Translation, cross-cultural adaptation, and validation of the sino-nasal outcome test (snot)-22 for Finnish patients.

PURPOSE: The Sino-Nasal Outcome Test-22 (SNOT-22) is the most commonly used disease-specific quality of life questionnaire in rhinology. The purpose of this prospective study was to translate and validate SNOT-22 into Finnish. METHODS: The validation process followed the guidelines proposed for cross-cultural adaptation of health-related measures of quality of life. The study consisted of three groups: rhinologic out-patients (N = 96), FESS patients (N = 49) and healthy controls (N = 79). Out-patient and FESS groups completed the questionnaire twice (answers A and B), out-patients after two weeks and FESS patients after 3 months. Validity, reliability and responsiveness were evaluated. RESULTS: The mean SNOT-22 sum score of the out-patient questionnaires were 35.3 points (answer A) and 32.4 points (answer B). ICC in out-patient group was 0.879. For the FESS patients, the mean pre- and postoperative (answer A and B) SNOT-22 sum scores were 46.8 and 21.9 points, respectively (p < 0.0001). The mean SNOT-22 of healthy controls was 8.9 points. The out-patients (answer A) and healthy controls had statistically significant difference in SNOT-22 scores (p < 0.0001). CONCLUSIONS: The results of our study show that the validated Finnish version of the SNOT-22 questionnaire demonstrates good validity, reliability and responsiveness.

Highlighting the need for de-implementation - Choosing Wisely recommendations based on clinical practice guidelines.

BACKGROUND: The Choosing Wisely campaign has spread to many countries. Methods for developing recommendations are inconsistent. We describe our process of developing such recommendations from a comprehensive national set of clinical practice guidelines (Current Care, CC) and the results of a one-year Choosing Wisely Finland project. METHODS: Two of the authors drafted the quality and process criteria for all the Choosing Wisely Finland recommendations. The quality criteria were relevance, feasibility, evidence-based and strength. These were discussed in editors' meetings and subsequently revised. Two different processes for developing recommendations within national clinical practice guidelines were designed and piloted (processes A and B). Process A was based on a published guideline. The recommendations are drafted by an editor and revised and approved by the guideline development group. In process B the development of the recommendations is integrated with guideline production or update. Choosing Wisely recommendations were then drafted for half of the published CC Guidelines. An additional process (process C) was designed for producing independent recommendations outside a guideline. RESULTS: At least one Choosing Wisely recommendation could be identified from 39 out of 52 reviewed guidelines. Of the 106 recommendations drafted, 62 (58%) were accepted for publication. The main reasons for rejection were inability to give a strong recommendation (n = 18, 41%) and insufficient relevance (n = 14, 32%). Two thirds (n = 41, 66%) of the published recommendations were based on high to moderate level of evidence, and 18% (n = 11) on low or very low level of evidence, whereas for the rest, the quality of evidence was not critically appraised. CONCLUSIONS: Choosing Wisely recommendations can be produced systematically from existing clinical practice guidelines. The rigorous methods of evidence-based medicine ensure high-quality recommendations. We welcome the use of our processes and methods describes in this article by other guideline-producing organizations.

Somatic symptoms in children who have a parent with cancer: A systematic review.

BACKGROUND: This systematic review explored the occurrence and types of somatic symptoms in children (0-20 years) who have experienced parental cancer. METHODS: We complemented a systematic literature search from PubMed and PsycInfo with a reference search. We identified 1,694 articles, which were independently screened by two authors; they further evaluated potentially relevant papers for quality and extracted the data. We found nine relevant studies (10 publications) on altogether 672 children with a parent who had cancer; four studies included a control group. RESULTS: The studies typically focused on children's psychosocial reactions on parental cancer rather than somatic complaints, so symptom prevalence cannot be reliably summarized. Several studies were small, and the types of somatic symptoms were only specified in five studies. Somatic symptoms were reported as a measure of emotional reactions in the remaining four studies. Three studies provided longitudinal data. The main types of specific symptoms reported were eating problems, pain, sleeping troubles, and bed-wetting. Children of cancer patients tended to show an increase of unspecified somatic symptoms and pain, but evidence was inconsistent. There was a tendency that somatic complaints were associated with increased emotional distress in the children. The material did not allow for separate analysis by age group or bereavement status. CONCLUSIONS: Children in families with parental cancer may present with somatic complaints, but the prevalence and significance is not possible to estimate due to very sparse research in this area. Health professionals or counselling providers should not overlook this possible sign of distress. Qualitative studies report significant health anxiety in these children; this may represent a specific topic for counselling in this population. Targeted studies are needed to evaluate the prevalence and significance of somatic symptoms, and especially vulnerable groups need to be identified.

