Impact of systemic diseases and tooth-based factors on outcome of root canal treatment.

AIM: To investigate the impact of systemic health and tooth-based factors on the outcome of root canal treatment (RCT). METHODOLOGY: The target population consisted of all patients receiving RCT at the Helsinki University Clinic in 2008-2011. The inclusion criteria were diagnosable pre- and postoperative (minimum 6 months after root filling) radiographs and adequate patient records of RCT available. Teeth extracted for nonendodontic reasons were excluded. Patient documents including digital radiographs of 640 permanent teeth in 504 patients were scrutinized. The radiographs were assessed by two examiners under standardized conditions. The Periapical Index was used to define radiographically 'healthy' and 'healing' cases as successful. Data included systemic health, technical quality of root fillings, type of restoration and level of alveolar bone loss. Statistical evaluation of differences between groups included chi-squared tests and Fisher's exact tests. Logistic regression modelling utilizing robust standard errors to allow for clustering within patients was applied to analyse factors related to the outcome of RCT. RESULTS: The mean age of patients was 51.5 years (standard deviation (SD) 15.0; range 10-83), and 49% were female. In 41 cases (6%), the patient had diabetes mellitus (DM), in 132 (21%) cardiovascular disease and in 284 (44%) no systemic disease. The follow-up period was 6-71 months (mean 22.7). In the primary analyses, the success rate of RCT was 73.2% in DM patients and 85.6% in patients with no systemic disease (P = 0.043); other systemic diseases had no impact on success. In the multifactorial analysis, the impact of DM became nonsignificant and RCTs were more likely to succeed in the absence of apical periodontitis (AP; odds ratio (OR) = 4.4; P < 0.001), in teeth with optimal root filling quality (OR = 2.5; P < 0.001), in teeth restored with indirect restorations (OR = 3.7; P = 0.002) and in teeth with none/mild alveolar bone loss (OR = 2.4; P = 0.003). CONCLUSIONS: DM diminished the success of RCT, especially in teeth with apical periodontitis. However, tooth-based factors had a more profound impact on the outcome of RCT. This should be considered in clinical decision-making and in assessment of RCT prognosis.

FLIM reveals alternative EV-mediated cellular up-take pathways of paclitaxel.

In response to physiological and artificial stimuli, cells generate nano-scale extracellular vesicles (EVs) by encapsulating biomolecules in plasma membrane-derived phospholipid envelopes. These vesicles are released to bodily fluids, hence acting as powerful endogenous mediators in intercellular signaling. EVs provide a compelling alternative for biomarker discovery and targeted drug delivery, but their kinetics and dynamics while interacting with living cells are poorly understood. Here we introduce a novel method, fluorescence lifetime imaging microscopy (FLIM) to investigate these interaction attributes. By FLIM, we show distinct cellular uptake mechanisms of different EV subtypes, exosomes and microvesicles, loaded with anti-cancer agent, paclitaxel. We demonstrate differences in intracellular behavior and drug release profiles of paclitaxel-containing EVs. Exosomes seem to deliver the drug mostly by endocytosis while microvesicles enter the cells by both endocytosis and fusion with cell membrane. This research offers a new real-time method to investigate EV kinetics with living cells, and it is a potential advancement to complement the existing techniques. The findings of this study improve the current knowledge in exploiting EVs as next-generation targeted drug delivery systems.

Comparison of Xpert Norovirus and RidaGene Norovirus assays for the detection of noroviruses in clinical fecal specimens.

The purpose of this study was to investigate the usability and performance of the Xpert Norovirus and RidaGene Norovirus assays for the detection of noroviruses in fecal specimens. Of the 186 stool specimens, 53 (28.5%) were considered true-positive for norovirus (NoV). Of the true-positive specimens, Xpert detected 53 and RidaGene detected 52. The respective sensitivity and specificity were 100% and 94.7% [95% confidence interval (CI), 91.0-98.5%] for the Xpert assay, and 98.1% (95% CI, 94.4-100%) and 97.0% (95% CI, 94.1-99.9%) for the RidaGene assay. Positive and negative predictive values (PPVs and NPVs) were 88.3% and 100% for the Xpert assay, and 92.9% and 99.2% for the RidaGene assay, respectively. Based on this study, it can be concluded that there were no significant differences (p-value > 0.5) between the results of the Xpert and RidaGene Norovirus assays. We found that both assays are useful for the detection of noroviruses in clinical stool samples.

