Caries risk assessment. A systematic review.

OBJECTIVE: To assess the ability of multivariate models and single factors to correctly identify future caries development in pre-school children and schoolchildren/adolescents. STUDY DESIGN: A systematic literature search for relevant papers was conducted with pre-determined inclusion criteria. Abstracts and full-text articles were assessed independently by two reviewers. The quality of studies was graded according to the QUADAS tool. The quality of evidence of models and single predictors was assessed using the GRADE approach. RESULTS: Ninety original articles fulfilled the inclusion criteria. Seven studies had high quality, 35 moderate and the rest poor quality. The accuracy of multivariate models was higher for pre-school children than for schoolchildren/adolescents. However, the models had seldom been validated in independent populations, making their accuracy uncertain. Of the single predictors, baseline caries experience had moderate/good accuracy in pre-school children and limited accuracy in schoolchildren/adolescents. The period of highest risk for caries incidence in permanent teeth was the first few years after tooth eruption. In general, the quality of evidence was limited. CONCLUSIONS: Multivariate models and baseline caries prevalence performed better in pre-school children than in schoolchildren/adolescents. Baseline caries prevalence was the most accurate single predictor in all age groups. The heterogeneity of populations, models, outcome criteria, measures and reporting hampered the synthesis of results. There is a great need to standardize study design, outcome measures and reporting of data in studies on caries risk assessment. The accuracy of prediction models should be validated in at least one independent population.

Radiological diagnosis of periapical bone tissue lesions in endodontics: a systematic review.

This systematic review evaluates the diagnostic accuracy of radiographic methods employed to indicate presence/absence and changes over time of periapical bone lesions. Also investigated were the leads radiographic images may give about the nature of the process and the condition of the pulp in nonendodontically treated teeth. Electronic literature search included the databases PubMed, Embase and CENTRAL from January 1950 to June 2011. All languages were accepted provided there was an abstract in English. The MeSH terms were 'Cone beam computed tomography (CBCT)', 'Radiography, panoramic', 'Periapical diseases', 'Dental pulp diseases', 'Sensitivity and specificity', 'receiver operating characteristics (ROC) curve', 'Cadaver', 'Endodontics' and 'Radiography dental'. Two reviewers independently assessed abstracts and full text articles. An article was read in full text if at least one of the two reviewers considered an abstract to be potentially relevant. Altogether, 181 articles were read in full text. The GRADE approach was used to assess the quality of evidence of each radiographic method based on studies of high or moderate quality. Twenty-six studies fulfilled criteria set for inclusion. None was of high quality; 11 were of moderate quality. There is insufficient evidence that the digital intraoral radiographic technique is diagnostically as accurate as the conventional film technique. The same applies to CBCT. No conclusions can be drawn regarding the accuracy of radiological examination in identifying various forms of periapical bone tissue changes or about the pulpal condition.

Diagnosis of the condition of the dental pulp: a systematic review.

The aim of this systematic review was to appraise the diagnostic accuracy of signs/symptoms and tests used to determine the condition of the pulp in teeth affected by deep caries, trauma or other types of injury. Radiographic methods were not included. The electronic literature search included the databases PubMed, EMBASE, The Cochrane Central Register of Controlled Trials and Cochrane Reviews from January 1950 to June 2011. The complete search strategy is given in an Appendix S1 (available online as Supporting Information). In addition, hand searches were made. Two reviewers independently assessed abstracts and full-text articles. An article was read in full text if at least one of the two reviewers considered an abstract to be potentially relevant. Altogether, 155 articles were read in full text. Of these, 18 studies fulfilled pre-specified inclusion criteria. The quality of included articles was assessed using the QUADAS tool. Based on studies of high or moderate quality, the quality of evidence of each diagnostic method/test was rated in four levels according to GRADE. No study reached high quality; two were of moderate quality. The overall evidence was insufficient to assess the value of toothache or abnormal reaction to heat/cold stimulation for determining the pulp condition. The same applies to methods for establishing pulp status, including electric or thermal pulp testing, or methods for measuring pulpal blood circulation. In general, there are major shortcomings in the design, conduct and reporting of studies in this domain of dental research.

Treatment of haemophilia A and B and von Willebrand's disease: summary and conclusions of a systematic review as part of a Swedish health-technology assessment.

