The survival of Class V restorations in general dental practice: part 3, five-year survival.

OBJECTIVE: To evaluate the survival over five years of Class V restorations placed by UK general practitioners, and to identify factors associated with increased longevity. DESIGN: Prospective longitudinal cohort multi-centre study. SETTING: UK general dental practices. MATERIALS AND METHOD: Ten general dental practitioners each placed 100 Class V restorations of varying sizes, using a range of materials and recorded selected clinical information at placement and recall visits. After five years the data were analysed using the Kaplan-Meier method, log-rank tests and Cox regressions models to identify significant associations between the time to restoration failure and different clinical factors. RESULTS: After five years 275/989 restorations had failed (27.8%), with 116 (11.7%) lost to follow-up. Cox regression analysis identified that, in combination, the practitioner, patient age, cavity size, moisture contamination and cavity preparation were found to influence the survival of the restorations. CONCLUSIONS: At least 60.5% of the restorations survived for five years. The time to failure of Class V restorations placed by this group of dentists was reduced in association with the individual practitioner, smaller cavities, glass ionomer restorations, cavities which had not been prepared with a bur, moisture contamination, increasing patient age, cavities confined to dentine and non-carious cavities.

The survival of Class V restorations in general dental practice. Part 2, early failure.

OBJECTIVE: To evaluate Class V restorations placed by UK general practitioners comparing those failing or surviving after two years, and to identify factors associated with early failure. DESIGN: Prospective longitudinal cohort multi-centre study. Setting UK general dental practices. MATERIALS & METHODS: Ten dentists each placed 100 Class V restorations and recorded selected clinical information at placement and recall visits. Univariate associations were assessed between recorded clinical factors and whether restorations had failed or not at two years. Multi-variable binary logistic regression was also undertaken to identify which combination of factors had a significant effect on the probability of early failure. RESULTS: At two years, 156 of 989 restorations had failed (15.8%), with 40 (4%) lost to follow-up. Univariate analysis showed a significant association between restoration failure and increasing patient age, payment method, the treating practitioner, non-carious cavities, cavities involving enamel and dentine, cavity preparation and restoration material. Multi-variable analysis indicated a higher probability of early failure associated with the practitioner, older patients, glass ionomer and flowable composite, bur-preparation and moisture contamination. CONCLUSIONS: Among these practitioners, both analytic methods identified significant associations between early failure of Class V restorations and the practitioner, cavity preparation method, restoration material and patient's age.

The survival of Class V restorations in general dental practice. Part 1, baseline data.

OBJECTIVE: Evidence on the survival of different restorations in general practice is scarce and so to address this need, a study was designed to monitor the outcome of Class V restorations placed in UK general practices. DESIGN: Prospective longitudinal cohort multi-centre study. SETTING: UK general dental practice. MATERIALS AND METHODS: Ten UK dentists each placed 100 Class V restorations and recorded selected clinical information at placement and at recall visits on record cards. Dentists selected materials and techniques which they felt appropriate to each clinical situation. RESULTS: Data cards for 11 restorations were incorrectly completed or information was missing leaving 989 for analysis. The majority of restorations were placed in patients between 51 and 60 years of age, in canines or premolars (68.4%) and under private contract (63%). Composite (40.85%) and compomer (23.46%) were the most frequently placed materials overall but were not the most frequently placed restorative by some dentists. CONCLUSIONS: Different dentists use different methods to manage Class V lesions but each dentist tends to use one restorative material predominantly. There is a degree of overlap among practitioners in the materials which they employ, but clear preferences were displayed in the materials used and handling techniques.

Prevalence and predictors of human papillomavirus infection in women in Ontario, Canada. Survey of HPV in Ontario Women (SHOW) Group.

