Outcome of Chair-Side Dental Fear Treatment: Long-Term Follow-Up in Public Health Setting.

AIM: Purpose of this practice and data-based study was to evaluate the outcome of dental fear treatment of patients referred to the Clinic for Fearful Dental Patients (CFDP) in the primary oral health care, City of Oulu, Finland, during period 2000-2005. METHODS: A psychological approach including behavioral interventions and cognitive behavioral therapy (BT/CBT) was used for all participants combined with conscious sedation or dental general anesthesia (DGA), if needed. The outcome was considered successful if later dental visits were carried out without any notifications in the patient records of behavioral problems or sedation. Data collection was made in 2006; the average length of the observation period from the last visit in the CFPD to data collection was 2 y 3 m (SD 1 y 5 m). All information was available for 163 patients (mean age 8.9 y at referral). Study population was dominated by males (58.0%). Cause for referrals was mostly dental fear (81.0%) or lack of cooperation. RESULTS: The success rate was 69.6% among females and 68.1% among males. Success seemed to be (p=0.053) higher for those treated in ≤12 years compared with the older ones. The participants, without need for dental general anesthesia (DGA) in the CFDP, had significantly a higher success rate (81.4%) compared with those who did (54.8%, p < 0.001). Use of conscious oral sedation (p=0.300) or N2O (p=0.585) was not associated with the future success. CONCLUSIONS: A chair-side approach seems successful in a primary health care setting for treating dental fear, especially in early childhood. Use of sedation seems not to improve the success rate.

Laser fluorescence in monitoring the influence of targeted tooth brushing on remineralization of initial caries lesions on newly erupted molar teeth - RCT.

OBJECTIVE: This study aimed to monitor mineralization changes in initial caries lesions on newly erupted second molars using laser fluorescence (LF) scanning after a 1-month targeted tooth brushing intervention. METHODS: Altogether, 124 13- to 14-year-old school children were invited to participate. Of those who fulfilled the clinical criteria (at least one initial lesion with LF value >10 in second molars), 51 gave their written consent to participate. Laser fluorescence values were registered at baseline and after 1-month follow-up period. All participants were individually taught targeted tooth brushing of their second molars and randomly provided tooth paste with 0 or 1500 ppm fluoride. Brushing frequency was investigated at baseline and after the follow-up. Change in LF values was compared considering the tooth, content of fluoride in the paste and brushing frequency. RESULTS: In lesions with LF values ≤30 at baseline, change in LF values demonstrated improvement. Improvement was detected especially in upper molars. In lesions with LF values >30 at baseline, improvement was least detected. Brushing frequency increased slightly during the intervention. CONCLUSIONS: Laser fluorescence is a simple method and useful in monitoring remineralization of incipient lesions even in weeks. Targeted tooth brushing seems to induce remineralization even in weeks. Laser fluorescence could be a valuable motivating tool in promoting patients' self-care.

Identification of C12orf4 as a gene for autosomal recessive intellectual disability.

Intellectual disability (ID) is a major health problem in our society. Genetic causes of ID remain unknown because of its vast heterogeneity. Here we report two Finnish families and one Dutch family with affected individuals presenting with mild to moderate ID, neuropsychiatric symptoms and delayed speech development. By utilizing whole exome sequencing (WES), we identified a founder missense variant c.983T>C (p.Leu328Pro) in seven affected individuals from two Finnish consanguineous families and a deletion c.799_1034-429delinsTTATGA (p.Gln267fs) in one affected individual from a consanguineous Dutch family in the C12orf4 gene on chromosome 12. Both the variants co-segregated in the respective families as an autosomal recessive trait. Screening of the p.Leu328Pro variant showed enrichment in the North Eastern sub-isolate of Finland among anonymous local blood donors with a carrier frequency of 1:53, similar to other disease mutations with a founder effect in that region. To date, only one Arab family with a three affected individuals with a frameshift insertion variant in C12orf4 has been reported. In summary, we expand and establish the clinical and mutational spectrum of C12orf4 variants. Our findings implicate C12orf4 as a causative gene for autosomal recessive ID.

The impact of living arrangements and deinstitutionalisation in the health status of persons with intellectual disability in Europe.

