Survey of the use of transport by recipients of a regional Electric Indoor/Outdoor Powered (EPIOC) wheelchair service.

PURPOSE: To determine the extent to which Electric Indoor/Outdoor Powered wheelchair (EPIOC) users travel in vehicles, their concerns about safety, any accidents occurring during transportation and difficulties with their equipment. METHOD: All 268 EPIOC users on the departmental database were sent a purpose-designed postal questionnaire asking whether the respondent:--used the chair during transportation and in what type of vehicle; understood clamping processes; had a 'mishap' or an 'accident'; felt safe during transportation and wished to comment. Replies from two mailings resulted in 203 usable replies (76%). Responses and comments were entered into an Excel database. RESULTS: Thirty-seven (18%) users did not use any transport. Of the 170 (82%) who did: 51% used Dial-a-Ride, 44% taxis, 41% ambulances, 37% local authority transport, 34% cars and others 17%. Twenty-one (12%) experienced 'mishaps'--8 toppled out of their chairs and 6 reported clamping-related accidents. Headrests were only used by 69 (41%). Thirty-four (19%) of 182 expressing a view about 'feeling safe' felt unsafe sometimes. Wheelchair users often feel vulnerable when being transported by public providers. DISCUSSION: Risks of vehicular travel by wheelchair users could be reduced with appropriate equipment and regular review of NHS prescriptions, education of users, wheelchair services and transport providers.

Introduction of a new NHS electric-powered indoor/outdoor chair (EPIOC) service: benefits, risks and implications for prescribers.

OBJECTIVE: To determine problems associated with electric-powered indoor/outdoor wheelchairs (EPIOCs) and the benefits perceived by their users. DESIGN: Hospital-based cohort study of all patients referred over a 19-month period. SETTING: Regional Wheelchair Service for North West London serving nine district wheelchair services. SUBJECTS: Of the 174 subjects referred, 10 withdrew their application or were found to be unsuitable at screening, 164 were assessed and 124 were prescribed chairs. One hundred and thirteen subjects were interviewed by telephone four months after provision of the chair. MAIN MEASURES: Demographic and diagnostic data; current chair usage; self-reported accidents and component faults were compared with those recorded in the unit records; new activities embarked on since delivery; and benefits reported for main carers. RESULTS: Seventeen 'mishaps' were reported by 15 users including tipping from chairs (6) and falls during transfers (3). Three probably reflected mechanical failure. Component failure was found in 39% of EPIOCs, mostly affecting control boxes (22), frames (10) and footrests (10). New activities were undertaken by 56 (50%) users, usually shopping and visits to friends/family. Eighty-five per cent of users felt that the chairs made life easier for their informal carers through increased independence, reducing transfers and reduced need for 'pushing'. CONCLUSIONS: The component failures and self-reported accidents (some potentially dangerous) have implications for the NHS, manufacturers, prescribers and users. EPIOCs enhance the independence of severely physically disabled individuals in the community and assist carers by lessening dependence and enhancing social interaction. This study demonstrated the need for follow-up of EPIOC users and chairs.

Microleakage of Class II resin-based composite restorations with flowable composite in the proximal box.

PURPOSE: To compare microleakage of Class II hybrid resin-based composite (RBC) restorations with and without low viscosity (flowable) RBC in the proximal box. MATERIALS AND METHODS: Conservative Class II cavity preparations were made in 50 extracted premolars randomly assigned to five groups (n = 10). OptiBond FL dentin bonding agent, and Prodigy hybrid RBC were used to restore all cavity preparations. Preparations in four of the five groups were restored with flowable RBC as the initial increment in the proximal box. The four flowable RBCs tested were: AEliteFlo, Revolution, UltraSeal XT and Flow-It. In the control group, the entire preparation was restored only with hybrid RBC. Specimens were stored in water at 37 degrees C for 24 hrs after restoration, thermocycled 1,000x, immersed in 2% basic fuchsin, sectioned and evaluated for microleakage. Microleakage was scored on a 0-4 scale. RESULTS: Non-parametric Kruskal-Wallis one-way ANOVA followed by Wilcoxon signed ranks test was used for statistical analysis. The use of any of the four flowable RBCs tested did not influence microleakage significantly (P > 0.05) in Class II RBC restorations.

Bonding amalgam to a resin-modified glass-ionomer base.

