Prolonged grief during and beyond the pandemic: factors associated with levels of grief in a four time-point longitudinal survey of people bereaved in the first year of the COVID-19 pandemic.

Background: The COVID-19 pandemic has been a devastating and enduring mass-bereavement event, with uniquely difficult sets of circumstances experienced by people bereaved at this time. However, little is known about the long-term consequences of these experiences, including the prevalence of Prolonged Grief Disorder (PGD) and other conditions in pandemic-bereaved populations. Methods: A longitudinal survey of people bereaved in the UK between 16 March 2020 and 2 January 2021, with data collected at baseline (n = 711), c. 8 (n = 383), 13 (n = 295), and 25 (n = 185) months post-bereavement. Using measures of Prolonged Grief Disorder (PGD) (Traumatic Grief Inventory), grief vulnerability (Adult Attitude to Grief Scale), and social support (Inventory of Social Support), this analysis examines how participant characteristics, characteristics of the deceased and pandemic-related circumstances (e.g., restricted visiting, social isolation, social support) are associated with grief outcomes, with a focus on symptoms of PGD. Results: At baseline, 628 (88.6%) of participants were female, with a mean age of 49.5 (SD 12.9). 311 (43.8%) deaths were from confirmed/suspected COVID-19. Sample demographics were relatively stable across time points. 34.6% of participants met the cut-off for indicated PGD at c. 13 months bereaved and 28.6% at final follow-up. Social isolation and loneliness in early bereavement and lack of social support over time strongly contributed to higher levels of prolonged grief symptoms, while feeling well supported by healthcare professionals following the death was associated with reduced levels of prolonged grief symptoms. Characteristics of the deceased most strongly associated with lower levels of prolonged grief symptoms, were a more distant relationship (e.g., death of a grandparent), an expected death and death occurring in a care-home. Participant characteristics associated with higher levels of prolonged grief symptoms included low level of formal education and existence of medical conditions. Conclusion: Results suggest higher than expected levels of PGD compared with pre-pandemic times, with important implications for bereavement policy, provision and practice now (e.g., strengthening of social and specialist support) and in preparedness for future pandemics and mass-bereavement events (e.g., guidance on infection control measures and rapid support responses).

Structure-Activity Relationships of Low Molecular Weight Alginate Oligosaccharide Therapy against Pseudomonas aeruginosa.

Low molecular weight alginate oligosaccharides have been shown to exhibit anti-microbial activity against a range of multi-drug resistant bacteria, including Pseudomonas aeruginosa. Previous studies suggested that the disruption of calcium (Ca2+)-DNA binding within bacterial biofilms and dysregulation of quorum sensing (QS) were key factors in these observed effects. To further investigate the contribution of Ca2+ binding, G-block (OligoG) and M-block alginate oligosaccharides (OligoM) with comparable average size DPn 19 but contrasting Ca2+ binding properties were prepared. Fourier-transform infrared spectroscopy demonstrated prolonged binding of alginate oligosaccharides to the pseudomonal cell membrane even after hydrodynamic shear treatment. Molecular dynamics simulations and isothermal titration calorimetry revealed that OligoG exhibited stronger interactions with bacterial LPS than OligoM, although this difference was not mirrored by differential reductions in bacterial growth. While confocal laser scanning microscopy showed that both agents demonstrated similar dose-dependent reductions in biofilm formation, OligoG exhibited a stronger QS inhibitory effect and increased potentiation of the antibiotic azithromycin in minimum inhibitory concentration and biofilm assays. This study demonstrates that the anti-microbial effects of alginate oligosaccharides are not purely influenced by Ca2+-dependent processes but also by electrostatic interactions that are common to both G-block and M-block structures.

Survey of practices for documenting evidence of bruises from physical abuse during child protection proceedings.

Accurate recording of forensically important information on bruises is vital in child protection proceedings (Royal College of Paediatrics and Child Health (RCPCH)). An online survey was distributed to the RCPCH child protection committees to assess compliance with guidance. 56 individuals were contacted by email, 47 (84%) completed the survey. Results showed that the paediatricians always or usually record size (n=41; 87%), site (n=45; 96%), shape (n=32; 68%) and colour (n=36; 77%); n=10; 22% of the paediatricians stated that they 'always' used a ranking system for likelihood of abuse; n=12; 35% of those surveyed 'sometimes' estimated the size of the bruise. Results showed that paediatric bruise reporting is inconsistent and incomplete for some fields compared with national guidance.