Antibiotics for acute rhinosinusitis in adults.

BACKGROUND: Acute rhinosinusitis is an acute infection of the nasal passages and paranasal sinuses that lasts less than four weeks. Diagnosis of acute rhinosinusitis is generally based on clinical signs and symptoms in ambulatory care settings. Technical investigations are not routinely performed, nor are they recommended in most countries. Some trials show a trend in favour of antibiotics, but the balance of benefit versus harm is unclear.We merged two Cochrane Reviews for this update, which comprised different approaches with overlapping populations, resulting in different conclusions. For this review update, we maintained the distinction between populations diagnosed by clinical signs and symptoms, or imaging. OBJECTIVES: To assess the effects of antibiotics versus placebo or no treatment in adults with acute rhinosinusitis in ambulatory care settings. SEARCH METHODS: We searched CENTRAL (2017, Issue 12), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 1950 to January 2018), Embase (January 1974 to January 2018), and two trials registers (January 2018). We also checked references from identified trials, systematic reviews, and relevant guidelines. SELECTION CRITERIA: Randomised controlled trials of antibiotics versus placebo or no treatment in people with rhinosinusitis-like signs or symptoms or sinusitis confirmed by imaging. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data about cure and side effects and assessed the risk of bias. We contacted trial authors for additional information as required. MAIN RESULTS: We included 15 trials involving 3057 participants. Of the 15 included trials, 10 appeared in our 2012 review, and five (631 participants) are legacy trials from merging two reviews. No new studies were included from searches for this update. Overall, risk of bias was low. Without antibiotics, 46% of participants with rhinosinusitis, whether or not confirmed by radiography, were cured after 1 week and 64% after 14 days. Antibiotics can shorten time to cure, but only 5 to 11 more people per 100 will be cured faster if they receive antibiotics instead of placebo or no treatment: clinical diagnosis (odds ratio (OR) 1.25, 95% confidence interval (CI) 1.02 to 1.54; number needed to treat for an additional beneficial outcome (NNTB) 19, 95% CI 10 to 205; I² = 0%; 8 trials; high-quality evidence) and diagnosis confirmed by radiography (OR 1.57, 95% CI 1.03 to 2.39; NNTB 10, 95% CI 5 to 136; I² = 0%; 3 trials; moderate-quality evidence). Cure rates with antibiotics were higher when a fluid level or total opacification in any sinus was found on computed tomography (OR 4.89, 95% CI 1.75 to 13.72; NNTB 4, 95% CI 2 to 15; 1 trial; moderate-quality evidence). Purulent secretion resolved faster with antibiotics (OR 1.58, 95% CI 1.13 to 2.22; NNTB 10, 95% CI 6 to 35; I² = 0%; 3 trials; high-quality evidence). However, 13 more people experienced side effects with antibiotics compared to placebo or no treatment (OR 2.21, 95% CI 1.74 to 2.82; number needed to treat for an additional harmful outcome (NNTH) 8, 95% CI 6 to 12; I² = 16%; 10 trials; high-quality evidence). Five fewer people per 100 will experience clinical failure if they receive antibiotics instead of placebo or no treatment (Peto OR 0.48, 95% CI 0.36 to 0.63; NNTH 19, 95% CI 15 to 27; I² = 21%; 12 trials; high-quality evidence). A disease-related complication (brain abscess) occurred in one participant (of 3057) one week after receiving open antibiotic therapy (clinical failure, control group). AUTHORS' CONCLUSIONS: The potential benefit of antibiotics to treat acute rhinosinusitis diagnosed either clinically (low risk of bias, high-quality evidence) or confirmed by imaging (low to unclear risk of bias, moderate-quality evidence) is marginal and needs to be seen in the context of the risk of adverse effects. Considering antibiotic resistance, and the very low incidence of serious complications, we conclude there is no place for antibiotics for people with uncomplicated acute rhinosinusitis. We could not draw conclusions about children, people with suppressed immune systems, and those with severe sinusitis, because these populations were not included in the available trials.

Women's reasons for choosing abortion method: A systematic literature review.