PURPOSE: To determine which surface treatment of a resin-modified glass-ionomer (RMGI) will result in optimal bond strength to amalgam when used with an amalgam adhesive. MATERIALS AND METHODS: Fifty discs of Fuji II LC (4 mm thick) were cured in acrylic testing holders and randomly divided into 5 groups of 10 each. The surface of the glass-ionomer was treated in 1 of 5 ways: (1) no treatment (control) (2) no etch, Amalgambond (AB) primer and AB adhesive (3) citric acid etch, AB primer, and AB adhesive (per manufacturer's instructions) (4) 37.5% phosphoric acid etch, AB primer and AB adhesive, and (5) microetch, 37.5% phosphoric acid etch, AB primer and AB adhesive. Amalgam was condensed onto the treated RMGI surface. Samples were stored in water at 37 degrees C and tested at 24 hours for shear bond strength. The data was analyzed statistically by ANOVA followed by Scheffé post hoc tests for significance. Glass-ionomer discs were also treated as described in each group, sputter-coated and examined using a scanning electron microscope. RESULTS: No significant improvement in bond strengths to amalgam was observed with any of the treatments of the RMGI surface. Amalgambond significantly increased the bond strength of the amalgam to the RMGI.

A smoking cessation programme conducted through dental practices in the UK.

OBJECTIVES: To assess the feasibility of using primary care dentists and the dental team providing smoking cessation advice in practice. DESIGN: A prospective study to examine the success of a smoking cessation programme. SETTING: 54 primary care dental practices in the UK. METHOD: Training and educational materials were supplied to members of the dental team and to potential recruits smoking 10 or more cigarettes a day. Recruitment was over 6 months and subjects were followed up for 9 months. In addition to dentists' counselling, nicotine patches were made available, on request, at cost price. Salivary cotinine assay was used for validation of smoking levels at initial counselling and 9 months after recruitment. RESULTS: 54 practices were enrolled but only 22 recruited patients. Records of 154 eligible patients were evaluated. Compliance to attend follow up clinics was poor--only 74 reported at 9 months. Among them 17 (11%) were successful in giving-up tobacco for 9 months as validated by patient histories and salivary cotinine assay. A large variation performance of the dental practices was noted. CONCLUSIONS: Motivated dentists with staff support and access to information on smoking counselling are able to contribute to tobacco control measures in the community. The success of this programme closely parallels those reported in general medical practice settings. In view of the very considerable attrition rates found at all levels of the programme in the present study and the uneven performance of the participating practices the quit rate reported here may not accurately reflect what could be achieved in an individual primary care setting.

Two-year clinical evaluation of an amalgam adhesive.

This study compared the clinical effectiveness of an amalgam adhesive as the principal mode of retention for large, complex amalgam restorations with traditional pin-retained amalgams. Restorations were evaluated for retention and reinforcement, postoperative sensitivity, marginal adaptation and recurrent decay. At the end of two years, all restorations were completely retained and rated Alfa for each of the parameters evaluated. An amalgam adhesive proved clinically effective as a suitable alternative to pin retention.

Effect of dantrolene sodium on contractility of isolated human uterine muscle.

The administration of intravenous dantrolene in a parturient susceptible to malignant hyperthermia has been associated with post partum uterine atony. We examined the effect of dantrolene sodium for injection (Dantrium Intravenous) on spontaneous contractility of uterine smooth muscle from women in term pregnancy in an isolated preparation. Dantrolene sodium for injection at 5 microg/ml and 10 microg/ml had no effect on the spontaneous contractility of the uterine muscle preparations. At a cumulative concentration of 20 microg/ml, a mild depression (16 +/- 14%) in the frequency of spontaneous contractions was noted. However, a similar depression in the muscle preparations treated with mannitol suggests that the depression observed with the dantrolene was likely due to the mannitol that was included in the dantrolene formulation rather than to dantrolene sodium itself. We conclude that dantrolene sodium has no effect on the spontaneous contractility of uterine smooth muscle. The depression of uterine muscle activity observed with dantrolene for injection appears attributable to the mannitol.

Randomised controlled trial of nasal nicotine spray in smoking cessation.