Initial Steps towards a Multilevel Functional Principal Components Analysis Model of Dynamical Shape Changes.

In this article, multilevel principal components analysis (mPCA) is used to treat dynamical changes in shape. Results of standard (single-level) PCA are also presented here as a comparison. Monte Carlo (MC) simulation is used to create univariate data (i.e., a single "outcome" variable) that contain two distinct classes of trajectory with time. MC simulation is also used to create multivariate data of sixteen 2D points that (broadly) represent an eye; these data also have two distinct classes of trajectory (an eye blinking and an eye widening in surprise). This is followed by an application of mPCA and single-level PCA to "real" data consisting of twelve 3D landmarks outlining the mouth that are tracked over all phases of a smile. By consideration of eigenvalues, results for the MC datasets find correctly that variation due to differences in groups between the two classes of trajectories are larger than variation within each group. In both cases, differences in standardized component scores between the two groups are observed as expected. Modes of variation are shown to model the univariate MC data correctly, and good model fits are found for both the "blinking" and "surprised" trajectories for the MC "eye" data. Results for the "smile" data show that the smile trajectory is modelled correctly; that is, the corners of the mouth are drawn backwards and wider during a smile. Furthermore, the first mode of variation at level 1 of the mPCA model shows only subtle and minor changes in mouth shape due to sex; whereas the first mode of variation at level 2 of the mPCA model governs whether the mouth is upturned or downturned. These results are all an excellent test of mPCA, showing that mPCA presents a viable method of modeling dynamical changes in shape.

Factors Associated With Higher Levels of Grief and Support Needs Among People Bereaved During the Pandemic: Results from a National Online Survey.

We identified factors associated with higher levels of grief and support needs among 711 people bereaved during the COVID-19 pandemic in the UK (deaths 16 March 2020-2 January 2021). An online survey assessed grief using the Adult Attitude to Grief (AAG) scale, which calculates an overall index of vulnerability (IOV) (range 0-36), and practical and emotional support needs in 13 domains. Participants' mean age was 49.5 (SD 12.9); 628 (88.6%) female. Mean age of deceased 72.2 (SD 16.1). 311 (43.8%) deaths were from confirmed/suspected COVID-19. High overall levels of grief and support needs were observed; 28.2% exhibited severe vulnerability (index of vulnerability ≥24). Grief and support needs were higher for close relationships with the deceased (vs. more distant) and reported social isolation and loneliness (p < 0.001), and lower when age of deceased was above 40-50. Other associated factors were place of death and health professional support post-death (p < 0.05).

'It was brutal. It still is': a qualitative analysis of the challenges of bereavement during the COVID-19 pandemic reported in two national surveys.

Background: The COVID-19 pandemic has been a devastating, mass bereavement event characterised by high levels of disruption to end-of-life, grieving and coping processes. Quantitative evidence is emerging on the effects of the pandemic on grief outcomes, but rich qualitative evidence on the lived experiences of people bereaved during these times is lacking. Methods: We analysed qualitative data from two independent UK-wide online surveys to describe the experiences of 881 people bereaved during the pandemic. We analysed the data in two phases, conducting an inductive thematic analysis and then applying Stroebe and Schut's Dual Process Model (DPM) and concepts of loss-oriented and restoration-oriented coping (1999; 2010) as an analytic lens to further contextualise and interpret the data. Results: We identified six main themes: troubled deaths; mourning, memorialisation and death administration; mass bereavement, the media and the ongoing threat of the pandemic; grieving and coping; work and employment; and support from the health and social care system. Examples of loss-oriented stressors included being unable to visit and say goodbye at the end of life and restricted funeral and memorialisation practices. Associated reactions were feelings of guilt, anger, and problems accepting the death and beginning to grieve. Examples of restoration-oriented stressors and reactions were severely curtailed support-systems and social/recreational activities, which impacted people's ability to cope. Conclusion: Study results demonstrate the exceptionally difficult sets of experiences associated with pandemic bereavement, and the utility of the DPM for conceptualising these additional challenges and their impacts on grieving. Our analysis builds and expands on previous use of the DPM in explicating the impact of the pandemic on bereavement. We make recommendations for statutory, private and third sector organisations for improving the experiences of people bereaved during and following this and future pandemics.

