Is it time to reconsider the use of vital teeth bleaching in children and adolescents in Europe?

PURPOSE: The aim of this study was to determine whether carbamide peroxide is effective in bleaching vital permanent teeth in children. METHODS: A literature search was conducted using all keywords relevant to the research subject. The outcome measures were identified as colour change, tooth sensitivity, oral irritation and patient satisfaction. The certainty of evidence for each outcome was assessed using the current GRADE guidelines. RESULTS: Of 115 potentially relevant articles, 112 were excluded, as they did not exclusively involve children, intervention involved additional treatment such as microabrasion or restorative work, or case studies. Patient satisfaction was not assessed in the three articles so no analysis could be made with regards to this outcome. The GRADE assessment showed that all of the three articles demonstrated very low certainty of evidence for the other assessed outcomes. The overall findings from the studies suggest that a 10% carbamide peroxide overnight tray system is effective at bleaching vital permanent teeth in children and associated tooth sensitivity and oral irritation are found to be in a similar range compared to those reported in adult studies. However, due to the very low certainty of the evidence, it is not possible to draw these conclusions. CONCLUSION: Better quality randomised controlled trials are needed to investigate the indication, short and long term effectiveness and side effects of carbamide teeth in vital permanent teeth in children.

Decision-making around admission to intensive care in the UK pre-COVID-19: a multicentre ethnographic study.

Predicting who will benefit from admission to an intensive care unit is not straightforward and admission processes vary. Our aim was to understand how decisions to admit or not are made. We observed 55 decision-making events in six NHS hospitals. We interviewed 30 referring and 43 intensive care doctors about these events. We describe the nature and context of the decision-making and analysed how doctors make intensive care admission decisions. Such decisions are complex with intrinsic uncertainty, often urgent and made with incomplete information. While doctors aspire to make patient-centred decisions, key challenges include: being overworked with lack of time; limited support from senior staff; and a lack of adequate staffing in other parts of the hospital that may be compromising patient safety. To reduce decision complexity, heuristic rules based on experience are often used to help think through the problem; for example, the patient's functional status or clinical gestalt. The intensive care doctors actively managed relationships with referring doctors; acted as the hospital generalist for acutely ill patients; and brought calm to crisis situations. However, they frequently failed to elicit values and preferences from patients or family members. They were rarely explicit in balancing burdens and benefits of intensive care for patients, so consistency and equity cannot be judged. The use of a framework for intensive care admission decisions that reminds doctors to seek patient or family views and encourages explicit balancing of burdens and benefits could improve decision-making. However, a supportive, adequately resourced context is also needed.

Educational weight loss interventions in obese and overweight adults with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials.

AIM: The worldwide prevalence of type 2 diabetes mellitus is increasing, with most individuals with the disease being overweight or obese. Weight loss can reduce disease-related morbidity and mortality and weight losses of 10-15 kg have been shown to reverse type 2 diabetes. This review aimed to determine the effectiveness of community-based educational interventions for weight loss in type 2 diabetes. METHODS: This is a systematic review and meta-analysis of randomized controlled trials (RCT) in obese or overweight adults, aged 18-75 years, with a diagnosis of type 2 diabetes. Primary outcomes were weight and/or BMI. CINAHL, MEDLINE, Embase, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to June 2019. Trials were classified into specified a priori comparisons according to intervention type. A pooled standardized mean difference (SMD) (from baseline to follow-up) and 95% confidence intervals (95% CI) between trial groups (difference-in-difference) were estimated through random-effects meta-analyses using the inverse variance method. Heterogeneity was quantified using I2 and publication bias was explored visually using funnel plots. RESULTS: Some 7383 records were screened; 228 full-text articles were assessed and 49 RCTs (n = 12 461 participants) were included in this review, with 44 being suitable for inclusion into the meta-analysis. Pooled estimates of education combined with low-calorie, low-carbohydrate meal replacements (SMD = -2.48, 95% CI -3.59, -1.49, I2  = 98%) or diets (SMD = -1.25, 95% CI -2.11, -0.39, I2  = 95%) or low-fat meal replacements (SMD = -1.15, 95%CI -2.05, -1.09, I2  = 85%) appeared most effective. CONCLUSION: Low-calorie, low-carbohydrate meal replacements or diets combined with education appear the most promising interventions to achieve the largest weight and BMI reductions in people with type 2 diabetes.