In an ongoing health-technology assessment of haemophilia treatment in Sweden, performed by the governmental agency Dental and Pharmaceutical Benefits Agency (TLV; tandvårds-och lakemedelsförmånsverket), the Swedish Council on Health Technology Assessment (SBU; statens beredning för medicinsk utvardering) was called upon to evaluate treatment of haemophilia A and B and von Willebrand's disease (VWD) with clotting factor concentrates. To evaluate the following questions: What are the short-term and long-term effects of different treatment strategies? What methods are available to treat haemophilia patients that have developed inhibitors against factor concentrates? Based on the questions addressed by the project, a systematic database search was conducted in PubMed, NHSEED, Cochrane Library, EMBASE and other relevant databases. The literature search covered all studies in the field published from 1985 up to the spring of 2010. In most instances, the scientific evidence is insufficient for the questions raised in the review. Concentrates of coagulation factors have good haemostatic effects on acute bleeding and surgical intervention in haemophilia A and B and VWD, but conclusions cannot be drawn about possible differences in the effects of different dosing strategies for acute bleeding and surgery. Prophylaxis initiated at a young age can prevent future joint damage in persons with haemophilia. The available treatment options for inhibitors have been insufficiently assessed. The economic consequences of various treatment regimens have been insufficiently analysed. Introduction of national and international registries is important.

[Multilevel analysis of regional disparities in survival after heart failure: differences between county health services affect little patients' prognosis]. / Multinivåanalys av regionala skillnader i överlevnad efter hjärtsvikt: landstingens egenskaper har föga inflytande på patientens prognos.

The prognosis for patients suffering from heart failure in Sweden differs from county to county, indicating a need for a comparative study in order to uncover the reasons. Conventional single-level analytical methods, however, underestimate the statistical uncertainty in such studies, leading to an inappropriate ranking of regions. Consequently, public opinion and decision-making may be misled. Conventional methods are also unable to disentangle the extent to which differences in prognosis may depend on individual or regional factors. Multilevel analysis, on the other hand, provides a better estimate of statistical uncertainty, and can both identify and quantify the extent to which differences in prognosis depend on either patient-related or regional factors. Using multilevel analysis, we examined the one-year mortality of 38,343 heart failure patients for the period 1992-1995 in every county in Sweden. Regional differences in one-year mortality were found to be very small, the most relevant factors being individual ones. The limited differences distinguishable at the county level may be explained in part by physician density: the more physicians in a county, the better an individual patient's prognosis.

Cost of illness of adult diabetes mellitus underestimated if comorbidity is not considered.

OBJECTIVE: To determine costs of illness for adult diabetes mellitus (DM), including complications caused by DM. DESIGN: A population-based multicentre cross- sectional study including an interview and a physical examination of patients identified as having DM. The patients' medical records were analysed regarding diagnoses and complications attributable to DM. SETTING: Eight health care centres of six primary care districts in Southern Sweden. SUBJECTS: 1677 adults aged 25+, cared for at the health care centres, entered the study. MAIN OUTCOME MEASURES: Utilization of health care and care from relatives and the municipality, absence of short- and long-term sickness, cost of illness. RESULTS: The average annual direct and indirect costs for an adult with DM were calculated to be 61 700 Swedish Kronor (SEK) or 2.5 times higher than earlier estimates. The incremental cost of DM was 34 100 SEK. The cost distribution was 28% for health care, 31% for the municipality and relatives and 41% lost productivity. CONCLUSIONS: Calculations for the cost of illness of DM are underestimated if comorbidity caused by DM is not considered. When DM-related complications are included to identify the actual burden of disease to society, the cost of illness as a result of DM in Sweden is substantially higher than previously estimated.

Prevention of osteoporosis--a cost-effectiveness. Analysis regarding fractures.

Osteoporosis increases for postmenopausal women. The risks of complications, i e fractures, from osteoporosis is recognized. The affected women with fractures suffer and the costs of health care are considerable. Screening by bone mineral density (BMD) measurement in combination with estrogen prevention of osteoporosis may reduce fractures in elderly women. The question whether benefits will exceed costs is studied for a cohort of women, aged 50-54 years, in Malmöhus county council.

Kinetic retrieval of eosinophil cationic protein, hyaluronan, secretory IgA, albumin, and urea during BAL in healthy subjects.

Determination of absolute concentrations of various soluble components of the epithelial lining fluid (ELF) may be valuable to estimate inflammatory activities within the underlying lung tissue. Internal standards may then be used as markers of dilution of bronchoalveolar lavage (BAL). The aim of this study was to determine whether different dwell times would affect the relationship between the concentrations of any of the three potential internal standards (secretory IgA [SIgA], albumin, and urea), and the concentrations of two potential markers of inflammation (eosinophil cationic protein [ECP] and hyaluronan [HA]) in BAL. A series of aliquots of BAL fluid were aspirated every 60 s up to 8 min after a bolus instillation of saline solution in 20 healthy subjects (10 smokers). The BAL concentrations of albumin and urea increased with time, consistent with continuous diffusion from the body water pool, absorption of the BAL fluid, or both. The rate constant of diffusion was 1,000 times higher for urea than for albumin (3.38 x 10(-1) and 3.64 x 10(-4), respectively), reflecting the difference in molecular weights, and in agreement with the notion that albumin and urea appeared in BAL fluid by a rate-limited procedure related to osmotic transfer. Biexponential increases of SIgA were recorded, suggesting a two-compartmental origin of this compound, normally located to mucosal membranes and presumed to be dissolved in ELF. Time-dependent increases in BAL fluid of HA also were recorded, but on the other hand, the ECP concentrations tended to level off after an initial increase, suggesting that the bulk of ECP appeared in BAL by a nonosmotic mechanism. We conclude that the kinetics of these three internal standards in BAL fluid differs greatly from each other and from the kinetics of the two selected markers of inflammation. Consequently, internal standards for determination of absolute concentrations of markers of inflammation in ELF should be carefully selected because of the requirement of matched kinetics of the markers.