An Exploration of Pathologies of Multilevel Principal Components Analysis in Statistical Models of Shape.

3D facial surface imaging is a useful tool in dentistry and in terms of diagnostics and treatment planning. Between-group PCA (bgPCA) is a method that has been used to analyse shapes in biological morphometrics, although various "pathologies" of bgPCA have recently been proposed. Monte Carlo (MC) simulated datasets were created here in order to explore "pathologies" of multilevel PCA (mPCA), where mPCA with two levels is equivalent to bgPCA. The first set of MC experiments involved 300 uncorrelated normally distributed variables, whereas the second set of MC experiments used correlated multivariate MC data describing 3D facial shape. We confirmed results of numerical experiments from other researchers that indicated that bgPCA (and so also mPCA) can give a false impression of strong differences in component scores between groups when there is none in reality. These spurious differences in component scores via mPCA decreased significantly as the sample sizes per group were increased. Eigenvalues via mPCA were also found to be strongly affected by imbalances in sample sizes per group, although this problem was removed by using weighted forms of covariance matrices suggested by the maximum likelihood solution of the two-level model. However, this did not solve problems of spurious differences between groups in these simulations, which was driven by very small sample sizes in one group. As a "rule of thumb" only, all of our experiments indicate that reasonable results are obtained when sample sizes per group in all groups are at least equal to the number of variables. Interestingly, the sum of all eigenvalues over both levels via mPCA scaled approximately linearly with the inverse of the sample size per group in all experiments. Finally, between-group variation was added explicitly to the MC data generation model in two experiments considered here. Results for the sum of all eigenvalues via mPCA predicted the asymptotic amount for the total amount of variance correctly in this case, whereas standard "single-level" PCA underestimated this quantity.

Factors associated with dental fluorosis among Malaysian children exposed to different fluoride concentrations in the public water supply.

OBJECTIVES: To determine the prevalence of dental fluorosis, and factors associated with its occurrence in two cohorts of children exposed to different fluoride concentrations in the Malaysian water supply. METHODS: A cross-sectional study was conducted among lifelong residents (n = 1,155) aged 9 and 12 years old living in fluoridated and nonfluoridated areas. Malaysian children aged 12 years were born when the level of fluoride in the public water supply was 0.7 ppm while those aged 9 years were born after the level was reduced to 0.5 ppm. Fluorosis was blind scored using standardized photographs of maxillary central incisors using Dean's criteria. Fluoride exposures and other factors were assessed by parental questionnaire. Data were analyzed using descriptive statistics, Chi-squared analyses, and logistic regression. RESULTS: Fluorosis prevalence was lower (31.9 percent) among the younger children born after the reduction of fluoride concentration in the water, compared to a prevalence of 38.4 percent in the older cohort. Early tooth brushing practices and fluoridated toothpaste were not statistically associated with fluorosis status. However, the prevalence of fluorosis was significantly associated with parents' education level, parents' income, fluoridated water, type of infant feeding method, age breast feeding ceased, use of formula milk, duration of formula milk intake, and type of water used to reconstitute formula milk via simple logistic regression. Fluoridated water remained a significant risk factor for fluorosis in multiple logistic regression. CONCLUSIONS: Fluorosis was lower among children born after the adjustment of fluoride concentration in the water. Fluoridated water remained as a strong risk factor for fluorosis after downward adjustment of its fluoride concentration.

Dental and maxillofacial radiology: confidence, knowledge and skills in the newly graduated dentist.

Introduction The UK General Dental Council says that the new graduate will have the range of skills required to begin working as part of a dental team and be well-prepared for independent practice. This study examines the views of new dental graduates in the area of dental and maxillofacial radiology.Materials and methods A questionnaire survey of newly graduated dentists in Wales and South West England asked about their experience of undergraduate education in dental and maxillofacial radiology, and their confidence in the use and interpretation of imaging techniques in early independent practice.Results Most survey participants were confident in the teaching they had received in dental radiography and radiology, and that they could apply their knowledge and understanding to the more common investigations used in general dental practice. They were less confident in the uncommonly used techniques, such as oblique lateral and lateral cephalometric views.Discussion This study is encouraging in that new dental graduates say that their undergraduate education has given them the knowledge to be able to take, interpret and make clinical diagnoses using the commonest radiological investigations. This tends to validate the undergraduate education received and identifies areas to improve.Conclusion New dental graduates are confident in their knowledge and skills, and apply these to the most commonly used radiological investigations used in general dental practice.