A process evaluation of the WHiTE Two trial comparing total hip arthroplasty with and without dual mobility component in the treatment of displaced intracapsular fractures of the proximal femur: Can a trial investigating total hip arthroplasty for hip fracture be delivered in the NHS?

OBJECTIVES: The annual incidence of hip fracture is 620 000 in the European Union. The cost of this clinical problem has been estimated at 1.75 million disability-adjusted life years lost, equating to 1.4% of the total healthcare burden in established market economies. Recent guidance from The National Institute for Health and Clinical Excellence (NICE) states that research into the clinical and cost effectiveness of total hip arthroplasty (THA) as a treatment for hip fracture is a priority. We asked the question: can a trial investigating THA for hip fracture currently be delivered in the NHS? METHODS: We performed a contemporaneous process evaluation that provides a context for the interpretation of the findings of WHiTE Two - a randomised study of THA for hip fracture. We developed a mixed methods approach to situate the trial centre within the context of wider United Kingdom clinical practice. We focused on fidelity, implementation, acceptability and feasibility of both the trial processes and interventions to stakeholder groups, such as healthcare providers and patients. RESULTS: We have shown that patients are willing to participate in this type of research and that surgeons value being part of a team that has a strong research ethos. However, surgical practice does not currently reflect NICE guidance. Current models of service delivery for hip fractures are unlikely to be able to provide timely total hip arthroplasty for suitable patients. CONCLUSIONS: Further observational research should be conducted to define the population of interest before future interventional studies are performed.Cite this article: C. Huxley, J. Achten, M. L. Costa, F. Griffiths, X. L. Griffin. A process evaluation of the WHiTE Two trial comparing total hip artroplasty with and without dual mobility component in the treatment of displaced intracapsular fractures of the proximal femur: Can a trial investigating total hip arthroplasty for hip fracture be delivered in the NHS? Bone Joint Res 2016;5:444-452. DOI: 10.1302/2046-3758.510.BJR-2015-0008.R1.

Evaluation of recruitment methods for a trial targeting childhood obesity: Families for Health randomised controlled trial.

BACKGROUND: Recruitment to trials evaluating the effectiveness of childhood obesity management interventions is challenging. We report our experience of recruitment to the Families for Health study, a randomised controlled trial evaluating the effectiveness of a family-based community programme for children aged 6-11 years, versus usual care. We evaluated the effectiveness of active recruitment (contacting eligible families directly) versus passive recruitment (informing the community through flyers, public events, media). METHODS: Initial approaches included passive recruitment via the media (newspapers and radio) and two active recruitment methods: National Child Measurement Programme (letters to families with overweight children) and referrals from health-care professionals. With slow initial recruitment, further strategies were employed, including active (e.g. targeted letters from general practices) and passive (e.g. flyers, posters and public events) methods. At first enquiry from a potential participant, families were asked where they heard about the study. Further quantitative (questionnaire) and qualitative data (one-to-one interviews with parents/carers), were collected from recruited families at baseline and 3-month follow-up and included questions about recruitment. RESULTS: In total, 194 families enquired about Families for Health, and 115 (59.3 %) were recruited and randomised. Active recruitment yielded 85 enquiries, with 43 families recruited (50.6 %); passive recruitment yielded 99 enquiries with 72 families recruited (72.7 %). Information seen at schools or GP surgeries accounted for over a quarter of enquiries (28.4 %) and over a third (37.4 %) of final recruitment. Eight out of ten families who enquired this way were recruited. Media-led enquiries were low (5 %), but all were recruited. Children of families recruited actively were more likely to be Asian or mixed race. Despite extensive recruitment methods, the trial did not recruit as planned, and was awarded a no-cost extension to complete the 12-month follow-up. CONCLUSIONS: The higher number of participants recruited through passive methods may be due to the large number of potential participants these methods reached and because participants may see the information more than once. Recruiting to a child obesity treatment study is complex and it is advisable to use multiple recruitment strategies, some aiming at blanket coverage and some targeted at families with children who are overweight. TRIAL REGISTRATION: Current Controlled Trials ISRCTN45032201 (Date: 18 August 2011).