Sample selection may bias the outcome of an adolescent mental health survey: results from a five-year follow-up of 4171 adolescents.

OBJECTIVES: The representativeness of the data is one of the main issues in evaluating the significance of research findings. Dropping out is common in adolescent mental health research, and may distort the results. Nevertheless, very little is known about the types of systematic bias that may affect studies in a) the informed consent phase and b) later in follow-up phases. STUDY DESIGN: The authors addressed this gap in knowledge in a five-year follow-up study on a sample of adolescents aged 13-18 years. METHODS: The data were collected using self-report questionnaires. The baseline sample consisted of 4171 adolescents, 1827 (43.8%) of whom gave consent to be contacted for a follow-up survey, but only 797 (19.1%) participated in the follow-up. Binary logistic regression models were used to explain the participation. RESULTS: Young age, female gender, a high number of hobbies, good performance at school in the native language and general subjects, family disintegration such as divorce, high parental employment, and symptoms of depression and anxiety were associated with both consent and participation. However, the effect of mental health aspects was smaller than the effect of age and gender. CONCLUSIONS: This study confirmed the possibility of systematic selection bias by adolescents' sociodemographic characteristics. The representativeness of the study sample might have been improved by more intense recruitment strategies.

Priority criteria tool for elective specialist level adolescent psychiatric care predicts treatment received.

BACKGROUND: Little validation data has so far been published on scoring systems and the literature on prioritization in psychiatry is especially meagre. OBJECTIVE: To explore if the priority criteria score for elective specialist level adolescent psychiatric care in Finland is associated with treatment received and whether the association between the priority criteria scores and treatment given is similar among different subgroups. METHODS: Adolescents currently in treatment contact in three adolescent psychiatric outpatient clinics (n = 450) were rated according to the criteria of the priority rating tool for specialist level adolescent psychiatric care and information about adolescent's age, sex, diagnosis, and treatments was gathered using a structured form. RESULTS: When sex, age and psychiatric diagnosis were controlled for, the likelihood of receiving specific therapies and medications was significantly associated with the highest priority scores. Except for very frequent individual therapy, there were no differences in the probability of receiving any psychosocial treatment or medication between the sexes. Receiving individual therapy, lengthy treatment contacts and medications were more frequent among older adolescents. The rating tool worked best among adolescents with affective or anxious disorders and worst among those with conduct disorders. CONCLUSION: The present study indicates that the structured tool used in Finland, originally modified from a Canadian priority rating tool for child and adolescent psychiatry, is able to identify adolescents requiring specified, multiple and lengthy treatments, indicating a need for specialist level services. The scoring system tested is a good candidate for a transparent prioritization tool for European adolescent psychiatric services.

Parental conceptions of self-mutilation among Finnish adolescents.

The purpose of this paper is to describe self-mutilation from the viewpoint of parents of self-mutilating Finnish adolescents. Four parents of self-mutilating adolescents were interviewed in depth. Qualitative content analysis was applied. Four main categories emerged: the phenomenon of self-mutilation, factors contributing to self-mutilation, the purposes of self-mutilation and sequels of self-mutilation. Factors contributing to self-mutilation could be divided into those relating to the adolescent and those relating to the family, especially the mother. The purposes of self-mutilation were purposes relating to the adolescent and those relating to others, while sequels of self-mutilation could be divided into sequels for the adolescent and those for the parents. Sequels of self-mutilation for the adolescent could be further divided into sequels for the adolescent herself and for the relationship with significant others, including parents, siblings and peers, and sequels in relation to healthcare staff. While knowledge of self-mutilation is inadequate among parents, it evokes strong negative emotions when it occurs in their own family. Self-mutilation should be raised by healthcare professionals and discussed in health promotion or in parents' meetings at schools.