Initial Investigations of the Cranial Size and Shape of Adult Eurasian Otters (Lutra lutra) in Great Britain.

Three-dimensional (3D) surface scans were carried out in order to determine the shapes of the upper sections of (skeletal) crania of adult Eurasian otters (Lutra lutra) from Great Britain. Landmark points were placed on these shapes using a graphical user interface (GUI) and distance measurements (i.e., the length, height, and width of the crania) were found by using the landmark points. Male otters had significantly larger skulls than females (P < 0.001). Differences in size also occurred by geographical area in Great Britain (P < 0.05). Multilevel Principal Components Analysis (mPCA) indicated that sex and geographical area explained 31.1% and 9.6% of shape variation in "unscaled" shape data and that they explained 17.2% and 9.7% of variation in "scaled" data. The first mode of variation at level 1 (sex) correctly reflected size changes between males and females for "unscaled" shape data. Modes at level 2 (geographical area) also showed possible changes in size and shape. Clustering by sex and geographical area was observed in standardized component scores. Such clustering in a cranial shape by geographical area might reflect genetic differences in otter populations in Great Britain, although other potentially confounding factors (e.g., population age-structure, diet, etc.) might also drive regional differences. This work provides a successful first test of the effectiveness of 3D surface scans and multivariate methods, such as mPCA, to study the cranial morphology of otters.

Multilevel Analysis of the Influence of Maternal Smoking and Alcohol Consumption on the Facial Shape of English Adolescents.

This cross-sectional study aims to assess the influence of maternal smoking and alcohol consumption during pregnancy on the facial shape of non-syndromic English adolescents and demonstrate the potential benefits of using multilevel principal component analysis (mPCA). A cohort of 3755 non-syndromic 15-year-olds from the Avon Longitudinal Study of Parents and Children (ALSPAC), England, were included. Maternal smoking and alcohol consumption during the 1st and 2nd trimesters of pregnancy were determined via questionnaire at 18 weeks gestation. 21 facial landmarks, used as a proxy for the main facial features, were manually plotted onto 3D facial scans of the participants. The effect of maternal smoking and maternal alcohol consumption (average 1-2 glasses per week) was minimal, with 0.66% and 0.48% of the variation in the 21 landmarks of non-syndromic offspring explained, respectively. This study provides a further example of mPCA being used effectively as a descriptive analysis in facial shape research. This is the first example of mPCA being extended to four levels to assess the influence of environmental factors. Further work on the influence of high/low levels of smoking and alcohol and providing inferential evidence is required.

Cellulose Nanofibril Formulations Incorporating a Low-Molecular-Weight Alginate Oligosaccharide Modify Bacterial Biofilm Development.

Cellulose nanofibrils (CNFs) from wood pulp are a renewable material possessing advantages for biomedical applications because of their customizable porosity, mechanical strength, translucency, and environmental biodegradability. Here, we investigated the growth of multispecies wound biofilms on CNF formulated as aerogels and films incorporating the low-molecular-weight alginate oligosaccharide OligoG CF-5/20 to evaluate their structural and antimicrobial properties. Overnight microbial cultures were adjusted to 2.8 × 109 colony-forming units (cfu) mL-1 in Mueller Hinton broth and growth rates of Pseudomonas aeruginosa PAO1 and Staphylococcus aureus 1061A monitored for 24 h in CNF dispersions sterilized by γ-irradiation. Two CNF formulations were prepared (20 g m-2) with CNF as air-dried films or freeze-dried aerogels, with or without incorporation of an antimicrobial alginate oligosaccharide (OligoG CF-5/20) as a surface coating or bionanocomposite, respectively. The materials were structurally characterized by scanning electron microscopy (SEM) and laser profilometry (LP). The antimicrobial properties of the formulations were assessed using single- and mixed-species biofilms grown on the materials and analyzed using LIVE/DEAD staining with confocal laser scanning microscopy (CLSM) and COMSTAT software. OligoG-CNF suspensions significantly decreased the growth of both bacterial strains at OligoG concentrations >2.58% (P < 0.05). SEM showed that aerogel-OligoG bionanocomposite formulations had a more open three-dimensional structure, whereas LP showed that film formulations coated with OligoG were significantly smoother than untreated films or films incorporating PEG400 as a plasticizer (P < 0.05). CLSM of biofilms grown on films incorporating OligoG demonstrated altered biofilm architecture, with reduced biomass and decreased cell viability. The OligoG-CNF formulations as aerogels or films both inhibited pyocyanin production (P < 0.05). These novel CNF formulations or bionanocomposites were able to modify bacterial growth, biofilm development, and virulence factor production in vitro. These data support the potential of OligoG and CNF bionanocomposites for use in biomedical applications where prevention of infection or biofilm growth is required.