Spreading of healthy mood in adolescent social networks.

Depression is a major public health concern worldwide. There is evidence that social support and befriending influence mental health, and an improved understanding of the social processes that drive depression has the potential to bring significant public health benefits. We investigate transmission of mood on a social network of adolescents, allowing flexibility in our model by making no prior assumption as to whether it is low mood or healthy mood that spreads. Here, we show that while depression does not spread, healthy mood among friends is associated with significantly reduced risk of developing and increased chance of recovering from depression. We found that this spreading of healthy mood can be captured using a non-linear complex contagion model. Having sufficient friends with healthy mood can halve the probability of developing, or double the probability of recovering from, depression over a 6-12-month period on an adolescent social network. Our results suggest that promotion of friendship between adolescents can reduce both incidence and prevalence of depression.

Response of phytoplankton photophysiology to varying environmental conditions in the Sub-Antarctic and Polar Frontal Zone.

Climate-driven changes are expected to alter the hydrography of the Sub-Antarctic Zone (SAZ) and Polar Frontal Zone (PFZ) south of Australia, in which distinct regional environments are believed to be responsible for the differences in phytoplankton biomass in these regions. Here, we report how the dynamic influences of light, iron and temperature, which are responsible for the photophysiological differences between phytoplankton in the SAZ and PFZ, contribute to the biomass differences in these regions. High effective photochemical efficiency of photosystem II (F'(q)/F'(m)0.4), maximum photosynthesis rate (P(B)(max)), light-saturation intensity (E(k)), maximum rate of photosynthetic electron transport (1/[Symbol: see text]PSII), and low photoprotective pigment concentrations observed in the SAZ correspond to high chlorophyll a and iron concentrations. In contrast, phytoplankton in the PFZ exhibits low F'(q)/F'(M) (~ 0.2) and high concentrations of photoprotective pigments under low light environment. Strong negative relationships between iron, temperature, and photoprotective pigments demonstrate that cells were producing more photoprotective pigments under low temperature and iron conditions, and are responsible for the low biomass and low productivity measured in the PFZ. As warming and enhanced iron input is expected in this region, this could probably increase phytoplankton photosynthesis in this region. However, complex interactions between the biogeochemical processes (e.g. stratification caused by warming could prevent mixing of nutrients), which control phytoplankton biomass and productivity, remain uncertain.

Characterisation of linear predictability and non-stationarity of subcutaneous glucose profiles.

Continuous glucose monitoring is increasingly used in the management of diabetes. Subcutaneous glucose profiles are characterised by a strong non-stationarity, which limits the application of correlation-spectral analysis. We derived an index of linear predictability by calculating the autocorrelation function of time series increments and applied detrended fluctuation analysis to assess the non-stationarity of the profiles. Time series from volunteers with both type 1 and type 2 diabetes and from control subjects were analysed. The results suggest that in control subjects, blood glucose variation is relatively uncorrelated, and this variation could be modelled as a random walk with no retention of 'memory' of previous values. In diabetes, variation is both greater and smoother, with retention of inter-dependence between neighbouring values. Essential components for adequate longer term prediction were identified via a decomposition of time series into a slow trend and responses to external stimuli. Implications for diabetes management are discussed.

The Warwick Hip Trauma Evaluation - an abridged protocol for the WHiTE Study: A multiple embedded randomised controlled trial cohort study.

Fractures of the proximal femur are one of the greatest challenges facing the medical community, constituting a heavy socioeconomic burden worldwide. The National Hip Fracture Audit currently provides a framework for service evaluation. This evaluation is based upon the assessment of process rather than assessment of patient-centred outcome and therefore it fails to provide meaningful data regarding the clinical effectiveness of treatments. This study aims to capture data from the cohort of patients who present with a fracture of the proximal femur at a single United Kingdom Major Trauma Centre. Patient-centred outcomes will be recorded and provide a baseline cohort within which to test the clinical effectiveness of experimental interventions.