Alexithymia and depression: a prospective study of patients with major depressive disorder.

The authors conducted a 12-month follow-up study to determine the association between alexithymia and depression in 116 outpatients with major depressive disorder (MDD) and 540 control subjects from the general population. Alexithymia was screened using the Toronto Alexithymia Scale (TAS-20), and depression was assessed using the Beck Depression Inventory (BDI). The results show that the severity of depression was significantly associated with alexithymia. In addition, the BDI scores increased or decreased proportionately with the change in TAS-20 score in both groups. These results lend further support to the idea that alexithymia may be a state-dependent phenomenon.

A pessimistic attitude towards the future and low psychosocial functioning predict psychiatric diagnosis among treatment-seeking adolescents.

OBJECTIVE: The objective was to study factors associated with psychiatric diagnosis among adolescents (n = 164) seeking psychiatric care for mental symptoms. METHOD: Psychiatric diagnosis was confirmed by a structured diagnostic interview. Psychosocial functioning was assessed with the Global Assessment of Functioning Scale, and the Beck Depression Inventory and Offer Self-Image Questionnaire were also used. Background data were gathered. RESULTS: A majority (76%) of the adolescents met DSM-III-R criteria for psychiatric diagnosis. The self-image was more negative and the Beck score was higher among these adolescents than the others. All who had attempted suicide had a psychiatric disorder. Those diagnosed as having a psychiatric disorder consumed alcohol in order to get drunk more often than others. Continual conflicts with parents and smoking were not associated with the existence of a psychiatric disorder. In logistic regression analysis, low psychosocial functioning (OR = 3.9) and an uncertain or pessimistic attitude towards the future (OR = 9.1) proved to be independent risk factors for psychiatric disorders. CONCLUSIONS: Health service staff should be aware of factors associated with psychiatric disorders in adolescents so that they can identify those at high risk.

Heavy drinking is associated with more severe psychosocial dysfunction among girls than boys in Finland.

PURPOSE: To investigate social, psychological, and environmental factors related to heavy drinking by 15-year-old Finnish school pupils. METHODS: Each of 240 pupils completed a questionnaire about alcohol use, smoking, and illicit drug use; an Offer Self-Image Questionnaire; an Inventory of Parent and Peer Attachment; and a Psychosomatic Symptoms Questionnaire. Teachers assessed each pupil according to a Social Skills Rating Scale. Academic achievement was assessed on the basis of report grades. RESULTS: Heavy drinking was associated with smoking, trial of drugs, poor social skills in class, and poor school achievement in both boys and girls. In girls, heavy drinking was associated with psychosomatic symptoms and a negative social self-image. Girls who drank heavily also had more difficulty with concentration and externalizing problems and more problems with teachers than those who were abstinent or consumed alcohol moderately. The self-images of boys who drank heavily were more negative than those of alcohol-abstinent boys. In boys, heavy drinking was associated with higher numbers of peer relationships. CONCLUSIONS: Heavy drinking is associated with more severe psychosocial dysfunction among girls than boys. It may be possible to identify girls at school who drink heavily and guide them toward treatment.

Self-reported life satisfaction and recovery from depression in a 1-year prospective study.

OBJECTIVE: To study the relationship of a self-rated four-item life satisfaction scale (LS) to the self-rated 21-item Beck Depression Inventory (BDI) and the 17-item Hamilton Rating Scale for Depression (HAMD) and to study LS changes during recovery from depression. METHOD: A 1-year prospective study on 188 depressive patients receiving standard psychiatric outpatient treatment; 137 of the patients had major depression. RESULTS: LS correlated strongly with BDI and HAMD. It explained 46.6%) of the variation in BDI at baseline and 66.2% at 12 months. LS improved substantially during recovery. The main recovery occurred during the first 6 months, the change in the LS score explaining 46.5% of the change in the BDI score (P < 0.001). CONCLUSION: Life satisfaction is strongly affected in depression, but it improves concurrently with recovery from depression. LS scale may prove useful in screening for those whose subjective wellbeing deserves attention and in assessing alleviation from depression.

