The effect of machine learning tools for evidence synthesis on resource use and time-to-completion: protocol for a retrospective pilot study.

BACKGROUND: Machine learning (ML) tools exist that can reduce or replace human activities in repetitive or complex tasks. Yet, ML is underutilized within evidence synthesis, despite the steadily growing rate of primary study publication and the need to periodically update reviews to reflect new evidence. Underutilization may be partially explained by a paucity of evidence on how ML tools can reduce resource use and time-to-completion of reviews. METHODS: This protocol describes how we will answer two research questions using a retrospective study design: Is there a difference in resources used to produce reviews using recommended ML versus not using ML, and is there a difference in time-to-completion? We will also compare recommended ML use to non-recommended ML use that merely adds ML use to existing procedures. We will retrospectively include all reviews conducted at our institute from 1 August 2020, corresponding to the commission of the first review in our institute that used ML. CONCLUSION: The results of this study will allow us to quantitatively estimate the effect of ML adoption on resource use and time-to-completion, providing our organization and others with better information to make high-level organizational decisions about ML.

Automating risk of bias assessment in systematic reviews: a real-time mixed methods comparison of human researchers to a machine learning system.

BACKGROUND: Machine learning and automation are increasingly used to make the evidence synthesis process faster and more responsive to policymakers' needs. In systematic reviews of randomized controlled trials (RCTs), risk of bias assessment is a resource-intensive task that typically requires two trained reviewers. One function of RobotReviewer, an off-the-shelf machine learning system, is an automated risk of bias assessment. METHODS: We assessed the feasibility of adopting RobotReviewer within a national public health institute using a randomized, real-time, user-centered study. The study included 26 RCTs and six reviewers from two projects examining health and social interventions. We randomized these studies to one of two RobotReviewer platforms. We operationalized feasibility as accuracy, time use, and reviewer acceptability. We measured accuracy by the number of corrections made by human reviewers (either to automated assessments or another human reviewer's assessments). We explored acceptability through group discussions and individual email responses after presenting the quantitative results. RESULTS: Reviewers were equally likely to accept judgment by RobotReviewer as each other's judgement during the consensus process when measured dichotomously; risk ratio 1.02 (95% CI 0.92 to 1.13; p = 0.33). We were not able to compare time use. The acceptability of the program by researchers was mixed. Less experienced reviewers were generally more positive, and they saw more benefits and were able to use the tool more flexibly. Reviewers positioned human input and human-to-human interaction as superior to even a semi-automation of this process. CONCLUSION: Despite being presented with evidence of RobotReviewer's equal performance to humans, participating reviewers were not interested in modifying standard procedures to include automation. If further studies confirm equal accuracy and reduced time compared to manual practices, we suggest that the benefits of RobotReviewer may support its future implementation as one of two assessors, despite reviewer ambivalence. Future research should study barriers to adopting automated tools and how highly educated and experienced researchers can adapt to a job market that is increasingly challenged by new technologies.

Can Remote Patient Monitoring Be the New Standard in Primary Care of Chronic Diseases, Post-COVID-19?

Background: One lesson from the current COVID-19 pandemic is the need to optimize health care provision outside of traditional settings, and potentially over longer periods of time. An important strategy is remote patient monitoring (RPM), allowing patients to remain at home, while they transmit health data and receive follow-up services. Materials and Methods: We conducted an overview of the latest systematic reviews that had included randomized controlled trials with adult patients with chronic diseases. We summarized results and displayed these in forest plots, and used GRADE (Grading of Recommendations Assessment, Development, and Evaluation) to assess our certainty of the evidence. Results: We included 4 systematic reviews that together reported on 11 trials that met our definition of RPM, each including patients with diabetes and/or hypertension. RPM probably makes little to no difference on HbA1c levels. RPM probably leads to a slight reduction in systolic blood pressure, with questionable clinical meaningfulness. RPM probably has a small negative effect on the physical component of health-related quality of life, but the clinical significance of this reduction is uncertain. We have low confidence in the finding that RPM makes no difference to the remaining five primary outcomes. Conclusion: Most of our findings are consistent with reviews of other, broader definitions of RPM. The type of RPM examined in this review is as effective as standard treatment for patients with diabetes/hypertension. If this or other types of RPM are to be used for "long covid" patients or for other chronic disease groups post-pandemic, we need to understand why RPM may negatively affect quality of life.

Machine learning in systematic reviews: Comparing automated text clustering with Lingo3G and human researcher categorization in a rapid review.