The impact of a reduction in fluoride concentration in the Malaysian water supply on the prevalence of fluorosis and dental caries.

OBJECTIVE: To assess the prevalence and severity of dental fluorosis and caries among Malaysian children following the reduction in fluoride concentration from 0.7 to 0.5 parts per million (ppm) in the public water supply. METHODS: This study involved lifelong residents aged 9- and 12-year-olds in fluoridated and nonfluoridated areas in Malaysia (n = 1155). In the fluoridated area, children aged 12 years and 9 years were exposed to 0.7 and 0.5 ppm, respectively, at the times when maxillary central incisors developed. Standardized photographs of maxillary central incisors were blind scored for fluorosis using Dean's criteria. Dental caries was examined using ICDAS-II criteria. RESULTS: The prevalence of fluorosis (Dean's score ≥ 2) among children in the fluoridated area (35.7%, 95% CI: 31.9%-39.6%) was significantly higher (P < 0.001) than children in the nonfluoridated area (5.5%, 95% CI: 3.6%-7.4%). Of those in the fluoridated area, the prevalence of fluorosis decreased from 38.4% (95% CI: 33.1%-44.3%) for 12-year-olds to 31.9% (95% CI: 27.6%-38.2%) for 9-year-olds, although this difference was not statistically significant (P = 0.139). The mean caries experience in the permanent dentition was significantly lower in the fluoridated area than in the nonfluoridated area for both age groups (P < 0.05). In the multivariate models, the difference in the differences of caries experience between fluoridated and nonfluoridated areas remained statistically significant. This suggests that caries-preventive effect is still maintained at 0.5 ppm. CONCLUSION: Findings indicate that the change in fluoride level from 0.7 to 0.5 ppm has reduced fluorosis and maintains a caries-preventive effect. Although there is a reduction in fluorosis prevalence, the difference was not statistically significant.

What's in a Smile? Initial Analyses of Dynamic Changes in Facial Shape and Appearance.

Single-level principal component analysis (PCA) and multi-level PCA (mPCA) methods are applied here to a set of (2D frontal) facial images from a group of 80 Finnish subjects (34 male; 46 female) with two different facial expressions (smiling and neutral) per subject. Inspection of eigenvalues gives insight into the importance of different factors affecting shapes, including: biological sex, facial expression (neutral versus smiling), and all other variations. Biological sex and facial expression are shown to be reflected in those components at appropriate levels of the mPCA model. Dynamic 3D shape data for all phases of a smile made up a second dataset sampled from 60 adult British subjects (31 male; 29 female). Modes of variation reflected the act of smiling at the correct level of the mPCA model. Seven phases of the dynamic smiles are identified: rest pre-smile, onset 1 (acceleration), onset 2 (deceleration), apex, offset 1 (acceleration), offset 2 (deceleration), and rest post-smile. A clear cycle is observed in standardized scores at an appropriate level for mPCA and in single-level PCA. mPCA can be used to study static shapes and images, as well as dynamic changes in shape. It gave us much insight into the question "what's in a smile?".

A Comparative Study of ProTaper Universal and ProTaper Next Used by Undergraduate Students to Prepare Root Canals.