An international comparison of cancer survival: metropolitan Toronto, Ontario, and Honolulu, Hawaii.

OBJECTIVES: Comparisons of cancer survival in Canadian and US metropolitan areas have shown consistent Canadian advantages. This study tests a health insurance hypothesis by comparing cancer survival in Toronto, Ontario, and Honolulu, Hawaii. METHODS: Ontario and Hawaii registries provided a total of 9190 and 2895 cancer cases (breast and prostate, 1986-1990, followed until 1996). Socioeconomic data for each person's residence at the time of diagnosis were taken from population censuses. RESULTS: Socioeconomic status and cancer survival were directly associated in the US cohort, but not in the Canadian cohort. Compared with similar patients in Honolulu, residents of low-income areas in Toronto experienced 5-year survival advantages for breast and prostate cancer. In support of the health insurance hypothesis, between-country differences were smaller than those observed with other state samples and the Canadian advantage was larger among younger women. CONCLUSIONS: Hawaii seems to provide better cancer care than many other states, but patients in Toronto still enjoy a significant survival advantage. Although Hawaii's employer-mandated health insurance coverage seems an effective step toward providing equitable health care, even better care could be expected with a universally accessible, single-payer system.

An international comparison of cancer survival: relatively poor areas of Toronto, Ontario and three US metropolitan areas.

BACKGROUND: This study of cancer survival compared adults in Toronto, Ontario and three US metropolitan areas: Seattle, Washington; San Francisco, California; and Hartford, Connecticut. It examined whether socioeconomic status has a differential effect on cancer survival in Canada and the United States. METHODS: The Ontario Cancer Registry and the National Cancer Institute's Surveillance, Epidemiology and End RESULTS: (SEER) programme provided a total of 23,437 and 37,329 population-based primary malignant cancer cases for the Toronto and US samples, respectively (1986-1988, followed until 1994). Census-based measures of socioeconomic status were used to ecologically control absolute income status. RESULTS: Among residents of low-income areas, persons in Toronto experienced a 5 year survival advantage for 13 of 15 cancer sites [minimally one gender significant at 95 per cent confidence interval (CI)]. An aggregate 35 per cent survival advantage among the Canadian cohort was demonstrated (survival rate ratio (SRR) = 1.35, 95 per cent CI= 1.30-1.40), and this effect was even larger among younger patients not yet eligible for Medicare coverage in the United States (SRR = 1.46, 95 per cent CI = 1.40-1.52). CONCLUSION: Systematically replicating a previous Toronto-Detroit comparison, this study's observed consistent pattern of Canadian survival advantage across various cancer sites suggests that their more equitable access to preventive and therapeutic health care services may be responsible for the difference.

Effects of therapeutic touch on biochemical and mood indicators in women.

Previous research has shown therapeutic touch (TT) to be effective in reducing anxiety and discomfort and promoting relaxation. The present investigation experimentally evaluated the effects of TT on biochemical indicators and moods in a sample of 41 healthy female volunteers. Participants were randomly assigned to either an experimental group who received TT or to a control group who did not receive TT. Pretest and posttest urine samples were collected, and personality and mood inventories were administered across three consecutive monthly sessions. Results indicated that mood disturbance in the experimental group decreased significantly over the course of the three sessions, while the control group increased in mood disturbance over time. Specifically, experimental group participants showed significant reductions in tension, confusion, and anxiety and a significant increase in vigor across sessions. Analyses of the biochemical data indicated that TT produced a significant decrease in levels of nitric oxide in the experimental group by the third TT session. The results of the present investigation have important implications for reducing symptom distress in cancer patients undergoing chemotherapy.