Systematic reviews are resource-intensive. The machine learning tools being developed mostly focus on the study identification process, but tools to assist in analysis and categorization are also needed. One possibility is to use unsupervised automatic text clustering, in which each study is automatically assigned to one or more meaningful clusters. Our main aim was to assess the usefulness of an automated clustering method, Lingo3G, in categorizing studies in a simplified rapid review, then compare performance (precision and recall) of this method compared to manual categorization. We randomly assigned all 128 studies in a review to be coded by a human researcher blinded to cluster assignment (mimicking two independent researchers) or by a human researcher non-blinded to cluster assignment (mimicking one researcher checking another's work). We compared time use, precision and recall of manual categorization versus automated clustering. Automated clustering and manual categorization organized studies by population and intervention/context. Automated clustering failed to identify two manually identified categories but identified one additional category not identified by the human researcher. We estimate that automated clustering has similar precision to both blinded and non-blinded researchers (e.g., 88% vs. 89%), but higher recall (e.g., 89% vs. 84%). Manual categorization required 49% more time than automated clustering. Using a specific clustering algorithm, automated clustering can be helpful with categorization of and identifying patterns across studies in simpler systematic reviews. We found that the clustering was sensitive enough to group studies according to linguistic differences that often corresponded to the manual categories.

Effects of cervical restorations on the periodontal tissues: 5-year follow-up results of a randomized clinical trial.

OBJECTIVE: This study evaluated the effect of resin composite restorations of non-carious cervical lesions (NCCLs) on the occurrence/progression of gingival recession (GR), considering different tooth isolation techniques. METHODS: A randomized controlled split-mouth and blinded trial was carried out. Patients (n = 38) with at least two NCCLs were included. Before the cervical restoration placement, the NCCLs (181 teeth) were randomly allocated into two treatment groups according to the tooth isolation techniques: cotton roll or rubber dam. Experienced, trained, blinded, and calibrated examiners performed periodontal evaluations at baseline and 5-year follow-up, using a periodontal probe. Restorations were assessed with the FDI criteria. Thirty-two patients (154 teeth) were evaluated at 5 years. The occurrence/progression of GR between baseline and follow-up was considered the primary outcome. The relative risk (RR) and 95 % confidence interval (95 %CI) were calculated by Poisson regression (α < 0.05). RESULTS: After 5 year, 31 teeth (13.6 %) presented occurrence/progression of GR. In the multivariate analyses, the occurrence/progression of GR was associated with the use of rubber dam isolation (RR; 95 %CI: 2.65; 1.01-7.00) and a lack of marginal adaptation of the restoration (RR; 95 %CI: 10.98; 2.31-52.30). Toothbrush stiffness, use of abrasive dentifrice, tooth type, and the presence of biofilm or gingivitis did not present a statistically significant higher risk for occurrence/progression of GR. CONCLUSION: The use of rubber dam isolation associated with retraction clamp and the lack of a proper marginal adaptation of the composite restorations are risk indicators for the occurrence/progression of GR in individuals who received a restoration for an NCCL. CLINICAL SIGNIFICANCE: Isolation with a rubber dam and dental clamps may promote GR in sites with restored NCCLs. Moreover, clinical examinations for lack of marginal adaptations of the restorations may be included in a clinical setting.

Cytotoxicity of contemporary resin-based dental materials in contact with dentin.

In this study, the cytotoxicity of different combinations of contemporary resin-based restoratives (adhesives, composites, luting agents) against human keratinocytes (HaCaT) was evaluated under two conditions, whether materials were applied to dentin or not. Adhesives (3-step etch-and-rinse/3ER: OptiBond FL; 2-step self-etch/2SE Clearfil SE Bond; Single Bond Universal/UNI), composites (conventional composite resin/CCR: Filtek Z350XT; flowable/FCR: Filtek Z350XT Flow; self-adhesive composite resin/SACR: Dyad Flow), and luting agents (conventional luting agent/CLA: Variolink-II; self-adhesive luting agent/SLA: RelyXU200) were combined according to their clinical use. Eluates from polymerized specimens applied to dentin were placed in contact with cells grown for 1 and 7 d. The controls were defined by cells without material contact. Cell viability was determined using MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide)] assay. C=C conversion was investigated using Fourier-transform infrared spectroscopy. After 1 d of incubation, when dentin was not present, 2SE yielded the highest cell viability, whereas 3ER, UNI, and SACR showed higher cell viability in the presence of dentin. After 7 d, when dentin was absent, 2SE and CLA achieved significantly higher cell viability. The presence of dentin resulted in a drastically higher cell viability for all materials, except 2SE and CLA. UNI had the lowest C=C conversion. The presence of dentin was a significant factor, which resulted in higher cell viability than what was seen for the material specimens per se. All materials resulted in a lower viability of HaCaT than what was seen under the no-material control conditions, with effects mainly limited to the first 24 h.