BACKGROUND: Despite progress in the process of deinstitutionalisation, very little is known about the health conditions of people with intellectual disability (PWID) who live in large institutions and PWID living in small residential services, family homes or independent living within the community. Furthermore, there are no international comparison studies at European level of the health status and health risk factors of PWID living in fully staffed residential services with formal support and care compared with those living in unstaffed family homes or independent houses with no formal support. METHODS: A total of 1269 persons with ID and/or their proxy respondents were recruited and face-to-face interviewed in 14 EU countries with the P15, a multinational assessment battery for collecting data on health indicators relevant to PWID. Participants were grouped according to their living arrangements, availability of formal support and stage of deinstitutionalisation. RESULTS: Obesity and sedentary lifestyle along with a number of illnesses such as epilepsy, mental disorders, allergies or constipation were highly prevalent among PWID. A significantly higher presence of myocardial infarctions, chronic bronchitis, osteoporosis and gastric or duodenal ulcers was found among participants in countries considered to be at the early stage of deinstitutionalisation. Regardless of deinstitutionalisation stage, important deficits in variables related to such medical health promotion measures as vaccinations, cancer screenings and medical checks were found in family homes and independent living arrangements. Age, number of people living in the same home or number of places in residential services, presence of affective symptoms and obesity require further attention as they seem to be related to an increase in the number of illnesses suffered by PWID. DISCUSSION: Particular illnesses were found to be highly prevalent in PWID. There were important differences between different living arrangements depending on the level of formal support available and the stage of deinstitutionalisation. PWID are in need of tailored primary health programs that guarantee their access to quality health and health promotion and the preventative health actions of vaccination programs, systematic health checks, specific screenings and nutritional controls. Extensive national health surveys and epidemiological studies of PWID in the EC member states are urgently needed in order to reduce increased morbidity rates among this population.

The P15 - a multinational assessment battery for collecting data on health indicators relevant to adults with intellectual disabilities.

BACKGROUND: Health disparities between adults with intellectual disabilities (ID) and the general population have been well documented but, to date, no dedicated assessment battery for measuring health disparity has been available. This paper reports on the development and testing of a multinational assessment battery for collecting data on a range of health indicators relevant to adults with ID. METHODS: An assessment battery (the P15) was developed following piloting, and administered to samples of adults with ID, in 14 EU countries. Samples were neither random, nor representative of the countries from which they were drawn. However, within the local health administration areas selected in each country, efforts were made to ensure samples were broadly representative of the typical living circumstances, ages and ability levels of the administrative population of adults with ID. The total sample comprised 1269 adults with ID, of whom 49% were female. The mean age was 41 years (range 19 to 90). RESULTS: Overall, feasibility, internal consistency and face validity of the P15 was acceptable. CONCLUSIONS: With some refinement the P15 could be useful for collecting data on health indicators known to be particularly important for adults with ID. It is useable in a range of countries and has the potential to highlight health inequity for adults with ID at a national or local level. Larger scale epidemiological studies are needed to exploit the potential of the P15 to address health inequity in this group.

Fusion of dispatching centres into one entity: effects on performance.

BACKGROUND: Dispatching centres were fused into one of the 112 entity, which caused concerns regarding whether the medical calls could be processed effectively also in the new centre. We evaluated the effects of the reform on key performance criteria in medical calls. METHODS: This observational study in the Helsinki Dispatching Centre consisted of two periods: Period I 2 years before the reform and Period II 2 years after. The main outcome measures were answering and call processing times, accuracy of risk assessment and appropriate use of ambulances. RESULTS: In Period I (n=574,276), 92.2% of all incoming phone calls were answered within 10 s and in Period II (n=758,022) 82.8% (P<0.0001). Time to dispatch a first responding fire unit increased from 98 to 113 s (P<0.0001) and an advanced life support unit in category A calls increased from 73 to 84 s (P<0.0001). In Period I 47.7%, 34.8% and 17.5% of phone calls were completed in <3, 3-5 and >5 min and in Period II 29.8%, 36.1% and 34.1% (P<0.0001). The number of three studied non-transportation call types and unnecessary lights-and-siren responses increased significantly (P<0.0001 and 0.0001, respectively). Neither the accuracy of risk assessment in the three studied call types nor the rate of telephone-guided cardiopulmonary resuscitation changed. CONCLUSIONS: The reform increased the total number of ambulance dispatches, prolonged answering and call processing times and had a negative effect on the appropriate use of ambulances. The accuracy of risk assessment was not affected. Evidence-based data should be the basis for the future as dispatching centre processes are shown to be vulnerable during organisational reforms.

