Assessment of pain relief after four botulinum toxin A injection cycles in patients with post-stroke lower limb spasticity: A prospective, observational study

INTRODUCTION

Spasticity is common after a stroke and is an independent risk factor for developing pain. BotulinumtoxinA injection is the treatment of choice for focal spasticity. We examined the effect of intramuscular botulinumtoxinA on pain relief in patients in routine clinical practice who were experiencing pain as a primary complaint associated with post-stroke lower limb spasticity.

METHODS

Prospective, multicentre, post-marketing observational study. The study period was 16 months. The primary effectiveness variable was the mean change from baseline on the pain 0-10 Numerical Rating Scale after four botulinumtoxinA injection cycles. Secondary endpoints included changes from baseline on the pain 0-100 Visual Analogue Scale, Goal Attainment Scale, modified Ashworth Scale, 10-Meter Walk Test, Penn Spasm Frequency Scale, and 36-item Short-Form Health Survey.

RESULTS

Of 186 enrolled patients, 180 (96.8%) received botulinumtoxinA at least once. The mean (standard deviation) pain 0-10 Numerical Rating Scale score decreased significantly (p<0.0001) from 4.9 (2.2) at baseline to 2.5 (2.1) at study end, representing a 50% decrease in pain severity. Relief of pain due to spasticity was supported by improvement from baseline in all secondary variables except the 10-Meter Walk Test. Two adverse events (erysipelas and phlebitis) in one patient were considered likely to be related to botulinumtoxinA injection.

CONCLUSION

BotulinumtoxinA appears to provide pain relief as an additional benefit of local treatment in patients with post-stroke lower limb spasticity for whom pain relief is a primary therapeutic goal (a Lay Abstract has been provided as Appendix A).

Performance evaluation of three versions of a convolutional neural network for object detection and segmentation using a multiclass and reduced panoramic radiograph dataset

OBJECTIVES

To evaluate the diagnostic performance of three versions of a deep-learning convolutional neural network in terms of object detection and segmentation using a multiclass panoramic radiograph dataset.

METHODS

A total of 600 orthopantomographies were randomly selected for this study and manually annotated by a single operator using an image annotation tool (COCO Annotator v.11.0.1) to establish ground truth. The annotation classes included teeth, maxilla, mandible, inferior alveolar nerve, dento- and implant-supported crowns/pontics, endodontic treatment, resin-based restorations, metallic restorations, and implants. The dataset was then divided into training, validation, and testing subsets, which were used to train versions 5, 7, and 8 of You Only Look Once (YOLO) Neural Network. Results were stored, and a posterior performance analysis was carried out by calculating the precision (P), recall (R), F1 Score, Intersection over Union (IoU), and mean average precision (mAP) at 0.5 and 0.5-0.95 thresholds. The confusion matrix and recall precision graphs were also sketched.

RESULTS

YOLOv5s showed an improvement in object detection results with an average R = 0.634, P = 0.781, mAP0.5 = 0.631, and mAP0.5-0.95 = 0.392. YOLOv7m achieved the best object detection results with average R = 0.793, P = 0.779, mAP0.5 = 0.740, and mAP0.5-0.95 = 0,481. For object segmentation, YOLOv8m obtained the best average results (R = 0.589, P = 0.755, mAP0.5 = 0.591, and mAP0.5-0.95 = 0.272).

CONCLUSIONS

YOLOv7m was better suited for object detection, while YOLOv8m demonstrated superior performance in object segmentation. The most frequent error in object detection was related to background classification. Conversely, in object segmentation, there is a tendency to misclassify True Positives across different dental treatment categories.

CLINICAL SIGNIFICANCE

General diagnostic and treatment decisions based on panoramic radiographs can be enhanced using new artificial intelligence-based tools. Nevertheless, the reliability of these neural networks should be subjected to training and validation to ensure their generalizability.

Prognostic Significance of Positron Emission Tomography Delta Radiomics Following Bridging Therapy in Patients with Large B-Cell Lymphoma Undergoing CAR T-Cell Therapy

PURPOSE/OBJECTIVE(S)

CAR T-cell therapy is routinely used as a treatment option for relapsed/refractory large B-cell lymphoma (LBCL). Bridging therapy radiation therapy (bRT) is increasingly being utilized prior to chimeric antigen receptor (CAR) T-cell therapy for large B-cell lymphoma (LBCL). It is unknown how the extent of debulking as a result of bRT impacts outcomes following CAR T-cell infusion. We hypothesized that the extent of debulking is prognostic of overall response to therapy.

MATERIALS/METHODS

We reviewed patients with LBCL treated with bRT followed by commercially available CAR T-cell therapy between 2017 and 2022. Patients required a F-fluorodeoxyglucose (FDG) positron emission tomography (PET) scan prior to bRT and between completion of bRT and CAR T-cell infusion. On each scan, metabolic tumor volume (MTV), maximum standardized uptake value (SUVmax), SUVmean, and total lesion glycolysis (TLG) were determined. Delta-radiomics based on changes of these values between scans in patients overall and irradiated sites were then calculated. Optimal cut points were determined using maximally selected log-rank. The primary endpoints were progression-free survival (PFS) and local control (LC), measured from CAR T-cell infusion by Kaplan-Meier and Fine-Gray competing risk survival analyses, respectively.

RESULTS

Twenty-three patients with LBCL with 33 irradiated sites were reviewed. All metabolically active disease was treated in 10 patients. Median equivalent dose in 2 Gy fractions (EQD2) was 26 Gy (14-44). Median interval from bRT to PET was 9 days (2-30). Following bRT, 2 patients achieved complete responses, 16 had partial responses, and 5 had progressive disease. Five irradiated sites progressed through bRT. No local failures were observed when EQD2>32.5 Gy was given. LC was improved with EQD2>20 Gy (24 mo LC: 94.5% vs 68.6%; p = 0.075). Following BRT, median overall decreases in MTV, SUVmax, SUVmean, and TLG were 22.2 cc (63.1%), 8.9 (36.8%), 3.4 (31.1%), and 297.9 cc (75.8%), respectively. Median decreases in MTV, SUVmax, SUVmean, and TLG in irradiated sites were 15.6 cc (91.1%), 17.0 (74.6%), 6.8 (55.3%), and 157.0 cc (94.6%), respectively. PFS was significantly improved in patients with reductions of MTV of at least 36 cc (24 mo PFS: 69.2% vs 0%; p = 0.047) or SUVmax of at least 15 (24-mo PFS: 80.0% vs 28.1%; p < 0.001). LC was significantly improved in lesions with reductions of SUVmax of at least 14 (24-mo LC: 100% vs 67.3%; p < 0.001) or SUVmean of at least 7 (24-mo LC: 100% vs 74.4%; p < 0.001).