Methods and Measures Used to Evaluate Patient-Operated Mobile Health Interventions: Scoping Literature Review.

BACKGROUND: Despite the prevalence of mobile health (mHealth) technologies and observations of their impacts on patients' health, there is still no consensus on how best to evaluate these tools for patient self-management of chronic conditions. Researchers currently do not have guidelines on which qualitative or quantitative factors to measure or how to gather these reliable data. OBJECTIVE: This study aimed to document the methods and both qualitative and quantitative measures used to assess mHealth apps and systems intended for use by patients for the self-management of chronic noncommunicable diseases. METHODS: A scoping review was performed, and PubMed, MEDLINE, Google Scholar, and ProQuest Research Library were searched for literature published in English between January 1, 2015, and January 18, 2019. Search terms included combinations of the description of the intention of the intervention (eg, self-efficacy and self-management) and description of the intervention platform (eg, mobile app and sensor). Article selection was based on whether the intervention described a patient with a chronic noncommunicable disease as the primary user of a tool or system that would always be available for self-management. The extracted data included study design, health conditions, participants, intervention type (app or system), methods used, and measured qualitative and quantitative data. RESULTS: A total of 31 studies met the eligibility criteria. Studies were classified as either those that evaluated mHealth apps (ie, single devices; n=15) or mHealth systems (ie, more than one tool; n=17), and one study evaluated both apps and systems. App interventions mainly targeted mental health conditions (including Post-Traumatic Stress Disorder), followed by diabetes and cardiovascular and heart diseases; among the 17 studies that described mHealth systems, most involved patients diagnosed with cardiovascular and heart disease, followed by diabetes, respiratory disease, mental health conditions, cancer, and multiple illnesses. The most common evaluation method was collection of usage logs (n=21), followed by standardized questionnaires (n=18) and ad-hoc questionnaires (n=13). The most common measure was app interaction (n=19), followed by usability/feasibility (n=17) and patient-reported health data via the app (n=15). CONCLUSIONS: This review demonstrates that health intervention studies are taking advantage of the additional resources that mHealth technologies provide. As mHealth technologies become more prevalent, the call for evidence includes the impacts on patients' self-efficacy and engagement, in addition to traditional measures. However, considering the unstructured data forms, diverse use, and various platforms of mHealth, it can be challenging to select the right methods and measures to evaluate mHealth technologies. The inclusion of app usage logs, patient-involved methods, and other approaches to determine the impact of mHealth is an important step forward in health intervention research. We hope that this overview will become a catalogue of the possible ways in which mHealth has been and can be integrated into research practice.

Bond Stability of Universal Adhesives Applied To Dentin Using Etch-And-Rinse or Self-Etch Strategies.

This study evaluated the immediate and 6-month dentin bond strength of universal adhesives used in etch-and-rinse or self-etch bonding strategies. The adhesives tested were Ambar Universal, G-Bond, Single Bond Universal, Tetric N-Bond Universal, and Ybond Universal. Gold standard adhesives (Scotchbond Multipurpose Plus and Clearfil SE Bond) were controls. Microtensile dentin bond strength (n=5 teeth), pH, and C=C conversion (n=3) were evaluated. Data were analyzed at α=0.05. All adhesives showed differences in pH. Ybond had intermediately strong aggressiveness, whereas the others were ultra-mild. The C=C conversion was different in most adhesives. In the etch-and-rinse strategy, all adhesives showed similar results generally except for G-Bond, which had lower bond strength than most adhesives. G-Bond and Tetric-N-Bond showed lower bond strengths after 6 months compared with 24 h, whereas the other adhesives had stable dentin bonds. In the self-etch strategy, G-Bond had lower bond strength than most adhesives. After 6 months, Ambar was the only adhesive showing lower dentin bond strength compared with 24 h. Most adhesives had discreet drops in bond strength during aging when used in the self-etch strategy. The failure modes were also material dependent, with a general pattern of increased adhesive and/or pre-testing failures after storage. In conclusion, the bonding performance of universal adhesives to dentin is material dependent. Most adhesives had stable dentin bonds with results comparable to the gold standard materials, particularly when applied in the self-etch mode. In general, it seems the use of universal adhesives in dentin should not be preceded by phosphoric acid etching.