Medical futility in asystolic out-of-hospital cardiac arrest.

OBJECTIVES: To study the factors associated with short- and long-term survival after asystolic out-of-hospital cardiac arrest, with a reference to medical futility. METHODS: This is a retrospective observational study conducted in Helsinki, Finland during 1 January 1997 to 31 December 2005. All out-of-hospital cardiac arrests were prospectively registered in the cardiac arrest database. Of 3291 arrests, 1455 had asystole as the first registered rhythm. These patients represent the study population. RESULTS: A short time interval to the initiation of advanced life support (ALS) was associated with a long-term benefit, but a short first responding unit (FRU) response time had only a short-term benefit. Conversion of asystole into a shockable rhythm provided only a short-term benefit. The prognosis was poor if the FRU response time was over 10 min or the ALS response time was over 11 min in bystander-witnessed arrests, and if the duration of resuscitation was over 8 min in emergency medical services (EMS)-witnessed arrests. Bystander-CPR was associated with increased 30-day mortality. The 30-day survival rate after an unwitnessed arrest (n=548) was 0.5%. All survivors in this group were either hypothermic or were victims of near-drowning. CONCLUSIONS: Resuscitation should be withheld in cases of unwitnessed asystole, excluding cases of hypothermia and near-drowning. The prognosis is poor if the FRU response time is over 10 min or the ALS response time is over 10-15 min in bystander-witnessed arrests. The decision of whether or not to attempt resuscitation should not be influenced by the presence of bystander-CPR. Early initiation of ALS should be prioritised in the treatment of out-of-hospital asystole.

Analysis of multiple casualty incidents - a prospective cohort study.

BACKGROUND: Our aim was to report the rate and causes for multiple casualty incidents (MCI) to analyse the prehospital part of responding to MCIs, report mortality and find areas for improvement. METHODS: A prospective cohort study conducted in an urban emergency medical service (EMS) between 1.3.1998 and 28.2.2004. RESULTS: Fifty-nine MCIs involving 263 patients (167 walking, 96 non-walking) occurred. The incidence of MCIs was 1.8/100,000 inhabitants year(-1). Traffic accidents were the most common cause followed by residential fires, intoxications and stabbings or shootings. Early MCI alarm by the dispatching centre was performed in 18 MCIs. Deviations from standard emergency medical care occurred in 12% of patients. Lack of immobilization of the neck or back in trauma patients and lack of administration of 100% oxygen in suspected carbon monoxide intoxication were the most common deviations. Deviations were related to the lack of presence of on-scene medical command (P = 0.0013) and inadequate resources (P = 0.0342). One hundred and ninety-two patients were transported to emergency departments. Mortality during the prehospital phase was 4.9% (13/263) and during the next 28 days 2.3% (6/263). Adequate resources for safe and effective management of a MCI were related to an early MCI alarm by the dispatching centre (P = 0,022) and to the presence of on-scene medical command (P < 0,001). CONCLUSIONS: Traffic accidents, residential fires and intoxications were the leading causes for MCIs. Emergency medical service could respond to most MCIs efficiently and safely. Majority of deviations from standard medical care seemed potentially preventable. Several areas for improvement were identified. From prehospital links, the dispatching centre and on-scene medical command had a vital role in the successful management of MCIs.

The use of undiluted amiodarone in the management of out-of-hospital cardiac arrest.