A multicentred randomised controlled trial of a primary care-based cognitive behavioural programme for low back pain. The Back Skills Training (BeST) trial.

OBJECTIVES: To estimate the clinical effectiveness of active management (AM) in general practice versus AM plus a group-based, professionally led cognitive behavioural approach (CBA) for subacute and chronic low back pain (LBP) and to measure the cost of each strategy over a period of 12 months and estimate cost-effectiveness. DESIGN: Pragmatic multicentred randomised controlled trial with investigator-blinded assessment of outcomes. SETTING: Fifty-six general practices from seven English regions. PARTICIPANTS: People with subacute and chronic LBP who were experiencing symptoms that were at least moderately troublesome. INTERVENTIONS: Participants were randomised (in a ratio of 2:1) to receive either AM+CBA or AM alone. MAIN OUTCOME MEASURES: Primary outcomes were the Roland Morris Disability Questionnaire (RMQ) and the Modified Von Korff Scale (MVK), which measure LBP and disability. Secondary outcomes included mental and physical health-related quality of life (Short Form 12-item health survey), health status, fear avoidance beliefs and pain self-efficacy. Cost-utility of CBA was considered from both the UK NHS perspective and a broader health-care perspective, including both NHS costs and costs of privately purchased goods and services related to LBP. Quality-adjusted life-years (QALYs) were calculated from the five-item EuroQoL. RESULTS: Between April 2005 and April 2007, 701 participants were randomised: 233 to AM and 468 to AM+CBA. Of these, 420 were female. The mean age of participants was 54 years and mean baseline RMQ was 8.7. Outcome data were obtained for 85% of participants at 12 months. Benefits were seen across a range of outcome measures in favour of CBA with no evidence of group or therapist effects. CBA resulted in at least twice as much improvement as AM. Mean additional improvement in the CBA arm was 1.1 [95% confidence interval (CI) 0.4 to 1.7], 1.4 (95% CI 0.7 to 2.1) and 1.3 (95% CI 0.6 to 2.1) change points in the RMQ at 3, 6 and 12 months respectively. Additional improvement in MVK pain was 6.8 (95% CI 3.5 to 10.2), 8.0 (95% CI 4.3 to 11.7) and 7.0 (95% CI 3.2 to 10.7) points, and in MVK disability was 4.3 (95% CI 0.4 to 8.2), 8.1 (95% CI 4.1 to 12.0) and 8.4 (95% CI 4.4 to 12.4) points at 3, 6 and 12 months respectively. At 12 months, 60% of the AM+CBA arm and 31% of the AM arm reported some or complete recovery. Mean cost of attending a CBA course was 187 pounds per participant with an additional benefit in QALYs of 0.099 and an additional cost of 178.06 pounds. Incremental cost-effectiveness ratio was 1786.00 pounds. Probability of CBA being cost-effective reached 90% at about 3000 pounds and remained at that level or above; at a cost-effectiveness threshold of 20,000 pounds the CBA group had an almost 100% probability of being considered cost-effective. User perspectives on the acceptability of group treatments were sought through semi-structured interviews. Most were familiar with key messages of AM; most who had attended any group sessions had retained key messages from the sessions and two-thirds talked about a reduction in fear avoidance and changes in their behaviour. Group sessions appeared to provide reassurance, lessen isolation and enable participants to learn strategies from each other. CONCLUSIONS: Long-term effectiveness and cost-effectiveness of CBA in treating subacute and chronic LBP was shown, making this intervention attractive to patients, clinicians and purchasers. Short-term (3-month) clinical effects were similar to those found in high-quality studies of other therapies and benefits were maintained and increased over the long term (12 months). Cost per QALY was about half that of competing interventions for LBP and because the intervention can be delivered by existing NHS staff following brief training, the back skills training programme could be implemented within the NHS with relative ease. TRIAL REGISTRATION: Current Controlled Trials ISRCTN37807450. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Effects of the Diabetes Manual 1:1 structured education in primary care.