Reabilitação oral estética com laminados cerâmicos ultrafinos / Aesthetic oral rehabilitation with ultrathin ceramic veneers

A utilização de laminados cerâmicos ultrafinos nas reabilitações orais estéticas tem-se tornado uma opção de tratamento cada vez mais popular. Entretanto não há elevado nível de evidência científica quanto à longevidade dessas restaurações. Com base nisso, o objetivo do presente artigo é relatar a instalação de laminados cerâmicos ultrafinos na bateria labial superior de uma paciente com queixa de insatisfação estética do sorriso após ter finalizado um tratamento ortodôntico, destacando aspectos relacionados ao diagnóstico, ao planejamento do caso e ao preparo dentário...

The use of ultrathin ceramic veneers for the aesthetic oral rehabilitation has become an increasingly popular treatment. However, there is few high-quality scientific evidence regarding the longevity of these restorations. Based on this fact, the purpose of this study is to report a clinical case of ultra-thin ceramic veneers in the maxillary teeth of a patient unsatisfied with her smile after the end of the orthodontic treatment, highlighting aspects related to diagnosis, treatment planning and tooth preparation...

Influence of filling technique and bevel preparation on marginal sealing of conventional and low shrinkage composite restorations

AIM: The aim of this study was to evaluate two composite restorations (conventional methacrylate-based and low shrinkage-based silorane), associated or not to beveling and incremental technique, in relation to the microleakage and marginal gap formation tests. MATERIAL AND METHODS: 30 sound human molars had their mesial and distal surfaces prepared with and without bevel. The teeth were divided into six groups according to the type of resin (conventional nanofilled or silorane resin), and restorative filling technique (incremental technique or builk). Microleakage and marginal gap formation data were statistically analyzed by Kruskal-Wallis and Chi-Square tests, with a significance level set at 5%. RESULTS: Group 1 (Z350 XT, without bevel, incremental technique) presented highest rate of microleakage and marginal gap in most of the restorations, with statistically significant differences. Groups 4 and 6 (P90, beveled, builk and P90, beveled and incremental technique) had lower rates of microleakage and absence of marginal gaps in most of the restorations. CONCLUSION: It's concluded that the silorane showed lower rates of marginal gaps and microleakage, when compared to the conventional methacrylate-based resin. Bevel preparation was effective in reducing microleakage and marginal gaps for both resins used. Incremental technique was not necessary when associated with low shrinkage composite resin.

Forensic evaluation in alleged sibling incest against children.

Sibling incest is a serious form of intrafamilial sexual abuse with health, social, and legal relevance. A retrospective study was conducted through the analysis of forensic medical reports of the alleged sibling incest of victims under 18 years old (n = 68) from 2004 to 2011 as well as the respective judicial outcomes. Results demonstrated that sibling's sexual abuse is associated with several circumstances that might exacerbate its severity such as vaginal, anal, and/or oral penetration. Moreover, the victim's young age, the proximity between victim and abuser, and the fact that it is committed at the victim's and/or abuser's home and by using physical violence and verbal threats justify a late detection of these cases.

Alleged biological father incest: a forensic approach.

Paternal incest is one of the most serious forms of intrafamilial sexual abuse with clinical, social, and legal relevance. A retrospective study was performed, based on forensic reports and judicial decisions of alleged cases of biological paternal incest of victims under 18 years old (n = 215) from 2003 to 2008. Results highlight that in a relevant number of cases: victims were female; the abuse begun at an early age with reiteration; the alleged perpetrator presented a history of sexual crimes against children; sexual practices were physically poorly intrusive, which associated with a forensic medical evaluation performed more than 72 h after the abuse, explain partially the absence of physical injuries or other evidence-these last aspects are different from extrafamilial cases. In conclusion, observations about paternal incest are likely to exacerbate the psychosocial consequences of the abuse and may explain the difficulty and delay in detect and disclose these cases. Few cases were legally prosecuted and convicted.

Are there universal restorative composites for anterior and posterior teeth?