AIMS: We aim to describe and classify reasons behind women's choice between medical and surgical abortion. METHODS: A systematic literature review was conducted in PubMed and PsycINFO in October 2015. The subjects were women in early pregnancy opting for abortion at clinics or hospitals in high-income countries. We extracted women's reasons for choice of abortion method and analysed these qualitatively, looking at main reasons for choosing either medical or surgical abortion. RESULTS: Reasons for choice of method were classified to five main groups: technical nature of the intervention, fear of complications, fear of surgery or anaesthesia, timing and sedation. Reasons for selecting medical abortion were often based on the perception of the method being 'more natural' and the wish to have abortion in one's home in addition to fear of complications. Women who opted for surgical abortion appreciated the quicker process, viewed it as the safer option, and wished to avoid pain and excess bleeding. Reasons were often based on emotional reactions, previous experiences and a lack of knowledge about the procedures. Some topics such as pain or excess bleeding received little attention. Overall the quality of the studies was low, most studies were published more than 10 years ago, and the generalisability of the findings was poor. CONCLUSION: Women did not base their choice of abortion method only on rational information from professionals but also on emotions and especially fears. Support techniques for a more informed choice are needed. Recent high-quality studies in this area are lacking.

International variation in programmes for assessment of children's neurodevelopment in the community: Understanding disparate approaches to evaluation of motor, social, emotional, behavioural and cognitive function.

BACKGROUND: Few areas of medicine demonstrate such international divergence as child development screening and surveillance. Many countries have nationally mandated surveillance policies, but the content of programmes and mechanisms for delivery vary enormously. The cost of programmes is substantial but no economic evaluations have been carried out. We have critically examined the history, underlying philosophy, content and delivery of programmes for child development assessment in five countries with comprehensive publicly funded health services (Denmark, Finland, Norway, Scotland and Sweden). The specific focus of this article is on motor, social, emotional, behavioural and global cognitive functioning including language. FINDINGS: Variations in developmental surveillance programmes are substantially explained by historical factors and gradual evolution although Scotland has undergone radical changes in approach. No elements of universal developmental assessment programmes meet World Health Organization screening criteria, although some assessments are configured as screening activities. The roles of doctors and nurses vary greatly by country as do the timing, content and likely costs of programmes. Inter-professional communication presents challenges to all the studied health services. No programme has evidence for improved health outcomes or cost effectiveness. CONCLUSIONS: Developmental surveillance programmes vary greatly and their structure appears to be driven by historical factors as much as by evidence. Consensus should be reached about which surveillance activities constitute screening, and the predictive validity of these components needs to be established and judged against World Health Organization screening criteria. Costs and consequences of specific programmes should be assessed, and the issue of inter-professional communication about children at remediable developmental risk should be prioritised.

Use of diagnostic tests and the appropriateness of the treatment decision in patients with suspected urinary tract infection in primary care in Denmark - observational study.

BACKGROUND: Inappropriate prescription of antibiotics is the leading driver of antimicrobial resistance (AMR). The majority of antibiotics are prescribed in primary care. Understanding how general practitioners (GPs) use diagnostic tests and the effect on treatment decision under daily practice conditions is important to reduce inappropriate prescription of antibiotics. The aim of the study was to investigate the use of diagnostic tests in primary care patients with suspected urinary tract infection (UTI) and to assess the appropriateness of the treatment decision (TD) under daily practice conditions in Denmark. METHODS: Prospective observational study. Symptomatic adult patients consulting general practice with suspected UTI recruited over 12 months. The diagnostic workup was registered in a standardized form. The appropriateness of the TD was assessed based on the results of a culture performed at a reference microbiological laboratory. TD was considered appropriate if a patient had a positive culture and was prescribed antibiotics or had a negative culture and was not prescribed antibiotics. TD was considered inappropriate if a patient had a negative culture and was prescribed antibiotics (overtreatment) or had a positive culture and was not prescribed antibiotics (undertreatment). RESULTS: Four hundred and eighty-eight patients were included. Dipstick was used in 98% of the patients and urine culture was used in 89% of the patients; 317 had the culture performed in practice and 117 had the culture performed at the hospital. The appropriateness of the final TD was significantly (p = 0.04) lower in patients without culture (55%) than in patients with culture performed in practice (71%) or at hospital (69%). CONCLUSION: In a context with wide availability of diagnostic tests, GPs use diagnostic tests for the decision-making process in all patients with suspected UTI. Urine culture is used in the majority of the patients and is associated with a higher proportion of appropriate treatment decisions. Performance of urine culture is therefore important in reducing inappropriate antibiotic prescribing in patients with suspected UTI seeking care in general practice in Denmark. TRIAL REGISTRATION: ClinicalTrials.gov NCT02249273 .