INTRODUCTION: The purpose of this study was to determine whether final-year undergraduate dental students achieved better shaping outcomes using the new ProTaper Next (PTN; Dentsply Sirona, Ballaigues, Switzerland) system to prepare root canals for the first time compared with the existing ProTaper Universal (PTU, Dentsply Sirona) system on which they had trained. A secondary aim was to explore the attitudes and preferences of the students toward both systems. METHODS: Forty students prepared 1 simulated S-shaped canal using PTN and another with PTU. Images of the canals were saved before and after preparation, and the outcomes assessed included the formation of aberrations and the amount of resin removed at specific points along the canal length. Student opinions relating to PTN and PTU were collected via a questionnaire completed immediately after using the systems. For statistical analysis, the McNemar test was used to compare the incidence of aberrations, and a paired t test was used to analyze the width measurements. Responses to the questionnaire were analyzed using frequencies. Thus, the McNemar test was used for paired binary data and the marginal homogeneity test for categoric data when more than 2 categories were used. Finally, the overall preferences (either PTN or PTU) were analyzed using the sign/binomial test, which is a standard statistical test that allows us to determine if the proportion preferring one or the other is equal or not. RESULTS: Canal ledges were formed in 30% of the canals prepared with PTU, whereas no ledges were formed with PTN (P < .001). A middle constriction, a form of canal aberration, was created by both systems although it occurred significantly (P = .006) more often with PTN. The "number of files" was judged by students to be significantly higher (P < .001) for PTU compared with PTN. Even though using PTN for the first time, students were more likely to recommend the system to other students for preparing S-shaped canals than PTU (P = .018) and preferred to use PTN in the future (P < .001). CONCLUSIONS: The students who had previous experience with the use of PTU were able to produce comparable shaping outcomes when they used PTN for the first time. For the preparation of S-shaped canals, the students preferred PTN over PTU in terms of the number of files and would prefer to use it in the future.

Improving the well-being of men by Evaluating and Addressing the Gastrointestinal Late Effects (EAGLE) of radical treatment for prostate cancer: study protocol for a mixed-method implementation project.

INTRODUCTION: Radiotherapy treatment for prostate cancer can cause bowel problems, which may lead to severe difficulties for cancer survivors including limiting travel, work or socialising. These symptoms can appear at any time following radiotherapy. This study focuses on the early identification and protocol-based management of effects known to cause long-term, or even permanent, changes to the well-being of prostate cancer survivors. The rationale of this study is to improve the care offered to men and their families following pelvic radiotherapy for prostate cancer. METHOD AND ANALYSIS: Implementation research methodology will be used to adopt a multicomponent intervention at three UK centres. The intervention package comprises a standardised clinical assessment of relevant symptoms in oncology outpatient clinics and rapid referral to an enhanced gastroenterological service for patients identified with bowel problems. Gastroenterology staff will be trained to use an expert-practice algorithm of targeted gastroenterology investigations and treatments. The evaluation of the intervention and its embedding within local practices will be conducted using a mixed-methods design. The effect of the new service will be measured in terms of the following outcomes: acceptability to staff and patients; quality of life; symptom control and cost-effectiveness. Data collection will take place at baseline, 6 months (±2 months), and 12 months (±2 months) after entry into the study. ETHICS AND DISSEMINATION: The study has ethical approval from the North West-Liverpool East Research Ethics Committee and the appropriate NHS governance clearance. All participants provide written informed consent. The study team aim to publish the results of the study in peer-reviewed journals as well as at national and international conferences. TRIAL REGISTRATION NUMBER: UKCRN16974.

Effectiveness of an audience response system on orthodontic knowledge retention of undergraduate dental students--a randomised control trial.

OBJECTIVE: To determine the effect of an audience response system (ARS) on knowledge retention of dental students and to gauge student perceptions of using the ARS. DESIGN: Randomised control study. SETTING: School of Dentistry, Cardiff University. PARTICIPANTS: Seventy four second-year dental students were stratified by gender and randomised anonymously to one of two groups. METHODS: One group received a lecture on orthodontic terminology and diagnosis in a traditional didactic format and the other received the same lecture integrated with ARS slides. Students completed an assessment of multiple-choice questions (MCQs) scored out of 20, before and immediately after the lecture. Students were also asked to complete a self-reported questionnaire on their perceptions of ARS. RESULTS: Both groups had statistically significant increases in MCQ scores post-lecture (ARS mean increase 3.6 SD2.0, 95% CI 2.2-3.5 and Didactic mean increase 2.9 SD2.3, 95% CI 2.8-4.3). A mixed-design analysis of variance showed that ARS led to an improved MCQ score (by 0.8 or 25%) compared to the didactic group, although this effect was not significant (P = 0.15). The effect of gender at baseline (P = 0.49), post-lecture (P = 0.73) and increase in MCQ score split by group (P = 0.46) was also not significant. Students reported that the ARS was easy to use, helped them engage with the lecture and encouraged them to work harder. CONCLUSION: The ARS did not lead to a significant increase in short-term orthodontic knowledge recall of students compared with didactic teaching. However, the use of ARS within orthodontic teaching could make lectures more interactive and engaging.