OBJECTIVE: This retrospective, longitudinal clinical study investigated the longevity up to 20 years of posterior restorations placed with 3 universal composites (Charisma, Herculite XR, Z100) and of anterior restorations placed with 2 universal composites (Charisma, Herculite XR). METHODS: Records from 90 patients were retrieved from a private practice (374 posterior, 219 anterior restorations). Clinical evaluation was performed by the FDI criteria. Survival analysis was assessed using Kaplan-Meier method and Log-Rank test, and factors associated with failure by multivariate Cox regression with shared frailty. RESULTS: In the first 10 years, almost 95% of the restorations were satisfactory, showing increased failure thereafter. Charisma showed the most failures in anterior and posterior areas. Annual failure rates varied between 0.3% and 2.5%, with slightly better performance for anterior restorations. Fracture (posterior) and aesthetics (anterior) were the main reasons for failure. CLINICAL SIGNIFICANCE: Differences were observed between restorative materials with different properties, but these became apparent only after more than 10 years of clinical service. The present study provides evidence that in a patient group with low caries risk, anterior and posterior restorations placed with universal composites may have excellent long-term clinical performance.

Chemical cleaning agents and bonding to glass-fiber posts

The influence of chemical cleaning agents on the bond strength between resin cement and glass-fiber posts was investigated. The treatments included 10% hydrofluoric acid, 35% phosphoric acid, 50% hydrogen peroxide, acetone, dichloromethane, ethanol, isopropanol, and tetrahydrofuran. Flat glass-fiber epoxy substrates were exposed to the cleaners for 60 s. Resin cement cylinders were formed on the surfaces and tested in shear. All treatments provided increased bond strength compared to untreated control specimens. All failures were interfacial. Although all agents improved the bond strength, dichloromethane and isopropanol were particularly effective.

Chemical cleaning agents and bonding to glass-fiber posts.

The influence of chemical cleaning agents on the bond strength between resin cement and glass-fiber posts was investigated. The treatments included 10% hydrofluoric acid, 35% phosphoric acid, 50% hydrogen peroxide, acetone, dichloromethane, ethanol, isopropanol, and tetrahydrofuran. Flat glass-fiber epoxy substrates were exposed to the cleaners for 60 s. Resin cement cylinders were formed on the surfaces and tested in shear. All treatments provided increased bond strength compared to untreated control specimens. All failures were interfacial. Although all agents improved the bond strength, dichloromethane and isopropanol were particularly effective.

Polymerization efficiency through translucent and opaque fiber posts and bonding to root dentin.

PURPOSE: To investigate the polymerization efficiency through translucent and opaque glass fiber posts and the bond strength of a self-adhesive resin to root dentin. METHODS: Translucent and opaque silanated conical posts, identical in length, diameter and shape (n=8), were cemented to incisor bovine roots using RelyX Unicem Clicker. Photoactivation was performed only through the posts. The roots were transversally sectioned (cervical, middle and apical thirds) and the push-out test was carried out. Data were analyzed using two-way ANOVA and Fisher's LSD method (5%). Failure modes were classified under magnification. An elastomer mold of a bovine incisor root was filled with flowable composite and the posts inserted into the mold. After photoactivation through the post and removal of unpolymerized material, the polymerization efficiency was estimated by percentage of mass gain (n=5). Data were analyzed using t-test (5%). RESULTS: The bond strength of the translucent post was higher than the opaque post for all root thirds. For both posts the bond strength at the cervical third was higher than at the middle and apical thirds. A predominance of adhesive failures was detected for all conditions. Mixed failures were more frequently observed for the opaque post. Almost all the composite polymerized and bonded to the extension of the translucent post, whereas polymerization of the composite was restricted to the cervical area of the opaque post. CONCLUSIONS: The use of translucent post may positively influence the polymerization efficiency and bond strength of resin cement to intraradicular dentin.

[Forensic procedures for interview physical exam and evidence collection in children and young people victims of physical and/or sexual abuse]. / Procedimentos forenses no âmbito da recolha de informação, exame físico e colheita de vestígios em crianças e jovens vítimas de abuso físico e/ou sexual.

The public nature of child abuse crime (domestic violence, maltreatment and sexual crimes) implies the opening of a criminal enquiry as soon as facts likely to be considered as such are known. Professionals who suspect of these cases are considered mandatory reporters as is the case of health care professionals. The work with abused children and youth involves several courses of action between institutions, namely as to the starting procedures to follow in case triage, reporting of suspicion, diagnosis and preservation of evidence for penal purposes, as well as to the protection of the victim(s), all of which still lack a clear definition in Portugal. Several professionals often take part simultaneously in these early procedures and it is crucial that their own personal intervention be articulated with one another's. With the aim of promoting that adequate articulation between the professionals and the acting services, technical orientations to be followed have to be established, namely as far as the articulation between the medicolegal services and the health care services are concerned. These orientations should aim at: ruling the reporting of the occurrence in good time; guarantee an appropriate collection of evidence; guarantee good medical procedures in medical exams and evidence collection; avoid repetition of exams of the victims, preventing secondary victimisation and cross-contamination of child report. Based on the internationally accepted rules for the matter and taking into consideration the Portuguese reality, namely in legal terms, the authors made a proposition concerning the procedures for the intervention in such cases that are herewith presented and were approved as General Recommendations for the Examination in Cases of Suspicion of Domestic Violence, Maltreatment or Sexual Crime Against Children by the National Institute of Legal Medicine, in January 2010. These were later confirmed by the Specialty College of Legal Medicine of the Medical Board Association.