Antibiotic prescriptions for suspected respiratory tract infection in primary care in South America.

OBJECTIVES: To describe and compare antibiotic prescribing patterns for primary care patients with respiratory tract infections (RTIs) in four South American countries. METHODS: This was a prospective observational study. General practitioners (GPs) from Argentina, Bolivia, Paraguay and Uruguay registered data about all consultations of patients with suspected RTIs in the winter of 2014 (June-August). Variation in antibiotic prescriptions was assessed using a two-level hierarchical logistic model. RESULTS: Participating GPs (n = 171) registered 11 446 patients with suspected RTI; 3701 (33%) of these received an antibiotic prescription. There was a wide variation across countries in the use and selection of antibiotics. For example, 94% of patients with acute bronchitis were prescribed antibiotics in Bolivia, while in Uruguay only 21% received antibiotics. Amoxicillin was the most commonly prescribed antibiotic across countries, but prescription rates varied between 45% in Bolivia and 69% in Uruguay. Compared with the overall mean prescribing rate, and after adjusting for clinical presentation and demographics, prescribing of antibiotics varied by a factor of 6, the OR ranging from 0.37 (95% CI = 0.21-0.65) in Uruguay to 2.58 (95% CI = 1.66-4) in Bolivia. CONCLUSIONS: The large variation in use and selection of antibiotics across countries is not explained by different patient populations. It could be explained by diagnostic uncertainty and contextual characteristics beyond clinical practice. Reducing uncertainty and country variation requires greater support from the healthcare systems by providing GPs with evidence-based guidelines and tools to apply them.

Pit and fissure sealants for preventing dental decay in permanent teeth.

BACKGROUND: Dental sealants were introduced in the 1960s to help prevent dental caries, mainly in the pits and fissures of occlusal tooth surfaces. Sealants act to prevent bacteria growth that can lead to dental decay. Evidence suggests that fissure sealants are effective in preventing caries in children and adolescents compared to no sealants. Effectiveness may, however, be related to caries incidence level of the population. This is an update of a review published in 2004, 2008 and 2013. OBJECTIVES: To compare the effects of different types of fissure sealants in preventing caries in occlusal surfaces of permanent teeth in children and adolescents. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched: Cochrane Oral Health's Trials Register (to 3 August 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2016, Issue 7), MEDLINE Ovid (1946 to 3 August 2016), and Embase Ovid (1980 to 3 August 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials to 3 August 2016. No restrictions were placed on language or date of publication. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing sealants with no sealant or a different type of sealant material for preventing caries of occlusal surfaces of premolar or molar teeth in children and adolescents aged up to 20 years. Studies required at least 12 months follow-up. We excluded studies that compared compomers to resins/composites. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results, extracted data and assessed risk of bias of included studies. We presented outcomes for caries or no caries on occlusal surfaces of permanent molar teeth as odds ratio (OR) or risk ratio (RR). We used mean difference (MD) for mean caries increment. All measures were presented with 95% confidence intervals (CI). We conducted meta-analyses using a random-effects model for comparisons where there were more than three trials; otherwise we used the fixed-effect model. We used GRADE methods to assess evidence quality. MAIN RESULTS: We included 38 trials that involved a total of 7924 children; seven trials were new for this update (1693 participants). Fifteen trials evaluated the effects of resin-based sealant versus no sealant (3620 participants in 14 studies plus 575 tooth pairs in one study); three trials with evaluated glass ionomer sealant versus no sealant (905 participants); and 24 trials evaluated one type of sealant versus another (4146 participants). Children were aged from 5 to 16 years. Trials rarely reported background exposure to fluoride of trial participants or baseline caries prevalence. Resin-based sealant versus no sealant: second-, third- and fourth-generation resin-based sealants prevented caries in first permanent molars in children aged 5 to 10 years (at 24 months follow-up: OR 0.12, 95% CI 0.08 to 0.19, 7 trials (5 published in the 1970s; 2 in the 2010s), 1548 children randomised, 1322 children evaluated; moderate-quality evidence). If we were to assume that 16% of the control tooth surfaces were decayed during 24 months of follow-up (160 carious teeth per 1000), then applying a resin-based sealant would reduce the proportion of carious surfaces to 5.2% (95% CI 3.13% to 7.37%). Similarly, assuming that 40% of control tooth surfaces were decayed (400 carious teeth per 1000), then applying a resin-based sealant would reduce the proportion of carious surfaces to 6.25% (95% CI 3.84% to 9.63%). If 70% of control tooth surfaces were decayed, there would be 19% decayed surfaces in the sealant group (95% CI 12.3% to 27.2%). This caries-preventive effect was maintained at longer follow-up but evidence quality and quantity was reduced (e.g. at 48 to 54 months of follow-up: OR 0.21, 95% CI 0.16 to 0.28, 4 trials, 482 children evaluated; RR 0.24, 95% CI 0.12 to 0.45, 203 children evaluated). Although studies were generally well conducted, we assessed blinding of outcome assessment for caries at high risk of bias for all trials (blinding of outcome assessment is not possible in sealant studies because outcome assessors can see and identify sealant). Glass ionomer sealant versus no sealant: was evaluated by three studies. Results at 24 months were inconclusive (very low-quality evidence). One sealant versus another sealant: the relative effectiveness of different types of sealants is unknown (very low-quality evidence). We included 24 trials that directly compared two different sealant materials. Comparisons varied in terms of types of sealant assessed, outcome measures chosen and duration of follow-up. Adverse events: only four trials assessed adverse events. No adverse events were reported. AUTHORS' CONCLUSIONS: Resin-based sealants applied on occlusal surfaces of permanent molars are effective for preventing caries in children and adolescents. Our review found moderate-quality evidence that resin-based sealants reduced caries by between 11% and 51% compared to no sealant, when measured at 24 months. Similar benefit was seen at timepoints up to 48 months; after longer follow-up, the quantity and quality of evidence was reduced. There was insufficient evidence to judge the effectiveness of glass ionomer sealant or the relative effectiveness of different types of sealants. Information on adverse effects was limited but none occurred where this was reported. Further research with long follow-up is needed.