BACKGROUND: Human papillomavirus (HPV) is thought to be the primary cause of cervical intraepithelial neoplasia and cervical cancer. We determined the age-specific prevalence of HPV infection and its risk factors in Ontario women. METHODS: We obtained 2 cervical specimens from randomly selected women (in 5-year age categories, from 15 to 49 years) who were being seen in 32 family practices for cytologic screening. The specimens were tested for carcinogenic HPV by the hybrid capture II assay (Digene Corp., Silver Spring, Md.) and by polymerase chain reaction (PCR) and genotyping. RESULTS: Of 1004 women eligible to participate, samples were obtained from 955 (95.1%). The prevalence of HPV (as determined by the hybrid capture II method) was highest, at 24.0% (95% confidence interval [CI] 16.5% to 31.5%), among women 20 to 24 years of age and was progressively lower in older age groups, reaching 3.4% (95% CI 0.1% to 6.7%) in women 45 to 49 years old. The prevalence of HPV (any type) as determined by PCR showed a similar pattern but was significantly higher (p = 0.01) among women 45 to 49 years old than among those 40 to 44 years old (13.0% [95% CI 6.4% to 19.6%] v. 3.3% [95% CI 0.1% to 6.5%]). Risk factors for positivity with the hybrid capture II method were never-married status, divorced or separated status, more than 3 lifetime partners, more than 1 partner in the preceding year, cigarette smoking and current use of oral contraceptives. The presence of squamous intraepithelial lesions on cytologic examination was strongly associated with positivity with the hybrid capture II assay (odds ratio 96.0, 95% CI 22.3 to 413.4; p < 0.01). INTERPRETATION: The highest prevalence of HPV was 24.0%, in women 20 to 24 years old. Risk factors supported a sexual mode of transmission, and there was a strong association between HPV and abnormal cervical cytologic results.

Effect of preventive home visits by a nurse on the outcomes of frail elderly people in the community: a randomized controlled trial.

BACKGROUND: Timely recognition and prevention of health problems among elderly people have been shown to improve their health. In this randomized controlled trial the authors examined the impact of preventive home visits by a nurse compared with usual care on the outcomes of frail elderly people living in the community. METHODS: A screening questionnaire identified eligible participants (those aged 70 years or more at risk of sudden deterioration in health). Those randomly assigned to the visiting nurse group were assessed and followed up in their homes for 14 months. The primary outcome measure was the combined rate of deaths and admissions to an institution, and the secondary outcome measure the rate of health services utilization, during the 14 months; these rates were determined through a medical chart audit by a research nurse who was blind to group allocation. RESULTS: The questionnaire was mailed to 415 elderly people, of whom 369 (88.9%) responded. Of these, 198 (53.7%) were eligible, and 142 consented to participate and were randomly assigned to either the visiting nurse group (73) or the usual care group (69). The combined rate of deaths and admissions to an institution was 10.0% in the visiting nurse group and 5.8% in the usual care group (p = 0.52). The rate of health services utilization did not differ significantly between the 2 groups. Influenza and pneumonia vaccination rates were significantly higher in the visiting nurse group (90.1% and 81.9%) than in the usual care group (53.0% and 0%) (p < 0.001). INTERPRETATION: The trial failed to show any effect of a visiting nurse other than vastly improved vaccination coverage.

Screening seniors for risk of functional decline: results of a survey in family practice.

OBJECTIVE: To measure functional status, determine risk of functional decline and assess consistency between responses and standardized instruments. DESIGN: A mailed survey which measured functional impairment, recent hospitalization and bereavement. A positive response on at least one of these factors indicated that the individual was "at risk" for functional decline. A random sample (n = 73) of "at risk" subjects (specifically, family practice patients aged 70 and older) were assessed by a nurse. RESULTS: The response rate was 89% (369/415), 59% of seniors were female and the mean age was 77.1 (SD = 5.5) years. Self-reported risk, based on activities of daily living (ADLs), was associated with impairment in at least one basic ADL (p < 0.0005) using a standardized instrument. The positive predictive value of the survey for ADL impairment was 65%. CONCLUSION: Response to a mailed survey was high and self-reported ADL risks were consistent with findings from standardized assessment tools.

Urine specimens from pregnant and nonpregnant women inhibitory to amplification of Chlamydia trachomatis nucleic acid by PCR, ligase chain reaction, and transcription-mediated amplification: identification of urinary substances associated with inhibition and removal of inhibitory activity.

