries clinical trial. The definition of survival time was taken to be the time from the start of the trial to when a surface is recorded as decayed or filled. Cluster analysis was used to divide the tooth surfaces into groups in such a way that surfaces in the same group have similar survival time distributions. The 13 groups identified were ordered from 1 to 13 starting with the group with the shortest survival time, i.e. the occlusal surfaces of the four first molars. Approximately 80% of symmetrical pairs of tooth surfaces were in the same group. The groups obtained using cluster analysis were compared to groups defined using dental/anatomical criteria. It is concluded that the cluster analysis method developed for grouping the tooth surfaces cn provide a useful descriptive measure of caries susceptibility which can be applied to data from any longitudinal study of caries.

A survey of the computer literacy of undergraduate dental students at a University Dental School in Ireland during the academic year 1997-98

As dental practice management becomes more computer-based, the efficient functioning of the dentist will become dependent on adequate computer literacy. A survey has been carried out into the computer literacy of a cohort of 140 undergraduate dental students at a University Dental School in Ireland (years 1-5), in the academic year 1997-98. Aspects investigated by anonymous questionnaire were: (1) keyboard skills; (2) computer skills; (3) access to computer facilities; (4) software competencies and (5) use of medical library computer facilities. The students are relatively unfamiliar with basic computer hardware and software: 51.1% considered their expertise with computers as "poor"; 34.3% had taken a formal typewriting or computer keyboarding course; 7.9% had taken a formal computer course at university level and 67.2% were without access to computer facilities at their term-time residences. A majority of students had never used either word-processing, spreadsheet, or graphics programs. Programs relating to "informatics" were more popular, such as literature searching, accessing the Internet and the use of e-mail which represent the major use of the computers in the medical library. The lack of experience with computers may be addressed by including suitable computing courses at the secondary level (age 13-18 years) and/or tertiary level (FE/HE) education programmes. Such training may promote greater use of generic softwares, particularly in the library, with a more electronic-based approach to data handling.