Body image and psychopathology in adolescence: a controlled clinical study.

The aim of this study was to investigate mentally disturbed adolescents' problems of acknowledging and accepting the physical changes and sexual maturation of their bodies, in comparison with healthy adolescents. The study sample consisted of 60 adolescents (30 boys and 30 girls), 15-18 years of age, who had been referred for psychiatric examination, and 60 healthy controls, matched on the basis of age, sex, place of residence and level of education. The study methods were the self-rated questionnaire and psychiatric in-depth interview modified on the basis of the diagnostic profile of adolescents. Mentally disturbed adolescents had more negative attitudes towards developmental body changes than healthy adolescents. They were unable to describe the physical changes they had undergone. Healthy adolescents were more aware of developing sexual characteristics. On discriminant analysis, independent background variables explaining problems relating to sexual maturation in mentally disturbed adolescents were found to be a lack of or low number of peer relationships, and long-term stress. In the healthy adolescents, independent variables associated with problems in sexual maturation were found to be a lack of or low number of peer relationships and a single-parent home. We conclude that adolescents with psychiatric problems seem to have a poorer capacity to process mentally the ongoing bodily and sexual maturation of their bodies than matched healthy controls.

Association between socioeconomic status and cancer incidence in Toronto, Ontario: possible confounding of cancer mortality by incidence and survival.

OBJECTIVE: To observe the association between socioeconomic status (SES) and cancer incidence in a cohort of Canadians. DESIGN: Cases of primary malignant cancer (83,666) that arose in metropolitan Toronto, Ont., from 1986 to 1993 were ascertained by the Ontario Cancer Registry and linked by residence at the time of diagnosis to a census-based measure of SES. Socioeconomic quintile areas were then compared by cancer incidence. RESULTS: Significant associations between SES and cancer incidence in the hypothesized direction--greater incidence in low-income areas--were observed for 15 of 23 cancer sites. CONCLUSIONS: These findings, together with the recently observed consistent pattern of significant associations between SES and cancer survival in the United States and the equally consistent pattern of nonsignificant associations in Canada, support the notion that differences in cancer incidence alone explain the observed cancer mortality differentials by SES in Canada. The cancer mortality differential by SES observed in the United States is probably a function of differences in both incidence and length of survival, whereas in Canada such mortality differentials are more likely to be merely a function of differences in incidence by SES. This pattern of associations primarily implicates differences in the 2 health care systems; specifically, the more egalitarian access to preventive, investigative and therapeutic services available in the single-payer Canadian system.

Breast irradiation in women with early stage invasive breast cancer following breast conservation surgery. Provincial Breast Disease Site Group.