The presence of endogenous amplification inhibitors in urine may produce false-negative results for the detection of Chlamydia trachomatis nucleic acids by tests such as PCR, ligase chain reaction (LCR), and transcription-mediated amplification (TMA). Consecutive urine specimens from 101 pregnant women and 287 nonpregnant women submitted for urinalysis were processed for C. trachomatis detection. Aliquots were spiked with the equivalent of one C. trachomatis elementary body and were tested by three commercial assays: AMPLICOR CT/NG, Chlamydia LCX, and Chlamydia TMA. The prevalence of inhibitors resulting in complete inhibition of amplification was 4.9% for PCR, 2.6% for LCR, and 7.5% for TMA. In addition, all three assays were partially inhibited by additional urine specimens. Only PCR was more often inhibited by urine from pregnant women than by urine from nonpregnant women (9.9 versus 3.1%; P = 0.011). A complete urinalysis including dipstick and a microscopic examination was performed. Logistic regression analysis revealed that the following substances were associated with amplification inhibition: beta-human chorionic gonadotropin (odds ratio [OR], 3.3) and crystals (OR, 3.3) for PCR, nitrites for LCR (OR, 14.4), and hemoglobin (OR, 3.3), nitrites (OR, 3.3), and crystals (OR, 3.3) for TMA. Aliquots of each inhibitory urine specimen were stored at 4 and -70 degreesC overnight or were extracted with phenol-chloroform and then retested at dilutions of 1:1, 1:4, and 1:10. Most inhibition was removed by storage overnight at 4 or -70 degreesC and a dilution of 1:10 (84% for PCR, 100% for LCR, and 92% for TMA). Five urine specimens (three for PCR and two for TMA) required phenol-chloroform extraction to remove inhibitors. The results indicate that the prevalence of nucleic acid amplification inhibitors in female urine is different for each technology, that this prevalence may be predicted by the presence of urinary factors, and that storage and dilution remove most of the inhibitors.

Management of common musculoskeletal problems: a survey of Ontario primary care physicians.

BACKGROUND: In Canada, primary care physicians manage most musculoskeletal problems. However, their training in this area is limited, and some aspects of management may be suboptimal. This study was conducted to examine primary care physicians' management of 3 common musculoskeletal problems, ascertain the determinants of management and compare management with that recommended by a current practice panel. METHODS: A stratified computer-generated random sample of 798 Ontario members of the College of Family Physicians of Canada received a self-administered questionnaire by mail. Respondents selected various items in the management of 3 hypothetical patients: a 77-year-old woman with a shoulder problem, a 64-year-old man with osteoarthritis of the knee and a 30-year-old man with an acutely hot, swollen knee. Scores reflecting the proportion of recommended investigations, interventions and referrals selected for each scenario were calculated and examined for their association with physician and practice characteristics and physician attitudes. RESULTS: The response rate was 68.3% (529/775 eligible physicians). For the shoulder problem, all of the recommended items were chosen by the majority of respondents. However, of the items not recommended, ordering blood tests was selected by almost half (242 [45.7%]) as was prescribing an NSAID (236 [44.7%]). For the knee osteoarthritis the majority of respondents chose the recommended items except exercise (selected by only 175 [33.1%]). Of the items not recommended, tests were chosen by about half of the respondents and inappropriate referrals (chiefly for orthopedic surgery) were chosen by a quarter. For the acutely hot knee, the majority of physicians chose all of the recommended items except use of ice or heat (selected by only 188 [35.6%]). Although most (415 [78.5%]) of the respondents selected the recommended joint aspiration for this scenario, 84 (15.9%) omitted this investigation or referral to a specialist. The selection of recommended items was strongly associated with training in musculoskeletal specialties during medical school and residency. INTERPRETATION: Primary care physicians' management of 3 common musculoskeletal problems was for the most part in accord with panel recommendations. However, the unnecessary use of diagnostic tests, inappropriate prescribing of NSAIDs, low use of patient-centred options such as exercise, and lack of diagnostic suspicion of infectious arthritis are cause for concern. The results point to the need for increased exposure to musculoskeletal problems during undergraduate and residency training and in continuing medical education.

Factors associated with appropriate physician management of sexually transmitted diseases in an urban Canadian center.