CONCLUSION

bRT led to significant reductions in MTV, SUVmax, SUVmean, and TLG. The extent of these decreases correlated with improved PFS and LC. There appears to be a dose-response relationship. Larger cohorts should validate the value of interim PET following bRT, and associated changes in disease burden as a means of prognosticating patients. Future work might evaluate whether escalation of BT in patients with suboptimal response, using either systemic therapy or higher radiation doses, has an impact on outcomes.

Long Term Evaluation of Cardiac Events and Outcomes Following Breast Cancer Irradiation

PURPOSE/OBJECTIVE(S)

Although whole heart dose has been associated with cardiac toxicity in patients receiving radiation therapy for breast cancer, data detailing the clinical significance of cardiac substructures, particularly the left anterior descending artery (LAD), are limited. We investigated whether dose to the LAD correlates with adverse cardiac events and death.

MATERIALS/METHODS

We identified 190 female patients treated from 2002 to 2019 who received breast or chest wall irradiation, with or without regional nodal irradiation. Ninety-three patients were treated on their right side, 95 on their left, and two were bilateral. Medical records were queried in healthcare software to identify cardiac events after radiation therapy. Mean and maximum LAD and heart doses, as well as V15LAD, were calculated. Univariate and multivariate Cox regression analyses were performed to determine their association with cardiac toxicity as well as death. Cumulative incidence curves for death and cardiac toxicity were also calculated for the patient population.

RESULTS

Median follow-up time was 68 months. Thirty patients experienced a cardiac event (15.7%), with three of these being grade 3 or higher. On univariate analyses, left side (hazard ratio 8, P<0.001), increased Mean LAD Dose per cGy (1.001, P = 0.01), Mean Heart Dose (1.16, P = 0.01), and anatomic stage (3.5, P = 0.003) were statistically significant predictors of death but not of adverse cardiac events. Statistically significant predictors of adverse cardiac events were the receipt of chemotherapy (2.68, p = 0.046) which remained significant even after adjusting for radiation parameters. There was no association with hormonal therapy use. Cumulative incidence curves predicted a 14.11% probability of a cardiac event 5 years after treatment and a 25.7% probability at 10 years after treatment. They also predicted a 9.43% probability of death at both 5- and 10-years post-treatment.

CONCLUSION

On this long-term analysis, doses to the heart seemed to negatively impact survival, but did not have a clear association between cardiac events. In contrast, utilizing cytotoxic systemic therapy seemed have an association, even when adjusted for on multivariable models for cardiac events.

“She is courageous because she does not care what people think about her…”: attitudes toward adolescent contraception use among Rwandan family planning providers and adult female modern contraceptive users

Introduction

In Rwanda, only 20% of sexually active unmarried young women use family planning as compared to 64% of married women. Adolescence is an important time of growth and development that often includes the initiation of sexual activity. Sexually active adolescents need support in accessing contraceptive services to prevent negative health outcomes. In sub-Saharan Africa, the adolescent population represents a large share of the total population and that proportion is predicted to expand over time. Adolescent contraceptive needs have largely been unmet, and with growing numbers, there is increased potential for negative health sequelae. Due to the low use of contraception by adolescents in Rwanda, and the growing population of adolescents, this study aims to explore the perspectives of family planning providers and adult modern contraceptive users on adolescent contraceptive use. Inclusion of adult community members in the study is a unique contribution, as research on adolescent contraceptive use in sub-Saharan Africa relies primarily on perspectives from adolescents and family planning providers.

Methods

This qualitative study in 2018 utilized 32 in-depth interviews with modern contraceptive users and eight focus group discussions with family planning providers. Respondents were from Musanze and Nyamasheke districts in Rwanda, the districts with the highest and lowest modern contraceptive use among married women, respectively. Coding was conducted in Atlas.ti.

Results

Stigma regarding premarital sex results in barriers to adolescent access to contraceptive services. Family planning providers do provide services to adolescents; however, they often recommend secondary abstinence, offer a limited method selection, and accentuate risks associated with sexual activity and contraceptive use. Providers support adolescent clients by emphasizing the need for privacy, confidentiality, and expedient services, particularly through youth corners, which are spaces within health facilities designed to meet youth needs specifically. Modern contraceptive-using adult female community members advocate for youth access to contraception, however mothers have mixed comfort discussing sexual health with their own youth.

Conclusion

To destigmatize premarital sexual activity, government efforts to initiate communication about this topic must occur at national and community levels with the goal of continued conversation within the family. The government should also train family planning providers and all health personnel interacting with youth on adolescent-friendly health services. Dialogue between community members and family planning providers about adolescent access to contraceptive services could also reduce barriers for adolescents due to community members’ generally supportive views on adolescent contraceptive use. Efforts to engage adolescent caregivers in how to talk to youth about sex could also contribute to expanded use.

In Rwanda, youth who are having sex use family planning less than married women. This study involved asking family planning providers and adults what they think about youth using family planning. Data for this study was collected in 2018, and included 32 interviews with adult family planning users and eight group discussions with family planning providers in two areas of Rwanda. The findings show that Rwandans believe youth should not have sex before they are married. Family planning providers do provide youth with services; however, they often push stopping sexual activity, offer a smaller selection of family planning methods, and exaggerate risks associated with sex and family planning use. Family planning providers support youth by honoring their need for privacy, keeping their secrets, and providing fast services so fewer people see them at the clinic. Providers like to help adolescents in youth corners, which are special spaces within health facilities just for youth. Importantly, adult women who use family planning want youth in their community to be able to use family planning, too. In order to respond to the issues raised, the Rwandan government can start conversations in villages and more broadly about the need for youth to have access to family planning. The government should also teach family planning providers and anyone who comes into contact with youth to offer helpful and friendly services. Setting up spaces for adults to talk with family planning providers about youth access to family planning could also contribute to fewer barriers to services for adolescents.

P-481 Characterization of the gene expression profile of breast cancer tumours in patients undergoing ovarian stimulation for fertility preservation purposes

Study question

Could controlled ovarian stimulation (COS) protocols with letrozole supplementation induce changes in the molecular footprints of estrogen receptor-positive (ER+) breast cancer (BC) women?