GUIDELINE QUESTIONS: 1) Should breast irradiation be given to women with early stage invasive breast cancer (stage I and II) following breast conservation surgery (lumpectomy with clear resection margins and axillary dissection)? 2) Is there an optimal schedule for breast irradiation? 3) What is a reasonable interval between definitive surgery and the start of breast irradiation? 4) Are there patients who can be spared breast irradiation after lumpectomy? OBJECTIVE: To make recommendations about the use of breast irradiation in women with early stage invasive breast cancer following breast conservation surgery. OUTCOMES: Local control is the primary endpoint of interest. Survival, quality of life (addressed through the adverse effects of radiotherapy) and cosmesis are also considered. PERSPECTIVE (VALUES): Evidence was selected and reviewed by 6 members of the Breast Disease Site Group (Breast DSG) of the Ontario Cancer Treatment Practice Guidelines Initiative. Earlier drafts of the evidence-based recommendation were reviewed, discussed and approved by the Breast DSG, which comprises medical oncologists, radiation oncologists, surgeons, epidemiologists, pathologists and a medical sociologist. There was no participation by a community representative in the development of this guideline. QUALITY OF EVIDENCE: There are 5 randomized controlled trials (RCTs) and 1 meta-analysis comparing breast irradiation with no breast irradiation following breast conservation surgery; 6 randomized trials comparing breast conservation surgery plus breast irradiation with mastectomy are also included, as well as several retrospective studies. BENEFITS: All of the 5 RCTs showed a significant decrease in local recurrence rates among patients receiving radiotherapy. In the 4 trials with a median follow-up of 5 years or longer, the relative risk reduction with breast irradiation ranged from 69% to 88%. The absolute differences ranged from 16% (p < 0.001) to 25% (p < 0.001). Despite the effect on local recurrence, no difference in survival was detected in any of the 5 trials. Most of the patients with local recurrence in these trials underwent mastectomy. HARMS: Major adverse effects of breast irradiation occur very infrequently. PRACTICE GUIDELINE: Women with early stage invasive breast cancer (stage I and II) who have undergone breast conservation surgery should be offered postoperative breast irradiation. The optimal fractionation schedule for breast irradiation has not been established, and the role of boost irradiation is unclear. Outside of a clinical trial, 2 commonly used fractionation schedules are suggested: 50 Gy in 25 fractions to the whole breast, or 40 Gy in 16 fractions to the whole breast with a local boost to the primary site of 12.5 Gy in 5 fractions. Shorter schedules (e.g., 40 or 44 Gy in 16 fractions) have also been used routinely in some centres. The enrollment of patients in ongoing clinical trials is encouraged. Women who have undergone breast conservation surgery should receive local breast irradiation as soon as possible after wound healing. A safe interval between surgery and the start of radiotherapy is unknown, but it is reasonable to start breast irradiation within 12 weeks after definitive surgery. For women who are candidates for chemotherapy, the optimal sequencing of chemotherapy and breast irradiation is unknown. It is reasonable to start radiotherapy after the completion of chemotherapy, or concurrently if anthracycline-containing regimens are not used. For further information, please refer to Ontario Cancer Treatment Practice Guidelines Initiative's practice guideline "Surgical Management of Early Stage Invasive Breast Cancer (stage I and II)."

An international comparison of cancer survival: Toronto, Ontario, and Detroit, Michigan, metropolitan areas.

OBJECTIVES: This study examined whether socioeconomic status has a differential effect on the survival of adults diagnosed with cancer in Canada and the United States. METHODS: The Ontario Cancer Registry and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program provided a total of 58,202 and 76,055 population-based primary malignant cancer cases for Toronto, Ontario, and Detroit, Mich, respectively. Socioeconomic data for each person's residence at time of diagnosis were taken from population censuses. RESULTS: In the US cohort, there was a significant association between socioeconomic status and survival for 12 of the 15 most common cancer sites; in the Canadian cohort, there was no such association for 12 of the 15 sites. Among residents of low-income areas, persons in Toronto experienced a survival advantage for 13 of 15 cancer sites at 1- and 5-year follow-up. No such between-country differentials were observed in the middle- or high-income groups. CONCLUSIONS: The consistent pattern of a survival advantage in Canada observed across various cancer sites and follow-up periods suggests that Canada's more equitable access to preventive and therapeutic health care services is responsible for the difference.

Design and implementation of an electronic point-of-contact oncology clinical record.

An electronic point-of-contact narrative clinical record was developed and implemented in a multidisciplinary regional cancer center with an annual new caseload of 1,200. Design principles included (1) natural clinician-intuitive interface with pen, touch, and sound input options; (2) structure and processes enabling direct input of both clinician-reported and patient-reported data; (3) embedding of decision support and practice guidelines directly into the interface; (4) incorporation of automated cancer staging algorithms; (5) automatic production of consultation and progress notes, limiting transcription requirements to sound fields; (6) outcomes--focused report formats; and (7) integrated billing and activity reporting. The system was implemented in Windows, both on a local area network and on mobile devices. Evaluation parameters included feasibility, acceptance, performance, cost of hardware and software development and/or customization, cost of system maintenance, and comparison of net clinician time for encounter documentation relative to a paper-based standard. Feasibility, acceptance, and cost-effectiveness were established.