AIMS: To determine the effects of the Diabetes Manual on glycaemic control, diabetes-related distress and confidence to self-care of patients with Type 2 diabetes. METHODS: A cluster randomized, controlled trial of an intervention group vs. a 6-month delayed-intervention control group with a nested qualitative study. Participants were 48 urban general practices in the West Midlands, UK, with high population deprivation levels and 245 adults with Type 2 diabetes with a mean age of 62 years recruited pre-randomization. The Diabetes Manual is 1:1 structured education designed for delivery by practice nurses. Measured outcomes were HbA(1c), cardiovascular risk factors, diabetes-related distress measured by the Problem Areas in Diabetes Scale and confidence to self-care measured by the Diabetes Management Self-Efficacy Scale. Outcomes were assessed at baseline and 26 weeks. RESULTS: There was no significant difference in HbA(1c) between the intervention group and the control group [difference -0.08%, 95% confidence interval (CI) -0.28, 0.11]. Diabetes-related distress scores were lower in the intervention group compared with the control group (difference -4.5, 95% CI -8.1, -1.0). Confidence to self-care Scores were 11.2 points higher (95% CI 4.4, 18.0) in the intervention group compared with the control group. The patient response rate was 18.5%. CONCLUSIONS: In this population, the Diabetes Manual achieved a small improvement in patient diabetes-related distress and confidence to self-care over 26 weeks, without a change in glycaemic control. Further study is needed to optimize the intervention and characterize those for whom it is more clinically and psychologically effective to support its use in primary care.

Lipid content determines aggregation of neuromelanin granules in vitro.

The neuromelanin pigment of the substantia nigra of the human brain is closely associated with lipids and other non-melanogenic compounds which appear to contribute to the unique and complex morphology of neuromelanin pigment granules. In this work we show that insoluble granules isolated from the human substantia nigra associate in vitro to form pigment aggregates similar to those present in the human brain. Extraction of neuromelanin-associated polar lipids by methanol and/or hexane significantly enhanced melanin aggregate size. A marked (10-fold) increase in granule size was seen after methanol treatment, whereas the application of hexane after methanol reduced this pro-aggregation effect. We have previously reported that hexane and methanol remove the neuromelanin-associated polyisoprenoids dolichol and cholesterol respectively. Thus, the current data suggests that pigment-associated lipids may be a factor regulating pigment aggregation and neuromelanin granule size in vivo.

Health professionals, their medical interventions and uncertainty: a study focusing on women at midlife.

Health professionals face a tension between focusing on the individual and attending to health issues for the population as a whole. This tension is intrinsic to medicine and gives rise to medical uncertainty, which here is explored through accounts of three medical interventions focused on women at midlife: breast screening, hormone replacement therapy and bone densitometry. The accounts come from interviews with UK health professionals using these medical interventions in their daily work. Drawing on the analysis of Fox [(2002). Health and Healing: The public/private divide (pp. 236-253). London: Routledge] we distinguish three aspects of medical uncertainty and explore each one of them in relation to one of the interventions. First is uncertainty about the balance between the individual and distributive ethic of medicine, explored in relation to breast screening. Second is the dilemma faced by health professionals when using medical evidence generated through studies of populations and applying this to individuals. We explore this dilemma for hormone replacement therapy. Thirdly there is uncertainty because of the lack of a conceptual framework for understanding how new micro knowledge, such as human genetic information, can be combined with knowledge of other biological and social dimensions of health. The accounts from the bone denistometry clinic indicate the beginnings of an understanding of the need for such a framework, which would acknowledge complexity, recognising that factors from many different levels of analysis, from heredity through to social factors, interact with each other and influence the individual and their health. However, our analysis suggests biomedicine continues to be dominated by an individualised, context free, concept of health and health risk with individuals alone responsible for their own health and for the health of the population. This may continue to dominate how we perceive responsibilities for health until we establish a conceptual framework that recognises the complex interaction of many factors at macro and micro level affecting health.