Prospective analysis of patient-reported late toxicity following pelvic radiotherapy for gynaecological cancer.

BACKGROUND AND PURPOSE: As late radiotherapy toxicity impacts negatively on the quality-of-life of cancer survivors and is often under reported, a study was set up to prospectively collect patient-reported data in an unselected series of patients with gynaecological malignancy. Aim 1 - To provide 3 year results for the longitudinal study. Aim 2 - To improve the questionnaire used to collect data by identifying redundant items and modifying for use to collect Common Terminology Criteria for Adverse Events (CTCAE) data. MATERIAL AND METHODS: Aim 1 - Patient reported outcome data were collected prospectively by 226 patients before and up to 3 years following radiotherapy for gynaecological cancer using a questionnaire developed to collect LENT subjective data. Aim 2 - A factor analysis was performed to identify which questions gave the most and least information. RESULTS: Aim 1 - Faecal urgency and incontinence (all grades) peaked at 79% and 24%, respectively at 1 year then settled to 69% and 18% at 3 years, respectively. Urinary urgency (all grades) increased with time and was described in 75% at 3 years. Other symptoms reported at 3 years include diarrhoea in 12%, urinary incontinence in 27% and vaginal dryness in 29%. A third of patients did not feel their sex life had changed following treatment, while a quarter felt that it had. Aim 2 - some questions overlapped and others were non-specific. The questionnaire has subsequently been altered. CONCLUSIONS: The extent of late toxicity is substantial. This detailed information is important for both patients and clinicians in terms of treatment decisions and follow-up care. The LENT questionnaire provides a feasible tool for capture of this information in the clinic.

Measurement error in statistical models of shape.

Active shape models (ASMs) are popular and sophisticated methods of extracting features in (especially medical) images. Here we analyse the error in placing ASM points on the boundary of the feature. By using replications, a corrected covariance matrix is presented that should reduce the effects of placement error. We show analytically and via simulations that the cumulative variability for a given number of eigenvalues retained in principal components analysis (PCA) ought to be reduced by increasing levels of point-placement error. Results for predicted errors are in excellent agreement with the set-up parameters of two simulated shapes and with anecdotal evidence from the trained experts for real data taken from the OSTEODENT project. We derive an equation for the reliability of placing the points and we find values of 0.79 and 0.85 (where 0=bad and 1=good) for the two clinical experts for the OSTEODENT data. These analyses help us to understand the sources and effects of measurement error in shape models.

Development of a patient-reported questionnaire for collecting toxicity data following prostate brachytherapy.

PURPOSE: To improve a questionnaire used to collect patient-reported outcomes from patients with early stage prostate cancer treated with brachytherapy. A secondary aim was to adapt the Late Effects of Normal Tissue (LENT) subjective toxicity questionnaire for use to collect Common Terminology Criteria for Adverse Events (CTCAE) data, the current preferred platform for assessing radiation toxicity. MATERIALS AND METHODS: Three hundred and seventy-seven patients were treated with permanent iodine-125 seed implant brachytherapy for early prostate cancer. Toxicity data were collected before and at nine time points post-treatment (0-36 months). Compliance rates for patients completing individual items and item-subsection correlation coefficients were calculated. A factor analysis was carried out to analyse responses to the questionnaire and identify less informative questions, which could be removed. Cronbach's α coefficient was used to measure reliability. RESULTS: Two thousand one hundred and eighty-eight questionnaires were analysed. There was poor compliance for questions specifically relating to operations and bowel medication. We found that the division of the questionnaire into subsections based on anatomical site was reasonable and that certain items could be safely removed. The high mean value for Cronbach's α across all questionnaires (0.752; 95% CI: 0.726-0.779) indicated that the questionnaire was reliable. Fifteen of the 44 questions were removed from the original questionnaires. Questions on urinary incontinence severity, management of urinary and bowel incontinence, effects of reduced flow of urine and the effects of symptoms on activity of daily living and change in sexual function were required to adapt the LENT subjective questionnaire for use to collect CTCAE data. CONCLUSIONS: A questionnaire, validated over 6 years to collect LENT subjective data were adapted and is a reliable approach for collecting CTCAE data after prostate brachytherapy.