INTRODUCTION: The Resuscitation 2000 Guidelines recommends amiodarone as the antiarrhythmic drug of choice in treatment of resistant ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Amiodarone has been associated with side-effects and difficulty of administration, due to recommended dilution, rendering it suboptimal for out-of-hospital cardiac arrest (CA) management. In the present study we report experiences and side-effects of the use of undiluted amiodarone in CA management in Helsinki Emergency Medical Service (EMS) during a 2-year period. METHODS: On October 1, the Resuscitation 2000 Guidelines were put into practice in Helsinki EMS. Thus, in the cardiac arrest treatment protocol, after three ineffective shocks and 1 mg of adrenaline (epinephrine), a bolus of 300 mg of undiluted amiodarone (Cordarone 50 mg ml(-1), Sanofi-Synthelabo, Helsinki, Finland) was administered into a vein located as centrally as possible. The Helsinki EMS performs systematic data collection according to the Utstein Guidelines. The blood pressure levels, heart rates and the need for vasopressors, of the patients with sustained return of spontaneous circulation (ROSC), were collected from the ambulance charts. RESULTS: During October 1, 2000 and September 30, 2002, 712 patients were considered for resuscitation and 566 were resuscitated. The initial rhythms were as follows: 32% had VF/VT, 36% had asystole and 32% had pulseless electrical activity (PEA). Of the 180 patients with VF/VT, 75 (42%) received undiluted amiodarone in addition to other resuscitative measures. Of the patients with asystole or PEA, 12 (6%) and 18 (10%), respectively, received amiodarone. The blood pressure levels and the need vasopressors after ROSC and during transportation to the hospital were similar among the patients who received and those who did not receive amiodarone. CONCLUSIONS: The present study suggests that amiodarone can be administered undiluted without unmanageable haemodynamical side-effects in the treatment of out-of-hospital cardiac arrest. This is likely to save time and simplifies the treatment protocol in the prehospital setting.

On the construction of a Finnish audiometric sentence test.

To respond to the demands of clinical practice and the needs of rehabilitation, a Finnish audiometric sentence test is being developed. The test consists of 10 sets of 10 sentences, each set serving as an independent test. The test is scored by words (50 per set). Homogeneity between the sets was guaranteed by a number of linguistic and phonetic criteria, controlled by using the Virko Sentence Analyzer, a programme especially constructed for the purpose. Recognition tests for the validation of the sentence sets were made with young normally hearing adults (n = 70; age group 18-25 years). Psychometric recognition properties of the test are described. The selection process of the final 10 sentence sets is illustrated.

Speech articulation after subtotal glossectomy and reconstruction with a myocutaneous flap.

Speech samples of 9 subjects (8 males, 1 female) were recorded before and 0.5-2 years after a partial glossectomy and reconstruction with a pectoralis major myocutaneous flap. A reading sample, a list of meaningful and nonsense words, and a list of sustained vowels were recorded. The speech samples were evaluated by pairs of naive listeners and using acoustic analysis of the vowel production. Each pair listened to the recordings of only one patient. Inter-rater agreement was satisfactory. The general impression of the speech outcome varied from normal to moderately impaired. The perceptually estimated impairments of speech articulation in the after/before comparisons were statistically significant. Only the first formant of the vowel /i/ (rise) and the second formant of the vowel /a/ (drop) changed significantly at the group level. There was a negative correlation (r = -0.79) between the extent of tongue resection and the drop of the second formant of the vowel /a/. The perceptual variables showed a relationship (r = 0.74-0.82) with the changes in the level of the second formant of the vowel /i/. The relationship that emerged between the perceptual estimates and the objective acoustic parameters suggests that it will be possible to develop clinically relevant test batteries for articulatory quality analysis.

Diagnosing acute maxillary sinusitis in primary care: a comparison of ultrasound, clinical examination and radiography.

In primary care, acute maxillary sinusitis may be diagnosed by clinical examination, ultrasound or radiography. Previous studies on the diagnostic accuracy of these methods are from secondary care settings and may not be generalisable to primary care. In this study of 39 primary care patients we have compared ultrasound, clinical examination and radiography to sinus irrigation. The sensitivity of ultrasound performed by general practitioners is 61% and specificity is 53%. Diagnostic accuracy does not improve when the general practitioner bases the diagnosis on combination of clinical examination and ultrasound. The most accurate way to diagnose sinusitis is radiography and when the radiographs are interpreted by a radiologist (sensitivity: 61%; specificity: 98%). The accuracy of the ultrasound examination performed by general practitioners is poorer than earlier results from ENT practices. More attention should be paid to education and quality management in the use of ultrasound in primary care.