Non-fatal gunshot wounds in the context of intimate partner violence. The importance of a multidisciplinary approach: a case report.

According to Portuguese law, if a case of intimate partner violence is noticed or suspected by a professional working in public services, reporting it to the police, medico-legal services or directly to the public prosecutor is mandatory. However, in most cases, reporting does not take place, despite its vital importance in triggering the multidisciplinary intervention that will ensure the correct and timely diagnosis and protection of the victim. In the present case, the victim, a 37 year-old woman, was sexually and physically abused by her husband in their home, and was physically abused again at the victim's mother's house. The victim mentioned that her husband struck her in the head with a hammer and shot a handgun while in her mother's house. However, she denied having a gunshot wound. The couple's daughter was also slapped in the face by her father. The police took the victim to the emergency room of a central hospital to receive medical attention, while the medical examiner on duty was called to the same emergency room to perform a medico-legal evaluation in the context of the intimate partner violence reported to the police. Medico-legal assessment revealed scalp injuries that had not been detected during the first inspection by the emergency room attending physicians who had performed a neurological examination, which revealed no neurological dysfunction. A cranial computed tomography with three-dimensional reconstitution and virtual dissection, requested by the medical examiner, revealed two projectiles trapped in between the inner and the outer table of the cranium, with linear fractures only in the inner table and no brain injuries. Gynecological examination with the collection of biological evidence, also performed by the medical examiner, made it possible to identify a male DNA profile matching her husband's. The victim was subjected to neurosurgery and a follow-up, and was released one month after the traumatic event. A forensic psychological evaluation, performed one month after the traumatic event, revealed the presence of reactive symptoms to the occurrence. This multidisciplinary intervention and the use of modern diagnosis imaging techniques allowed for a timely diagnosis and treatment, adequate protection of the victim and her family, as well as the identification of the aggressor, who was arrested.

Rehabilitation to crown-root fracture by fragment reattachment with resin-modified glass ionomer cement and composite resin restoration.

Tooth fragment reattachment in cases of enamel/dentin fracture is based on adhesive protocols and is indicated because of its technique simplicity. Complex cases of root fracture or extensive coronal damage demand the integration of biological properties with the mechanical characteristics of the restorative materials. This paper is a report from one patient with a favourable result that addresses the clinical procedures involved in the association of resin-modified glass ionomer cement and composite resin for cases of coronal fracture of anterior teeth with invasion of the periodontal biological space and/or proximity with the pulp tissue. The research-based background for establishment of the treatment plan is discussed and a case of crown fracture with root involvement in a maxillary central incisor illustrates the operative technique of tooth fragment reattachment. After 1 year of follow up, the clinical and radiographic findings demonstrate that the adopted clinical protocol was successful and yielded an excellent pulp and periodontal response as well as maintenance of function and aesthetics.

Sexual abuse of children. A comparative study of intra and extra-familial cases.

The existing data suggest that individuals experiencing intra-familial abuse are affected more significantly than those experiencing extra-familial abuse. This study aims to identify possible differences between these types of abuse. A retrospective study was performed based on medico-legal reports related to children suspected of being sexually abused (n=1054). The results revealed that 40.2% of the suspected abuses were intra-familial and were significantly different than extra-familial cases with respect to the following: (a) the complainants were younger; (b) their relationship to the alleged abuser was closer; (c) the alleged abusers had higher rates of previous sexual abuse; (d) the suspected abuses were less intrusive physically; (e) there was less physical but more psychological violence; (f) the delay between the last abuse and the medico-legal examination was greater; and (g) there were fewer physical signs and DNA evidence (none in the great majority of cases). These results highlight aspects of intra-familial abuse that have been identified as factors influencing the severity of its consequences - physically, these instances of abuse were less intrusive but psychologically they were more intrusive than extra-familial abuse. This justifies the use of different strategies in the diagnosis and support for victims within the family.