Summary answer

Ovarian stimulation with letrozole and gonadotropins does not change the gene expression profile of estrogen receptor-positive (ER+) breast malignant tumours as compared to non-stimulated patients.

What is known already

Fertility preservation (FP) strategies in ER+ BC patients involve modifications of the classical COS protocols to minimise the impact of estrogen levels during ovarian stimulation. The most common approaches are using the aromatase inhibitor letrozole to block the conversion of testosterone into estradiol in the granulosa cells or the use of tamoxifen to block the ER in the breast tissue. Although retrospective studies suggest that these strategies will have no impact on patient’s survival and disease progression, little is known regarding the effect of the ovarian stimulation on the genomic fingerprints of the exposed cancerous tissue.

Study design, size, duration

Retrospective, non-randomized, comparative study. Gene expression profiles were compared in biopsies at diagnosis and during excision surgery in two groups of ER+ BC patients: Patients undergoing COS for FP before surgery (COS group, n = 10) and patients not undergoing any type of COS (Control group, n = 11). The former received letrozole (5mg/day) supplements during COS. The latter included 7 patients not doing FP and 4 undergoing ovarian cortex cryopreservation. Patients were recruited between 2009 and 2021.

Participants/materials, setting, methods

Single 5-µm sections of formalin-fixed, paraffin-embedded (FFPE) needle core biopsy (NCB) and breast surgery (BS) tumour samples were obtained prior to starting gonadotoxic therapies. Differential gene expression and gene set analysis (GSA) was performed in tumour samples before (NCB-sample) and after COS (BS-sample). Simultaneous, quantitative detection of 2549 genes associated with tumour biology was performed with the HTG EdgeSeq Oncology Biomarker Panel. Tumour cell proliferation was also assessed by Ki67 staining.

Main results and the role of chance

Patients were younger in the COS group (COS: 30.2±3.4 vs Control: 34.5±2.3; p = 0.004). None of the patients experienced any relapse during the observation period. The length of COS was 11.5±3.5 days and 10.6±6.8 MII oocytes were vitrified. The exploratory analysis using principal component analysis revealed no relationships between the two BC biopsy samples and gene expression levels in the experimental groups. The differential expression analysis just revealed 6 genes significantly over-expressed after ovarian stimulation (DUSP1, FOS, EGFR1, NR4A1, JUN and CYR61). From these, DUSP1, FOS, and NR4A1 were also significantly upregulated in the unstimulated group. The GSA showed the cytochrome P450 pathway was significantly enriched after COS. No pathways related to cell proliferation were differentially expressed between groups. However, in unstimulated patients, 6 KEGG pathways were upregulated, with the cytokine-cytokine receptor interaction and the Jak-STAT signalling pathway being the most enriched. Ki67 immunostaining showed no differences in cell proliferation after COS (22.8±7.2 vs 24.0±6.9, p = 0.723). The rate of cell proliferation also remained constant in unstimulated patients (22.9±8.4 vs 25.1±8.1, p = 0.560).

Limitations, reasons for caution

The main limitations of the present study are the retrospective design and the associated risk of bias, although the population is very homogeneous when it comes to clinical characteristics; and the fact that molecular footprints are only interim markers of survival/response to the treatment.

Wider implications of the findings

The present study provides molecular evidence supporting the safety of COS using letrozole for oocyte vitrification in young BC patients undergoing ovarian stimulation. This information is crucial to support patient guidance during discussions about fertility preservation.

Trial registration number

Not applicable

Family planning demand generation in Rwanda: Government efforts at the national and community level impact interpersonal communication and family norms

Between 2005 and 2020, total contraceptive use among married women in Rwanda increased from 17% to 64%. The aim of this study is to better understand how the Rwandan government’s mobilization and demand generation efforts have impacted community norms and interpersonal discourse surrounding family planning. Eight focus group discussions with family planning providers and 32 in-depth interviews with experienced modern contraceptive users were conducted in 2018 in the two Rwandan districts with the highest and the lowest contraceptive prevalence rates. Results suggest that outspoken government support, mass media, and community meetings were valuable sources of information about family planning. Information received through these channels generated interpersonal dialogue about contraceptives through both conversation and observation; however, rumors and misinformation remained a significant barrier to use. A once taboo subject is now normative among married couples. Continuing to address common fears and misinformation through communication channels such as mass media and community meetings may help to further increase contraceptive uptake in Rwanda.

"…the availability of contraceptives is everywhere.": coordinated and integrated public family planning service delivery in Rwanda

Background

Contraceptive use in Rwanda tripled since 2005. This study aims to understand the role of coordinated and integrated public family planning service delivery in achieving this increase in contraceptive use in Rwanda.

Methods

This qualitative study in 2018 included eight focus group discussions with family planning providers and 32 in-depth interviews with experienced family planning users.

Results

Results indicate a well-coordinated public family planning service delivery system with community health workers and nurses filling different and complementary roles in meeting family planning client needs at the local level. In addition, integration of family planning into other maternal and child health services is the norm.

Conclusions

The coordination and integration of family planning across both providers and services may help explain the rapid increase in Rwanda’s contraceptive use and has potential applications for enhancing family planning service delivery in other settings.

Family planning use increased from 17 to 53% in Rwanda in between 2005 and 2015. The purpose of this study is to understand the roles of two types of family planning workers in providing family planning services, how those providers work together to achieve the goal to provide public services, and how the Rwandan health system includes family planning services in a variety of other types of health services. To achieve the study purpose, 32 women with experience using modern methods of contraception were interviewed. In addition, 88 providers participated in eight group discussions to discuss these topics. The results from the interviews and group discussions showed that family planning services are easy to access for Rwandans—due to two types of family planning providers filling different roles to assist Rwandans start and keep using family planning methods. Family planning services are included in services for pregnant, delivering, and postpartum mothers—as well as services for infants and children. These are all times when those adults using the services would also be in need of family planning services. The family planning service delivery team approach—as well as including family planning services in mother’s and children’s health services likely helps explain the increase in family planning use in Rwanda. Other nations might learn from Rwanda’s service delivery approach to family planning to also increase access to family planning for their citizens.

Family planning providers and contraceptive users in Rwanda employ strategies to prevent discontinuation

BACKGROUND

In Rwanda, nearly a third of contraceptive users discontinue within the first year of use. Family planning programs often focus more on recruitment of new users as opposed to maintaining use among current users. A focus on sustaining users and minimizing discontinuation is imperative for long-term family planning program success. This study explores the efforts providers and contraceptive users in Rwanda employ to prevent one of the greatest challenges to family planning programs: contraceptive discontinuation.