Cardiac arrests witnessed by EMS personnel in a multitiered system: epidemiology and outcome.

The purpose of the study was to determine the epidemiology and the etiology of cardiac arrests witnessed by emergency medical services (EMS) personnel and the survival from resuscitation according to the Utstein style. Consecutive prehospital cardiac arrests witnessed by EMS personnel in the Helsinki City EMS system between January 1, 1994 and December 31, 1995 were included in this prospective cohort study. A total of 809 cardiac arrests were registered during the study period, 108 (13.3%) of which were EMS-witnessed. The incidence of EMS-witnessed cardiac arrests was 1.8 per 1,000 urgent calls per year. Resuscitation was attempted in 94 patients, 45 of whom (47.9%) were hospitalized alive and 15 of whom (16.0%) were discharged. Fourteen of the survivors were discharged with overall performance category I or II. Cardiac etiology was verified in 60 (55.6%) cases. In multivariate analysis, initial rhythm of ventricular fibrillation and cardiac etiology remained independent factors of survival. These results indicate that overall survival rates in EMS-witnessed cardiac arrests have remained low but those who survive are discharged without major neurological sequelae. Noncardiac etiology accounts for 45% of cases and seems to be a major determinant of low overall survival rates.

Measuring voice under teachers' working circumstances: F0 and perturbation features in maximally sustained phonation.

This study is part of a larger project, the aim of which is to develop a method for collecting voice data in working places. In this part, maximally sustained phonation was studied to assess its stability in this kind of uncontrolled circumstances. The subjects were 11 female schoolteachers. Different portions of a sustained /a/ and two consecutively produced samples were measured. The acoustic variables measured were fundamental frequency (F0), jitter and shimmer. The results showed that two consecutively produced phonations were quite similar, but the place of the sample within the sustained vowel had a very small but statistically significant effect on the values of F0 and shimmer. Jitter varied quite a lot, and could perhaps be considered to be dependent on the recording circumstances.

Out-of-hospital cardiac arrests in Helsinki: Utstein style reporting.

OBJECTIVE: To determine the epidemiology of out-of-hospital cardiac arrests and survival after resuscitation and to apply the Utstein style of reporting to data collection. DESIGN: Prospective cohort study. SETTING: A middle-sized urban city (population 516,000) served by a single emergency medical services system. PATIENTS: Consecutive prehospital cardiac arrests occurring between 1 January and 31 December 1994. INTERVENTION: Advanced cardiac life support according to the recommendations of American Heart Association. MAIN OUTCOME MEASURES: Survival from cardiac arrest to hospital discharge, and factors associated with survival. RESULTS: Four hundred and twelve patients were considered for resuscitation. The overall incidence of out-of-hospital cardiac arrest was 79.8/100,000 inhabitants/year. Fifty seven patients (16.6%) survived to discharge when resuscitation was attempted. 32.5% survived when cardiac arrest was bystander witnessed and was of cardiac origin with ventricular fibrillation as the initial rhythm. When asystole or pulseless electrical activity was the first rhythm recorded, discharge rates were 6.2 and 2.7% respectively. The cause of cardiac arrest was cardiac in 66.5%, and ventricular fibrillation was the initial rhythm in 65.0% of bystander witnessed cardiac arrests of cardiac origin. 22.1% of patients received bystander initiated cardiopulmonary resuscitation. The mean time intervals from the receipt of the call to the arrival of a first response advanced life support unit and mobile intensive care unit at the patient's side and to the return of spontaneous circulation were 7.0 and 10.3 and 12.6 and 16.7 min respectively. In the logistic regression model bystander witnessed arrest, age, ventricular fibrillation as initial rhythm, and the call-to-arrival interval of the first response unit were independent factors relating to survival. Utstein style reporting with modification of time zero was found to be an appropriate form of data collection in this emergency medical services system. CONCLUSIONS: After implementation of major changes in the emergency medical services system during the 1980s survival from out-of-hospital cardiac arrest markedly increased. However, early access, which has turned out to be the weakest link in the chain of survival, should receive major attention in the near future. Utstein style reporting with a modified time zero was found to be appropriate, although laborious, protocol for data collection.