BACKGROUND AND OBJECTIVES: To explore physicians' management of selected sexually transmitted diseases (STDs), because previous studies suggest that physicians' management practices could be improved. GOALS: To determine the estimated annual incidence of STD seen by family/general practitioners (FPs), gynecologists (GYNs) and urologists (UROLs), adequacy of STD management practices, and any associations with demographic and other characteristics. STUDY DESIGN: A self-administered questionnaire was mailed to GYNs, UROLs, and a random sample of FPs in Hamilton, Ontario. RESULTS: Eighty-one of 102 (79.4%) FPs, 27 of 32 (84.4%) GYNs, and 7 of 8 (87.5%) UROLs responded. Vaginitis, male urethritis, and genital warts in women were the most frequently observed STDs. The treatment of bacterial vaginosis and pelvic inflammatory disease were most frequently at variance with published guidelines. CONCLUSIONS: Deficiencies exist in physicians' management of both common and potentially serious STD problems.

Management of the early and late presentations of rheumatoid arthritis: a survey of Ontario primary care physicians.

OBJECTIVE: To examine primary care physicians' management of rheumatoid arthritis, ascertain the determinants of management and compare management with that recommended by a current practice panel. DESIGN: Mail survey (self-administered questionnaire). SETTING: Ontario. PARTICIPANTS: A stratified computer-generated random sample of 798 members of the College of Family Physicians of Canada. OUTCOME MEASURES: Proportions of respondents who chose various items in the management of two hypothetical patients, one with early rheumatoid arthritis and one with late rheumatoid arthritis. Scores for investigations, interventions and referrals for each scenario were generated by summing the recommended items chosen by respondents and then dividing by the total number of items recommended in that category. The scores were examined for their association with physician and practice characteristics and physician attitudes. RESULTS: The response rate was 68.3% (529/775 eligible physicians). Recommended investigations were chosen by more than two thirds of the respondents for both scenarios. Referrals to physiotherapy, occupational therapy and rheumatology, all recommended by the panel, were chosen by 206 (38.9%), 72 (13.6%) and 309 (58.4%) physicians respectively for early rheumatoid arthritis. These proportions were significantly higher for late rheumatoid arthritis (p < 0.01). In multiple regression analysis, for early rheumatoid arthritis, internship or residency training in rheumatology was associated with higher investigation and intervention scores, for late rheumatoid arthritis, older physicians had higher intervention scores and female physicians had higher referral scores. CONCLUSIONS: Primary care physicians' investigation of rheumatoid arthritis was in accord with panel recommendations. However, rates of referral to rheumatologists and other health care professionals were very low, especially for the early presentation of rheumatoid arthritis. More exposure to rheumatology and to the role of physiotherapy, occupational therapy and social work during primary care training is strongly recommended.

Unmet service needs of children with rheumatic diseases and their parents in a metropolitan area.

OBJECTIVE: To identify perceived unmet service needs of children with rheumatic diseases and their parents in a metropolitan area in order to better plan and coordinate services. METHODS: A pretested questionnaire was sent to 327 families identified from the caseloads and mailing lists of local agencies and a parent support group. RESULTS: After 2 mailings and a telephone followup, 65.0% had responded, 34.4% with complete questionnaire data. The predominant diagnosis was juvenile rheumatoid arthritis (JRA), 58% of parents completing the questionnaire (children 45%) identified a need for additional services, most frequently education (newsletters/books) and teen support groups. Parents of male children selected more services. Problems in school, most commonly related to gym, mobility, and attendance, were reported by 45.5% of the school age children (by parents 49.1%). CONCLUSION: Services for children with rheumatic diseases need to address problems in school, the educational needs of parents and children, and the support needs of the teen group. These results will be used by the agencies involved to plan a more coordinated approach to care for these children.

Collaboration puts the ENB Higher Award into practice.

The ENB Framework for continuing professional education and Higher Award for nurses, midwives and health visitors was introduced in April 1992. The framework outlines 10 key characteristics to guide practitioners in the integration of theory and practice. This paper describes how a group of teachers and practitioners have applied the framework. They explain how it helps pull theoretical learning and practice together for practitioners. For educators, involvement with practitioners has helped them be more involved in practice. Three-way, or tripartite, tutorial work between the practitioner, the teacher and the facilitator in the clinical area is central to the success of this initiative.

Postpartum safety and satisfaction following early discharge.

Two Ontario sites were involved in the evaluation of an obstetrical discharge program. Before program implementation a group of eligible women were enrolled as the preprogram control group (n = 542). During the program, eligible women who agreed to early discharge (ED) became the ED group (n = 319), and those opting not to go home early but consenting to participate in the evaluation became the concurrent group (n = 456). All groups were mailed a self-administered postpartum questionnaire. On demographic characteristics, safety and satisfaction, the ED group was comparable to the concurrent group. Hospital readmission rates did not differ across groups after stratification by site or hospital. Multiple classification analyses revealed a similar pattern for overall satisfaction levels. This unique ED program, which allowed pre- or postnatal enrollment and did not require an initial home assessment, appears to be a safe, effective and flexible approach to obstetrical care.