METHODS

This was a qualitative study conducted in Rwanda between February and July 2018. It included eight focus group discussions with 88 family planning providers and 32 in-depth interviews with experienced modern contraceptive users. Data were collected in two districts with the highest (Musanze) and lowest (Nyamasheke) rates of contraceptive use. Data were analyzed using thematic content approach.

RESULTS

Family planning providers in this study used the following strategies to prevent discontinuation: counseling new users on the potential for side effects and switching, reminding clients about appointments for resupply, as well as supporting dissatisfied users by providing counseling, medicine for side effects, and discussing options for switching methods. Users, on the other hand, employed the following strategies to prevent discontinuation: having an understanding that experiences of side effects vary by individuals, supporting peers to sustain use, persisting with use despite experiences of side effects, and switching methods.

CONCLUSIONS

The strategies used by family planning providers and users in Rwanda to prevent discontinuation suggest the possibility of long-term sustained use of contraception in the country. Harnessing and supporting such strategies could contribute to sustaining or improving further contraceptive use in the country.

Condylar morphometry in adults with sagittal intermaxillary relationship class I, II and III using Cone Beam Computed Tomography in a Colombian population

OBJECTIVE

This study established the morphometry of the mandibular condyle in individuals with complete craniofacial growth and sagittal intermaxillary relationships class I, II and III using cone beam computed tomography (CBCT).

MATERIALS AND METHODS

Cone beam computed tomography was obtained for orthodontics diagnostic purposes. The sample was divided taking into account the ANB angle in sagittal classes I, II and III (age ranged from 18 to 40 years old). Linear measurements and shapes of 144 mandibular condyles were analyzed.

RESULTS

Statistically significant differences were found in measurements of the mediolateral diameter when compared with gender (P 0.000) being larger for males. Statistically significant differences between the mediolateral diameter and the coronal shape for the right as well as the left sides with P values of 0.000 and 0.47 respectively were found.

CONCLUSION

In this sample, it was not possible to conclusively determine the relationship between the skeletal class and the mediolateral diameter. However, more studies are required.

Are the unreamed nails indicated in diaphyseal fractures of the lower extremity? A biomechanical study

INTRODUCTION

Intramedullary nailing is generally accepted as the first choice for the treatment of diaphyseal fractures of femur and tibia, with a gradual incease in the use of unreamed nails. Different studies during last years show controversial outcomes. Some authors strongly favor unreamed nailing, but most of the authors conclude that reamed nailing have proved to be more successful.

MATERIAL AND METHODS

This study simulates unreamed intramedullary nailing of four femoral and three tibial fracture types by means of Finite Element (FE) models, at early postoperative stages with a fraction of physiological loads, in order to determine whether sufficient stability is achieved, and if the extent of movements and strains at the fracture site may preclude proper consolidation.

RESULTS

The behavior observed in the different fracture models is very diverse. In the new biomechanical situation, loads are only transmitted through the intramedullary nail. Mean relative displacement values of fractures in the femoral bone range from 0.30 mm to 0.82 mm, depending on the fracture type. Mean relative displacement values of the tibial fractures lie between 0.18 and 0.62 mm, depending on the type of fracture. Concerning mean strains, for femoral fractures the maximum strains ranged between 12.7% and 42.3%. For tibial fractures the maximum strains ranged between 10.9% and 40.8%.

CONCLUSIONS

The results showed that unreamed nailing provides a very limited mechanical stability, taking into account that analyzed fracture patterns correspond to simple fracture without comminution. Therefore, unreamed nailing is not a correct indication in femoral fractures and should be an exceptional indication in open tibial fractures produced by high-energy mechanism.

An examination of the barriers to and benefits from collaborative couple contraceptive use in Rwanda

Background

Supportive male involvement is strongly correlated with contraceptive use. In Rwanda, where the contraceptive prevalence rate among married women increased from 17 to 52% from 2005 to 2010, and stagnated at 53% in 2015, understanding the role of male partners in collaborative couple contraceptive use can help inform programs designed to further increase the use of contraception in Rwanda.

Methods

This study utilized qualitative methods in 2018, specifically 32 in-depth interviewers with mostly current users of modern contraceptive methods and eight focus group discussions with family planning providers—both family planning nurses and community health workers (CHWs). Respondents were from Musanze and Nyamasheke Districts, the districts with the highest and lowest modern contraceptive use, respectively, to explore the role of couple collaboration in family planning use in Rwanda. Data were analyzed using the thematic content approach in Atlas.ti (8).

Results

Findings demonstrate that some men are opposed to use of male methods of contraception, and some are opposed to any contraceptive use, which can lead to covert use. Women and providers prefer collaborative couple contraceptive use—as a result, providers advocate for and encourage male partner participation in contraceptive use. Women are most often burdened with seeking out information, initiating discussions, and sharing information discovered about contraceptive use with partners. Decision-making about contraceptive use, once discussed, can be collaborative and motivated by financial considerations. When couple contraceptive use is collaborative, benefits range from marital harmony to husband’s support of sustained use through reminders about appointments, joint counseling, and support in managing side effects.

Conclusion

Family planning providers at the community and clinic levels encourage collaborative contraceptive use among couples and some Rwandan couples communicate well about family planning use. Despite the positives, women are expected to source family planning information, share that information with their male partners, seek out family planning services, and use family planning. If more Rwandan male partners accepted use, used male methods of contraception, and participated even more in the work it takes to use family planning, the potential for sustained, and even enhanced, contraceptive use in Rwanda could be realized.

"… the way we welcome them is how we will lead them to love family planning.": family planning providers in Rwanda foster compassionate relationships with clients despite workplace challenges

BACKGROUND

Rwanda has markedly increased the nation's contraceptive use in a short period of time, tripling contraceptive prevalence in just 5 years between 2005 and 2010. An integral aspect of family planning programs is the interactions between family planning providers and clients. This study aims to understand the client-provider relationship in the Rwandan family planning program and to also examine barriers to those relationships.

METHODS

This qualitative study in Rwanda utilized convenience sampling to include eight focus group discussions with family planning providers, both family planning nurses and community health workers, as well as in-depth interviews with 32 experienced modern contraceptive users. Study participants were drawn from the two districts in Rwanda with the highest and lowest modern contraceptive rates, Musanze and Nyamasheke, respectively Data analysis was guided by the thematic content approach, Atlas.ti 8 was utilized for coding the transcripts and collating the coding results, and Microsoft Excel for analyzing the data within code.