Studies with nicotine chewing gum and nicotine skin patches indicate that nicotine replacement can help people to give up smoking. The rapidity with which nicotine is absorbed when given as a nasal spray suggests that it might be effective for those for whom the other means of replacement are too slow. The efficacy and safety of a nasal nicotine spray as an adjunct to group treatment for stopping smoking were assessed in a randomised, double-blind, placebo-controlled trial in which 227 cigarette smokers attending the Maudsley Hospital Smokers Clinic received 4 weeks of supportive group treatment plus active nicotine (0.5 mg per shot) or placebo nasal spray. The main end-point was biochemically validated complete abstinence from smoking from the third week of group treatment until the 12-month follow-up. Side-effects were assessed by self-reports and, where necessary, by physical examination. Of subjects assigned to active treatment 26% (n = 30) were validated abstinent throughout the year, compared with 10% (n = 11) of those assigned to placebo (relative abstinence rate 2.6, 95% CI 1.5-4.5, p less than 0.001). The advantage of the active spray was greatest in the heaviest smokers. Plasma nicotine concentrations from the spray were typically between one-half and three-quarters of baseline smoking levels. Tobacco-withdrawal symptoms, craving for cigarettes, and weight gain in abstinent subjects were reduced by the active spray. Minor irritant side-effects were frequent in both active and placebo sprays, but only 2 subjects had the spray discontinued as a result. No serious adverse effects were encountered. Nasal nicotine spray combined with supportive group treatment is an effective aid to smoking cessation.

Dream of absent-minded transgression: an empirical study of a cognitive withdrawal symptom.

Among 293 smokers abstinent for between 1 and 4 weeks, 33% reported having at least 1 dream about smoking. In most dreams, subjects caught themselves smoking and felt strong negative emotions, such as panic and guilt. Dreams about smoking were the result of tobacco withdrawal, as 97% of subjects did not have them while smoking, and their occurrence was significantly related to the duration of abstinence. They were rated as more vivid than the usual dreams and were as common as most major tobacco withdrawal symptoms. In subjects abstinent for 1 year, 63% recalled having dreams about smoking. They had on average 5 of them, and about a quarter occurred after the 6th month of abstinence. Having dreams about smoking was prospectively positively related to maintenance of abstinence. An explanation of this finding based on the association of smoking in dreams with aversive emotions is offered.

Abstinence from smoking and expired-air carbon monoxide levels: lactose intolerance as a possible source of error.

We investigated a possible source of contamination of expired-air carbon monoxide (CO) readings on CO monitors from raised expired-air hydrogen (H2) levels, namely lactose intolerance, the norm in certain ethnic groups. A significant correlation between expired-air CO and H2 readings was observed in four non-smoking lactose maldigesters.

Severity of withdrawal symptoms as a predictor of outcome of an attempt to quit smoking.

In 227 smokers' clinic clients who managed at least one week of abstinence, ratings of withdrawal symptoms were used to predict subsequent return to smoking. Depression, time spent with urges to smoke, and difficulty not smoking during the first week of abstinence were significantly associated with lapse back to smoking during the second week. Depression and difficulty not smoking during the second week significantly predicted smoking status during the third week. No withdrawal symptoms during the third week were associated with a return to smoking during the fourth week. The predictive power of withdrawal symptoms was over and above that of smoke intake and dependence. The findings provide some support for the view that reduction of withdrawal symptoms may be a worthwhile target in programmes for helping smokers to quit.

Time course of cigarette withdrawal symptoms while using nicotine gum.

Ratings of withdrawal symptoms were provided at weekly intervals by 147 smokers clinic clients who managed complete abstinence for 4 weeks. The ratings followed a similar temporal pattern regardless of amount of nicotine gum used. Irritability, depression, difficulty concentrating and restlessness peaked in the 1st week or two and returned to baseline by week 4. Hunger was more persistent. Craving was reported to be the most troublesome withdrawal symptom at first, although by the 4th week hunger was cited almost as often. Across all subjects, evenings were cited most often as the worst time of day for craving but among heavier smokers and those who used more nicotine gum mornings were considered worst.

Effect of smoke-free cigarettes on 24 h cigarette withdrawal: a double-blind placebo-controlled study.

In a double-blind randomised trial, 40 cigarette smokers used either nicotine-containing or placebo smoke-free cigarettes during 24 h abstinence from smoking. Subjects in the nicotine group experienced smaller increases in irritability and difficulty concentrating and fewer urges to smoke than those who received placebo. Nicotine smoke-free cigarettes were rated as more satisfying, more helpful and more effective in relieving craving than placebo. After 24 h use nicotine smoke-free cigarettes provided average blood nicotine levels of 6.3 ng/ml, i.e., 29.2% of smoking levels. The most frequent side effects were irritation of the throat and coughing. Overall, side effects were rated as not serious. Although the smoke-free cigarette in its present form is not very efficient in delivering nicotine, it was effective in alleviating initial tobacco withdrawal. It is possible that by providing both nicotine and "behavioural" replacement it may be particularly useful in the first stages of stopping smoking. The product is worth further investigation.