Determinants of physician confidence in the primary care management of musculoskeletal disorders.

OBJECTIVE: To examine the determinants of confidence in managing musculoskeletal (MSK) disorders among primary care physicians. METHOD: A self-administered questionnaire was mailed to a stratified (by urban/rural location) random sample of 798 Ontario primary care physicians who were members of the College of Family Physicians of Canada. Two mailings and a reminder postcard were used to increase response. As the main outcome measure, confidence was measured on a 10 point Likert-type scale. RESULTS: The overall response rate was 68.3%. Most respondents were practising in a full time group setting; their average age was 40.3 years. Respondents were significantly more confident in performing a comprehensive cardiovascular examination than a MSK examination. Highest levels of confidence were observed for using nonsteroidal antiinflammatory drugs and managing common MSK disorders. Lower scores were reported for doing a joint injection/aspiration. Rural physicians were more confident than urban physicians in doing a joint injection/aspiration and monitoring patients who were taking disease modifying agents. Previous continuing medical education (CME) was significantly (p < 0.01) related to all confidence outcomes using multiple regression analysis. For many outcomes, men reported higher confidence scores than women after adjustment for various demographic characteristics. CONCLUSION: CME may be the most important and modifiable variable to improve physician management of MSK disorders.

The effects of dietary n-3/n-6 ratio on brain development in the mouse: a dose response study with long-chain n-3 fatty acids.

This study examines the effects of the ratio of n-3/n-6 fatty acids (FA) on brain development in mice when long-chain n-3 FA are supplied in the diet. From conception until 12 days after birth, B6D2F1 mice were fed liquid diets, each providing 10% of energy from olive oil, and a further 10% from different combinations of free FA concentrates derived from safflower oil (18:2n-6), and fish oil (20:5n-3 and 22:6n-3). The range of dietary n-3/n-6 ratios was 0, 0.25, 0.5, 1.0, 2.0 and 4.0, with an n-6 content of greater than 1.5% of energy in all diets, and similar levels of total polyunsaturated fatty acids (PUFA). In an additional group of ratio 0.5, 18:2n-6 was partially replaced by its delta 6 desaturation product, 18:3n-6. Biochemical analyses were conducted on 12-day-old pup brains, as well as on samples of maternal milk. No obvious effects on overall pup growth and development were observed, apart from a smaller litter size at ratio 1. Co-variance analysis indicated that increasing the n-3/n-6 ratio was associated with slightly smaller brains, relative to body weight. We found that 18:2n-6 and 20:5n-3 were the predominant n-6 and n-3 FA in the milk; in the brain these were 20:4n-6 and 22:6n-3, respectively. Increasing dietary n-3/n-6 ratios generally resulted in an increase in n-3 FA, with a corresponding decrease in n-6 FA.(ABSTRACT TRUNCATED AT 250 WORDS)

Toxigenic fungi in food.

Forty-five fungal isolates from moldy supermarket foods were tested for toxicity to brine shrimp, and twenty-two of these isolates were subsequently tested for toxicity to chicken embryos. Highly toxigenic fungi were Cladosporium sphaerospermum from a bakery product, Fusarium oxysporum from carrots, F. solani from cabbage, Aspergillus niger and Penicillium corylophilum from bread, P. cyclopium and P. herguei from corn meal, P. lanosum from onions,P. steckii from chocolate syrup, Penicillium sp. from jelly, and Rhizopus nigricans isolates from sweet potato, applesauce, and strawberries. Approximately one-third of the fungal cultures were moderately to highly toxigenic to brine shrimp and chicken embryos, while several additional cultures were slightly toxigenic.

Medium-scale production of citrinin by Penicillium citrinum in a semisynthetic medium.

A convenient method is described for the production of up to 1.75 g of citrinin per liter by Penicillium citrinum growing in stationary culture in a 5-gallon (18.925 liters) carboy containing 4 liters of 4% sucrose and 2% yeast extract medium.