RESULTS

Data analysis revealed that, despite workplace related challenges - including inadequate staffing, training, and resources, relationships between providers and clients are strong. Family planning providers work hard to understand, learn from, and support clients in their initiation and sustained use of contraceptives.

CONCLUSION

Given the existing context of purposeful efforts on the part of family planning providers to build relationships with their clients, if the current level of government support for family planning service provision is enhanced, Rwanda will likely sustain many current users of contraception and engage even more Rwandans in contraceptive services in the future.

Ketamine specifically reduces cognitive symptoms in depressed patients: An investigation of associated neural activation patterns

Major depressive disorder (MDD) is characterized by heterogeneous cognitive, affective and somatic symptoms. Hence, the investigation of differential treatment effects on these symptoms as well as the identification of symptom specific biomarkers might crucially contribute to the development of individualized treatment strategies. We here aimed to examine symptom specific responses to treatment with ketamine, which repeatedly demonstrated rapid antidepressant effects in severe MDD. Additionally, we investigated working memory (WM) related brain activity associated with changes in distinct symptoms in order to identify specific response predictors. In a sample of 47 MDD patients receiving a single sub-anesthetic dose of ketamine, we applied a three-factor solution of the Beck Depression Inventory (BDI) to detect symptom specific changes 24 h post-infusion. A subsample of 16 patients underwent additional fMRI scanning during an emotional working memory task prior to ketamine treatment. Since functional aberrations in the default mode network (DMN) as well as in the dorsolateral prefrontal cortex (DLPFC) have been associated with impaired cognitive and emotional processing in MDD, we investigated neural activity in these regions. Our results showed that ketamine differentially affects MDD symptoms, with the largest symptom reduction in the cognitive domain. WM related neuroimaging results indicated that a more pronounced effect of ketamine on cognitive symptoms is predicted by lower DMN deactivation and higher DLPFC activation. Findings thereby not only indicate that ketamine's antidepressant efficacy is driven by a pro-cognitive mechanism, but also suggest that this might be mediated by increased potential for adaptive adjustment in the circumscribed brain regions.

Are thick leaves, large mesophyll cells and small intercellular air spaces requisites for CAM?

BACKGROUND AND AIMS

It is commonly accepted that the leaf of a crassulacean acid metabolism (CAM) plant is thick, with large mesophyll cells and vacuoles that can accommodate the malic acid produced during the night. The link between mesophyll characteristics and CAM mode, whether obligate or C3/CAM, was evaluated.

METHODS

Published values of the carbon isotopic ratio (δ 13C) as an indicator of CAM, leaf thickness, leaf micrographs and other evidence of CAM operation were used to correlate cell density, cell area, the proportion of intercellular space in the mesophyll (IAS) and the length of cell wall facing the intercellular air spaces (Lmes/A) with CAM mode.

KEY RESULTS

Based on 81 species and relatively unrelated families (15) belonging to nine orders, neither leaf thickness nor mesophyll traits helped explain the degree of CAM expression. A strong correlation was found between leaf thickness and δ 13C in some species of Crassulaceae and between leaf thickness and nocturnal acid accumulation in a few obligate CAM species of Bromeliaceae but, when all 81 species were pooled together, no significant changes with δ 13C were observed in cell density, cell area, IAS or Lmes/A.

CONCLUSIONS

An influence of phylogeny on leaf anatomy was evidenced in a few cases but this precluded generalization for widely separate taxa containing CAM species. The possible relationships between leaf anatomy and CAM mode should be interpreted cautiously.

First evaluation of neustonic microplastics in the Macaronesian region, NE Atlantic

Marine microplastic pollution is an issue of great concern nowadays since high concentrations have been detected in the ocean, mainly in the subtropical gyres that accumulate this type of debris. The long-term effects of this pollution on ecosystems and marine biota are still unknown. The aim of this study is to quantify and characterise microplastics and neustonic zooplankton in sub-surface waters of the Macaronesian region, an area that has been little studied to date. Our results show a great variability in the concentration of microplastics with values between 15,283 items/km² in Los Gigantes (Tenerife, Canary Islands) and 1,007,872 items/km² in Las Canteras (Gran Canaria, Canary Islands). The main types of debris found were plastic fragments and fibres. The abundances of neustonic zooplankton were also very variable between the different sampling areas, being the main components copepods and eggs. Regarding the microplastics-zooplankton ratio, values were obtained between 0.002 and 0.22. In Las Canteras, the highest accumulation zone, was found twice as much microplastics as zooplankton for the 1-5 mm fraction in dry weight. These values highlight the potential hazard of microplastics - and its associated chemical contaminants - for marine biota, especially for large filter feeders.

Biomechanical analysis of the stability of anterograde reamed intramedullary nails in femoral spiral fractures

Femoral shaft fractures present high morbidity and important complications and consequences, being spiral fractures the most complicated from a biomechanical point of view, being unstable and without possibility of getting a good contact between nail and femoral endosteum. Femoral diaphyseal fractures are treated, usually, by means of intramedullary nailing. So, it is necessary to know the osteosynthesis stability and which locking screws combination is optimal. This work studies the use of reamed locked intramedullary nails in spiral femoral fractures located along zones 2 and 4 of wiss, depending on the spire length, corresponding to 32-A spiral type in AO/OTA classification, which represent a percentage of 23% within the total of diaphyseal fractures. A three-dimensional finite element model of the femur was developed, modeling a spiral fracture with different spiral lengths and gaps. A femoral nail was used, considering two transversal screws both at the proximal and the distal parts. The study was focused on the immediately post-operative stage, verifying the appropriate stability of the osteosynthesis. Reamed intramedullary blocked nails provide appropriate stability of femoral spiral fractures, considering global mobility of femoral head with respect to femoral condyles, relative displacements between fragments at fracture site, stresses at nail and locking screws, and stresses at cortical bone. The obtained results show that the use of blocked reamed nails in spiral femoral fractures can be considered as an appropriate surgical technique, providing sufficient stability in order to obtain an adequate fracture healing.