Severe traumatic brain lesions in Sweden. Part 3: Economic aspects of aggressive neurosurgical intensive care.

The present study had two main objectives: Firstly, to document the economic differences between 'ordinary' and 'aggressive' neurosurgical intensive care and secondly, to evaluate the medical benefits in relation to costs for different subgroups of head-injured patients. The study compares patients injured in traffic accidents and treated in the Department of Neurosurgery, University Hospital of Lund, during 1977-1978 (n = 67) with similar patients treated during 1983-1984 (n = 87) after introduction of more vigorous neurosurgical intensive care. The economic analysis was performed by means of the CRISE-method (Cost Related Index Score Evaluation) and all costs were related to the monetary value in 1984. Adoption of a program for 'aggressive' neurosurgical intensive care increased the costs per treated patient by about 46% (from 70.887 Swedish Crowns (SEK) to 103.452 SEK). Mortality decreased significantly after the change in intensive care and the cost per surviving patient remained virtually unaffected (131.928 SEK vs. 132.357 SEK). Further, after introduction of the 'aggressive' programme a larger proportion of the economic expenditures were spent on patients who ultimately recovered well. It is concluded that the increase in costs following introduction of a more vigorous intensive care programme in patients with severe traumatic brain lesions is very reasonable in relation to the documented medical benefits.

Does flexible sigmoidoscopy have any justification as compared with complete colonoscopy. An analysis of cost-effectiveness and medical risks.

The authors present a medical risk- and cost-effectiveness analysis of what to do next when a single polyp is found in the distal 60 centimeters of the colorectum on a double contrast X-ray examination - sigmoidoscopy or colonoscopy.

Cyclic nucleotides and catecholamines in rheumatoid arthritis.

A controlled cross over study on the effect of fasting on cyclic nucleotide and catecholamine excretion was carried out in 12 female RA patients. They were hospitalized during a control and fasting period. The fasting period started with 3 days of habituation to hospital conditions, followed by 7 days of total fasting. Thereafter followed 3 days of realimentation. The control period was in every respect identical with the fasting period, with the exception of food intake. All medication was stopped when the patients were admitted to the hospital. The urinary concentrations of cAMP, cGMP, E and NE were monitored daily. The clinical status of the subjects was evaluated every second day using Ritchie's clinical index. Clinical and laboratory measures of inflammatory activity remained unaltered during the control period, but improved significantly during fasting. Excretion of cAMP and cGMP was low during the control period when compared with published normal levels. The cAMP/cGMP ratio in urine was normal, however. The urinary levels of E and NE were normal in the control period, but increased significantly during fasting. Excretion of cAMP decreased during fasting, while urinary cGMP levels decreased initially, but rose to prefasting levels towards the end of the fast. The cAMP/cGMP ratio increased during the first days of the fast, with a maximum on days 2 and 3. This increment coincided in time with the greatest rate of improvement in clinical joint activity.

Cyclic nucleotides in joint fluid in rheumatoid arthritis and in Reiter's syndrome.

Levels of cyclic adenosine 3',5'-monophosphate (cAMP) and cyclic guanosine 3',5'-monophosphate (cGMP) have been investigated in joint fluid in inflammatory arthropathies. A disturbed balance between cAMP and cGMP due to a depressed level of cAMP was found in rheumatoid arthritis (RA) and Reiter's syndrome, in comparison with patients with osteoarthritis. No correlation could be demonstrated between the absolute levels of cAMP or cGMP and the degree of local inflammatory activity, white cell count, or lysosomal enzyme activity in the joint fluid. Intra-articular injection of epinephrine showed just as good an effect on local pain as betamethasone (Cellestona), but the steriod reduced the swelling more effectively. An increase in intracellular levels of cAMP at 20 min was observed following injection of epinephrine with a slight change in cGMP. Intra-articular injection of dibutyryl-cAMP (db-cAMP) produced a marked easing of local pain and swelling in each of the 4 patients so treated. It is concluded that stimulation of the beta-adrenergic system or injection with db-cAMP may be beneficial in rheumatoid inflammation.