Long-term use of nicotine chewing gum. Occurrence, determinants, and effect on weight gain.

Among 538 clients of a Smokers Clinic who were treated with 2-mg nicotine chewing gum, 34 (6.3%) were still using the gum at one-year follow-up. This group represented 25% of lapse-free abstainers. At one-year follow-up, long-term gum users were using an average of 6.8 pieces of gum per day. Long-term gum users were similar to treatment failures in cigarette consumption and tobacco dependence, while "gum-free" successes were significantly lighter and less-dependent smokers. Long-term gum users used more gum during the four weeks of treatment than treatment failures, who in turn used more than the gum-free successes. It is suggested that for many the long-term use of gum was an essential ingredient of their success. Long-term gum users gained significantly less weight than other long-term treatment successes.

District programme to reduce smoking: can sustained intervention by general practitioners affect prevalence?

A total of 101 general practitioners in 27 practices in inner London took part in a quasi-experimental study designed to examine whether a brief intervention applied to all smokers seen by general practitioners and sustained on a continuous basis could in time have a cumulative effect and reduce the prevalence of smoking among their patients. Of 21 practices approached in our local district (Camberwell), seven were willing to undertake brief intervention with support from the smokers' clinic (SBI), four opted for intervention without support (BI), and six acted as usual care controls. A further 10 out of 12 practices approached in South Hammersmith provided an unselected group of usual care controls. A series of six cross-sectional surveys were conducted over a three-year period. Each survey consisted of all adult patients attending to see a doctor during a defined two-week period, sample sizes averaging just over 9000 per survey. The estimated decline in self-reported smoking prevalence over the 30-month period following the start of intervention was 5.5% (from 36.4% to 30.9%) in the SBI group compared with 2.1% for BI and 2.8% and 3.0% in the two usual care control groups, the decline in the SBI group being significantly greater than in the other groups which did not differ significantly between each other. These interim results provide encouraging evidence that brief intervention by general practitioners with support and back-up from a local smokers' clinic can, when sustained on a continuous basis, reach sufficient smokers to reduce smoking prevalence in their practice populations. However, firm conclusions must await longer periods of observation now that the other Camberwell practices have adopted the SBI procedures.

District programme to reduce smoking: effect of clinic supported brief intervention by general practitioners.

By encouraging and supporting general practitioners to undertake brief intervention on a routine basis smokers' clinics could reach many more smokers than are willing to attend for intensive treatment. In a study with 101 general practitioners from 27 practices 4445 cigarette smokers received brief intervention with the support of a smokers' clinic, brief intervention without such support, or the general practitioners' usual care. At one year follow up the numbers of smokers who reported that they were no longer smoking cigarettes were 51 (13%), 63 (9%), and 263 (8%), respectively (p less than 0.005). After an adjustment was made for those cases not validated by urine cotinine concentrations the respective success rates were 8%, 5%, and 5%. Use of nicotine chewing gum was associated with higher self reported success rates. General practitioners providing supported brief intervention encouraged not only more smokers to use the gum but also more effective use; gum users in this group reported a success rate of 27% at one year. Compliance by the general practitioners in recording smoking state averaged 45%, and significantly higher success rates were reported by patients whose smoking state had been recorded. Brief intervention by general practitioners with the support of a smokers' clinic thus significantly enhanced success rates based on self reports. Better results might be obtained if general practitioners' compliance with the procedure could be improved and if they encouraged more of their patients to try nicotine gum. Collaboration of this kind between a smokers' clinic and local general practitioners could deliver effective help to many more smokers than are likely to be affected if the two continue to work separately.

Positioning of separated conjoined twins with scoliosis/lordosis.

Infantile scoliosis has a potential for progression. This paper discusses the use of a soft material to correct scoliosis in a medically stable, at-risk infant. It illustrates that early intervention is desirable in preventing the progression of the lateral curve of the trunk. It also illustrates that the three-point positioning principle can be effective with soft materials with an infant. Foam rubber blocks were used to apply pressure at three strategic points, the shoulder, the hip, and the convex curve on an infant's trunk. At the age of 7 months the infant was able to move herself into a normal position with good head and body alignment.