Risk factors for major adverse cardiovascular events after osteoporotic hip fracture repair surgery

Osteoporotic hip fracture (OHF) is an increasingly frequent age-related pathology, which results in high rates of functional loss and mortality within the first year after surgery. This study assessed whether preoperative levels of brain natriuretic peptide (NT-proBNP) and troponin I were related to early occurrence (30d) of major adverse cardio-vascular events (MACE) after OHF repair surgery. During a 6-month period, perioperative clinical and analytical data from consecutive patients, without known history of cardiovascular disease and undergoing surgery for OHF repair at a single centre, were prospectively collected. MACE was defined as acute myocardial ischaemia or infarction, acute heart failure or cardiovascular death. amongst the 140 patients included, 23 (16.4%) developed postoperative MACE (MACE group) and 117 did not (Control group). Compared to those from control group, patients from MACE group were older, had poorer physical status (ASA III-IV), received preoperative red blood cell transfusion (RBCT) more frequently, presented with lower haemoglobin concentrations and higher NT-proBNP, creatinine and troponin I concentrations. Overall, RBCT requirements and 30d mortality rate were also higher in MACE group. However, in multivariate analysis, only preoperative RBCT, creatinine >1 mg/dL and NT-proBNP >450 pg/mL remained as independent preoperative risks factors for postoperative MACE, while 95% confidence intervals of odds ratios were wide. Though our findings require confirmation in a larger multicentre cohort, identifying risk factors for early postoperative MACE after OHF repair surgery, might facilitate assessing patients' risk prior to and following surgery, and targeting them the appropriate preventive and/or therapeutic interventions.

Phenotypic plasticity to photon flux density of physiological, anatomical and growth traits in a modern Criollo cocoa clone

Cocoa grows under shade, but some cultivars develop successfully in full sunlight. In order to characterize the response to photosynthetic photon flux density (PPFD) of a Modern Criollo cocoa clone, gas exchange, photochemical activity and leaf traits, and their relation to growth were measured in seedlings growing in a greenhouse at three different values of PPFD, as well as in adults in full sunlight and shade in the field. Plants showed changes in physiological, biochemical, and morpho-anatomical traits in response to the different light conditions, and in the phenotypic plasticity of these variables. Seedlings subjected to high PPFD in the greenhouse showed decreases in photosynthetic rate, apparent quantum yield of CO₂ fixation and photochemical quenching, and increases in non-photochemical quenching, suggesting down-regulation of PSII. In contrast, trees under full sunlight in the field showed a marked reduction in maximum quantum yield of PSII, indicating photoinhibition and supporting that cocoa is a shade tolerant crop. Cocoa showed higher plasticity of physiological and biochemical variables than morpho-anatomical variables in response to PPFD. Effects of time under treatment in the greenhouse and plant age (greenhouse vs field) on plasticity were observed. The acclimation observed in some of the variables studied after 6 months in high light did not represent a particular advantage to seedlings, since relative growth rate was lower than in low- and medium-light seedlings.

Examining the effect of Early Life Stress on autonomic and endocrine indicators of individual stress reactivity

Early life stress (ELS) is associated with altered stress reactivity and an increased risk for the development of psychopathological conditions in later life. However, depending on whether autonomic or endocrine measures were used as indicators of stress reactivity, previous studies reported conflicting findings of either increased or decreased stress reactivity after ELS experience. In the present study we therefore aimed to investigate the effect of ELS on both autonomic and endocrine indicators (heart rate and salivary cortisol) of individual stress reactivity and applied a psychosocial stress task in a sample of healthy participants with and without exposure to mild to moderate ELS. Results showed no significant effects of ELS on autonomic and endocrine indicators of individual stress reactivity. Importantly though, heart rate proved as more sensitive than salivary cortisol with regard to differentiating between stress and control conditions and thereby as a more feasible indicator of an individual's stress reactivity. Accordingly, our data suggest that sole reliance on salivary cortisol as an indicator of stress reactivity might lead to an oversight of more subtle effects of psychosocial stress.

Microplastic ingestion by Atlantic chub mackerel (Scomber colias) in the Canary Islands coast

In recent years, due to the increasing concerns about their negative impact on wildlife and possible toxicity to living organisms (including humans), microplastics have become the subject of intense investigations. In the ocean, microplastics can be easily ingested by numerous marine organisms because of their small size (<5 mm). The Northwest African upwelling system is an important fishery area, and the present study is the first one in the region to reveal the presence of microplastic particles in the digestive tract of Atlantic chub mackerel (Scomber colias). From the 120 examined fish gastrointestinal tracts, 78.3% contained some type of microplastics, 74.2% contained fibres, 17.5% plastic fragments, and 16.7% paint. More studies are needed on fish, but S. colias is a candidate for being a good indicator of microplastic contamination in the region.

The impact of hip fracture on health-related quality of life and activities of daily living: the SPARE-HIP prospective cohort study

PURPOSE

The medical morbidity and mortality associated with neck of femur fractures is well-documented, whereas there is limited data for patient-reported outcomes. The aim of this study was to characterize the impact of neck of femur fractures on activities of daily living and patient-reported health-related quality of life.

METHODS

Design and participants: Multicentric prospective cohort study. Consecutive sample patients with fragility hip fracture over 50 years old admitted in 48 hospitals in Spain.

OUTCOMES

daily living activity function (Barthel Index) and health-related quality of life (EQ-5D) pre-fracture, admission to hospital and at 1- and 4-month follow-up post-fracture.

STATISTICS

Barthel and EQ-5D over time are described as mean (SD) and median (interquartile range).

RESULTS

A total of 997 patients were recruited at baseline with 4-month outcomes available for, and 856 patients (89.5%). Barthel Index fell from 78.77 (23.75) at baseline to 43.62 (19.86) on admission to hospital with the fracture. Scores partially recovered to 54.89 (25.40) and 64.09 (21.35) at 1- and 4-month post-fracture, respectively. EQ-5D fell from a median of 0.75 (0.47-0.91) to - 0.01 (- 0.03 to 0.51) on admission. Partial recovery was observed again to (0.51 (- 0.06 to 0.67)) and (0.60 (0.10 to 0.80)) at 1- and 4-month post-fracture, respectively.

CONCLUSIONS

Hip fracture results in a large decline in the ability to perform activities of daily living and patient-reported health-related quality of life with only partial recovery amongst survivors 4-month post-fracture.