A critical analysis of the literature on the Internet and consumer health information.

A critical review of the published literature investigating the Internet and consumer health information was undertaken in order to inform further research and policy. A qualitative, narrative method was used, consisting of a three-stage process of identification and collation, thematic coding, and critical analysis. This analysis identified five main themes in the research in this area: (1) the quality of online health information for consumers; (2) consumer use of the Internet for health information; (3) the effect of e-health on the practitioner-patient relationship; (4) virtual communities and online social support and (5) the electronic delivery of information-based interventions. Analysis of these themes revealed more about the concerns of health professionals than about the effect of the Internet on users. Much of the existing work has concentrated on quantifying characteristics of the Internet: for example, measuring the quality of online information, or describing the numbers of users in different health-care settings. There is a lack of qualitative research that explores how citizens are actually using the Internet for health care.

Setting priorities and identifying barriers for general practice research in Europe. Results from an EGPRW meeting.

BACKGROUND: In spring 2002, WONCA Europe, the European Society of General Practice/Family Medicine and its Network organizations reached consensus on a 'new' European definition of general practice. Subsequently, the European General Practice Research Workshop (EGPRW) started working on a European General Practice Research Agenda. This topic was addressed during the 2002 EGPRW autumn meeting. OBJECTIVE: Our aim was to explore the views of European general practice researchers on needs and priorities as well as barriers for general practice research in Europe. METHODS: In seven discussion groups, 43 general practice researchers from 18 European countries had to answer the following questions. (i) What major topics should be included in a research agenda for general practice in your country? (ii) What are the barriers to adequate implementation of general practice research in your country? Group answers were listed and subsequently categorized by two authors. RESULTS: Research on 'clinical issues' (common diseases, chronic diseases, etc.), including diagnostic strategies, was considered to be the core content of general practice research, with primary care-based morbidity registration essential for surveillance of disease, clinical research and teaching in general practice. There was also consensus on the need for research on education and teaching. 'Insufficient funding opportunities' was perceived to be the major barrier to the development of general practice research. CONCLUSIONS: These findings could be used as a basis for national checklists of 'content of' and 'conditions for' general practice research. European general practice research training programmes should be developed further.

The dopamine receptor agonist lisuride attenuates iron-mediated dopaminergic neurodegeneration.

Many dopamine agonists used in the treatment of Parkinson's disease are suggested to be potentially neuroprotective. On the basis of its structure, the dopamine agonist lisuride may share this characteristic. In the current study discrete asymptomatic lesions were produced by the injection of iron-laden neuromelanin into the rat substantia nigra and the animals treated with lisuride to determine the protective potential of this substance. Two treatment regimes were utilised. In the neuroprotective protocol, animals were treated with 0.1 mg.kg(-1) lisuride twice daily 3 days prior to, and 7 days following, the iron lesion. In the neurorescue protocol, the animals received 0.1 mg.kg(-1) lisuride twice daily for 1 week beginning on the fourth day post surgery. Eight weeks post surgery, tyrosine hydroxylase-positive neurons surrounding the injection site (33% of total nigral volume) were counted. Dopamine neuron number in iron-lesioned animals was reduced to 50% of that in vehicle-injected animals. The absence of motoric disturbances or a striatal dopamine deficit in these animals suggests a subclinical dopaminergic lesion. Dopamine neuron number in the quantified area in sham-injected animals receiving lisuride or iron-lesioned animals receiving lisuride in both the neuroprotection and neurorescue groups were not significantly reduced. These results suggest that lisuride can protect neurons against iron-induced cell death and might thus be neuroprotective in Parkinson's disease.

Reflections from organization science on the development of primary health care research networks.

In the UK, policy changes in primary health care research and development have led to the establishment of primary care research networks. These organizations aim to increase research culture, capacity and evidence base in primary care. As publicly funded bodies, these networks need to be accountable. Organizational science has studied network organizations including why and how they develop and how they function most effectively. This paper draws on organizational science to reflect on why primary care research networks appear to be appropriate for primary care research and how their structures and processes can best enable the achievement of their aims.