A biomaterial with a channel-like pore architecture induces endochondral healing of bone defects

Biomaterials developed to treat bone defects have classically focused on bone healing via direct, intramembranous ossification. In contrast, most bones in our body develop from a cartilage template via a second pathway called endochondral ossification. The unsolved clinical challenge to regenerate large bone defects has brought endochondral ossification into discussion as an alternative approach for bone healing. However, a biomaterial strategy for the regeneration of large bone defects via endochondral ossification is missing. Here we report on a biomaterial with a channel-like pore architecture to control cell recruitment and tissue patterning in the early phase of healing. In consequence of extracellular matrix alignment, CD146+ progenitor cell accumulation and restrained vascularization, a highly organized endochondral ossification process is induced in rats. Our findings demonstrate that a pure biomaterial approach has the potential to recapitulate a developmental bone growth process for bone healing. This might motivate future strategies for biomaterial-based tissue regeneration.

The impact of advanced practice providers on the surgical resident experience: Agree to disagree?

BACKGROUND

We examined and compared APP versus surgical resident perceptions of the role of APPs in surgical subspecialty teams.

METHODS

Residents/first year surgical critical care fellows and inpatient service-specific APPs responded to a survey that examined perceptions about the APP-resident/fellow relationship. Statistical analysis compared responses using a Pearson chi-square test.

RESULTS

Thirty-two resident/fellows (48%) and 10 APPs (42%) responded. There was consensus that having an APP on service decreases workload, contributes to continuity of care and enhances resident-patient coordination education and agreement that there was clear communication and adequate collaboration. Both groups differed with respect to APPs contribution to resident/fellow clinical education, role definition and chain of command. The majority of trainees felt that APPs function at a PGY2 level (51.7%) compared to APPs, who felt that they functioned at a PGY4/5 (22%) or Fellow (44%) level.

CONCLUSION

APPs and resident/fellows agree that APPs impact resident workload, continuity of care and patient-coordination education.

Salinity induction of recycling Crassulacean acid metabolism and salt tolerance in plants of Talinum triangulare

Background and Aims

Crassulacean acid metabolism (CAM) can be induced by salinity, thus conferring the plant higher water-use efficiency. Talinum triangulare does not frequently encounter salt in its natural habitat but is cultivated in soils that may become salinized. Here we examined whether plants of T. triangulare can grow in saline soils and show salt-induced CAM.

Methods

Leaf gas exchange, carbon isotopic ratio (δ13C), nocturnal acid accumulation (ΔH+), water relations, photosynthetic pigment and mineral contents, leaf anatomy and growth were determined in greenhouse in plants irrigated with 0, 150, 300 and 400 mm NaCl.

Key Results

Salinity reduced gas exchange and induced CAM, ΔH+ reaching 50.2 μmol H+ g-1 fresh mass under 300 mm NaCl. No nocturnal CO2 uptake, but compensation, was observed. Values of δ13C were lowest under 0 and 400 mm NaCl, and highest under 150 and 300 mm. The difference in osmotic potential (ψs) between control and treated plants averaged 0.45 MPa for the three [NaCl] values, the decrease in ψs being accounted for by up to 63 % by Na+ and K+. Pigment contents were unaffected by treatment, suggesting lack of damage to the photosynthetic machinery. Changes in stomatal index with unchanged stomatal density in newly expanded leaves suggested inhibited differentiation of epidermal cells into stomata. Whole-leaf and parenchymata thickness increased under 150 and 300 mm NaCl. Only plants irrigated with 400 mm NaCl showed reductions in biomass (stems, 41 %; reproductive structures, 78 %). The K/Na molar ratio decreased with [NaCl] from 2.0 to 0.4.

Conclusions

The operation of CAM in the recycling mode was evidenced by increased ΔH+ with no nocturnal CO2 uptake. Talinum triangulare can be classified as a halo-tolerant species based on its low K/Na molar ratio under salinity and the relatively small reduction in growth only at the highest [NaCl].

Microplastic and tar pollution on three Canary Islands beaches: An annual study

Marine debris accumulation was analyzed from three exposed beaches of the Canary Islands (Lambra, Famara and Las Canteras). Large microplastics (1-5mm), mesoplastics (5-25mm) and tar pollution were assessed twice a month for a year. There was great spatial and temporal variability in the Canary Island coastal pollution. Seasonal patterns differed at each location, marine debris concentration depended mainly of local-scale wind and wave conditions. The most polluted beach was Lambra, a remote beach infrequently visited. The types of debris found were mainly preproduction resin pellets, plastic fragments and tar, evidencing that pollution was not of local origin, but it cames from the open sea. The levels of pollution were similar to those of highly industrialized and contaminated regions. This study corroborates that the Canary Islands are an area of accumulation of microplastics and tar rafted from the North Atlantic Ocean by the southward flowing Canary Current.

Early-Life stress modulates neural networks associated with habitual use of reappraisal

Recent evidence shows that early life stress (ELS) is associated with altered resting-state functional connectivity (RSFC) between amygdala and the prefrontal cortex, as well as with maladaptive emotion regulation strategies and negative mood. However, the relation between ELS and maladaptive emotion regulation is not deterministic. Adaptive emotion regulation strategies such as reappraisal can also ensue from experience and learning in adulthood and can prevent negative mood. The present study aims to investigate the joint influence of ELS, in particular early-life emotional abuse (EA), and habitual use of reappraisal on amygdala-centered RSFC and mood. We examined amygdala-centered RSFC using functional magnetic resonance imaging (fMRI) in 28 healthy adults with varied exposure to early-life emotional abuse. We found that in subjects with high early-life emotional abuse, reappraisal was predominantly associated with RSFC between left centromedial amygdala (CMA) and the ventrolateral prefrontal cortex (VLPFC), whereas in subjects with low early-life EA reappraisal predominantly involved RSFC between right CMA, premotor and supplementary motor regions. For subjects with high EA, reappraisal use was associated with a decrease in negative mood whereas it was associated with an increase in positive mood for subjects with low EA. The general findings of the study suggest that reappraisal use might act as a protective factor, notably for individuals who were exposed to ELS, and that this is mediated by alteration of amygdala-centered RSFC.

Mechanosensation across borders: fibroblasts inside a macroporous scaffold sense and respond to the mechanical environment beyond the scaffold walls

In tissue defects, cells face distinct mechanical boundary conditions, but how this influences early stages of tissue regeneration remains largely unknown. Biomaterials are used to fill defects but also to provide specific mechanical or geometrical signals. However, they might at the same time shield mechanical information from surrounding tissues that is relevant for tissue functionalisation. This study investigated how fibroblasts in a soft macroporous biomaterial scaffold respond to distinct mechanical environments while they form microtissues. Different boundary stiffnesses counteracting scaffold contraction were provided via a newly developed in vitro setup. Online monitoring over 14 days revealed 3.0 times lower microtissue contraction but 1.6 times higher contraction force for high vs. low stiffness. This difference was significant already after 48 h, a very early stage of microtissue growth. The microtissue's mechanical and geometrical adaptation indicated a collective cellular behaviour and mechanical communication across scaffold pore walls. Surprisingly, the stiffness of the environment influenced cell behaviour even inside macroporous scaffolds where direct cell-cell contacts are hindered. Mechanical communication between cells via traction forces is essential for tissue adaptation to the environment and should not be blocked by rigid biomaterials. Copyright © 2017 John Wiley & Sons, Ltd.

EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of optimal acute care for the patients aged 50 years and over with a recent fragility fracture and the prevention of subsequent fractures in high-risk patients, which can be facilitated by close collaboration between orthopaedic surgeons and rheumatologists or other metabolic bone experts. Therefore, the aim was to establish for the first time collaborative recommendations for these patients. According to the EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations, 7 rheumatologists, a geriatrician and 10 orthopaedic surgeons met twice under the leadership of 2 convenors, a senior advisor, a clinical epidemiologist and 3 research fellows. After defining the content and procedures of the task force, 10 research questions were formulated, a comprehensive and systematic literature search was performed and the results were presented to the entire committee. 10 recommendations were formulated based on evidence from the literature and after discussion and consensus building in the group. The recommendations included appropriate medical and surgical perioperative care, which requires, especially in the elderly, a multidisciplinary approach including orthogeriatric care. A coordinator should setup a process for the systematic investigations for future fracture risk in all elderly patients with a recent fracture. High-risk patients should have appropriate non-pharmacological and pharmacological treatment to decrease the risk of subsequent fracture.

Note. Pollen Analysis and Antibacterial Activity of Spanish Honeys

Antibacterial activity of twenty-five samples of honey from different botanical origin was evaluated. Staphylococcus aureus ATCC 25923 was used as the resistant microorganism. Pollen analysis revealed different botanical origins: Labiatae, rosemary, eucalyptus, heather and multifloral. The pH and acidity values were in the normal range, except for four samples that showed acidity values over 40 meq/kg, but none exhibited a state of fermentation. We have not found correlation between antibacterial activity and free acidity in the samples. Labiatae and rosemary honeys have exhibited the largest inhibition against Staphylococcus aureus ATCC, conversely to heather honeys, which showed lowest inhibition ability against this microorganism. Our results may indicate the presence of antimicrobial agents in Labiatae and rosemary honeys that have inhibited the growth of Staphylococcus aureus ATCC. Likewise, the free acids of heather honeys have not shown inhibitory activity over this microorganism.

A predictive mechanical model for evaluating vertebral fracture probability in lumbar spine under different osteoporotic drug therapies

Osteoporotic vertebral fractures represent a major cause of disability, loss of quality of life and even mortality among the elderly population. Decisions on drug therapy are based on the assessment of risk factors for fracture from bone mineral density (BMD) measurements. A previously developed model, based on the Damage and Fracture Mechanics, was applied for the evaluation of the mechanical magnitudes involved in the fracture process from clinical BMD measurements. BMD evolution in untreated patients and in patients with seven different treatments was analyzed from clinical studies in order to compare the variation in the risk of fracture. The predictive model was applied in a finite element simulation of the whole lumbar spine, obtaining detailed maps of damage and fracture probability, identifying high-risk local zones at vertebral body. For every vertebra, strontium ranelate exhibits the highest decrease, whereas minimum decrease is achieved with oral ibandronate. All the treatments manifest similar trends for every vertebra. Conversely, for the natural BMD evolution, as bone stiffness decreases, the mechanical damage and fracture probability show a significant increase (as it occurs in the natural history of BMD). Vertebral walls and external areas of vertebral end plates are the zones at greatest risk, in coincidence with the typical locations of osteoporotic fractures, characterized by a vertebral crushing due to the collapse of vertebral walls. This methodology could be applied for an individual patient, in order to obtain the trends corresponding to different treatments, in identifying at-risk individuals in early stages of osteoporosis and might be helpful for treatment decisions.

Behavior in vitro of the dentin-enamel junction in human premolars submitted to high temperatures: prediction of the maximum temperature based on logistic regression analysis

OBJECTIVE

The aim of the study was to provide scientific evidence that would permit DEJ separation to be used as a parameter to estimate the temperature to which burnt, carbonized or incinerated cadavers or human remains had been subjected.

MATERIALS AND METHODS

A descriptive pseudo-experimental study was carried out in vitro using cone beam tomography to determine the physical behavior of the dentine-enamel junction in 60 human premolars submitted to high temperatures (200°C, 400°C, 600°C, 800°C and 1000°C).

RESULTS

Spearman's concordance and correlation index was used to determine the relationship between longitudinal separation of the dentine-enamel junction (mm) and temperature (°C) and a simple linear regression model developed to show that once micro- and macrostructural changes are initiated in the enamel and dentine.

CONCLUSIONS

The dentine-enamel junction begins to separate from the cervical towards the occlusal as temperature increases.

Is personality relevant in the choice of bleaching?

OBJECTIVES

The purpose was to administer the NEO-FFI personality test to patients who did and did not want to have their teeth bleached and before and after bleaching to the participants who accepted the treatment. The research question is to correlate styles and personality factors with bleaching.

MATERIALS AND METHODS

There were 128 patients eligible for bleaching; 58 accepted (AB) while 70 refused (RB). The test was administered to both groups (AB-RB). The group AB was administered before and 1 week after the end of the bleaching. For each personality domain comparison, the Mann-Whitney test was used. For the group AB, the results for each domain before and after bleaching were compared using the Wilcoxon test.

RESULTS

There was a significant difference between the groups (AB-RB) in the extraversion factor (p = 0.01). There was no significant difference between any of the personality items before and after bleaching (p > 0.1). The comparison between groups by sex revealed significant differences in extraversion and neuroticism factors. Males who AB scored higher in extraversion than males who RB (p < 0.05). Females scored higher in neuroticism than males who AB (p < 0.05).

CONCLUSIONS

There were personality differences between people who decided to bleach compared with those who did not want the bleaching, which was mainly in the extroversion factor. This stereotypes the patients, who could be described as more sociable, extroverted, and concerned about esthetics and cleanliness. The bleaching protocol, however, cannot modify any of the personality factors.

CLINICAL SIGNIFICANCE

It is important to understand a patient's behavior to meet their needs and to determine the type of patients who would like to have their teeth bleached.