HTA IN CENTRAL-EASTERN-SOUTHERN EUROPE: FINDING ITS WAY TO HEALTH POLICY.

The number of publications on health technology assessment (HTA) from Central, Eastern, and Southern Europe (CESE countries) is still low compared with the north and west of Europe. It is not surprising, as the idea of HTA originated from high-income Western economies and was afterward adopted by the south-eastern part of Europe, which mostly consists of middle-income countries. These CESE countries, with less capacity and experience with HTA processes, must deal with even tougher decisions on financing health technologies than north-western Europe. There may even be a lack of confidence to open discussions on their specific needs for HTA.

IMPLEMENTING HEALTH TECHNOLOGY ASSESSMENT-BASED RECOMMENDATIONS IN FINLAND: MANAGED UPTAKE OF MEDICAL METHODS.

OBJECTIVES: The Managed Uptake of Medical Methods Program (MUMM) started 10 years ago as a joint venture of the Finnish Office for Health Technology Assessment (Finohta) and the twenty hospital districts in Finland. The aim is to offer information on the effectiveness, safety, organizational effects, and costs of new medical methods to support decisions concerning their uptake in secondary care. In this article, we discuss the successes and challenges of implementing the MUMM program. METHODS: A study of awareness and use of five MUMM recommendations for various medical specialties with short-form web-based surveys to hospitals. RESULTS: The recommendations were noticed and considered relevant. In overall assessment they received a mean rating of 8.4 (range: 4 to 10). Two thirds of the respondents thought MUMM recommendations were useful for practice, but only a third had actually used them in decision making. CONCLUSIONS: HTA-based MUMM recommendations were well received by physicians but in practice they are less used than clinical practice guidelines. Short-form electronic surveys were a useful way of gathering information about awareness and implementation. The surveys also functioned as another method of informing key physicians about the recommendations.

Pit and fissure sealants versus fluoride varnishes for preventing dental decay in the permanent teeth of children and adolescents.

BACKGROUND: Most of the detected increment in dental caries among children and adolescents is confined to occlusal surfaces of posterior permanent molars. Dental sealants and fluoride varnishes are much used preventive options for caries. Although the effectiveness of sealants and fluoride varnishes for controlling caries as compared with no intervention has been demonstrated in clinical trials and summarised in systematic reviews, the relative effectiveness of these two interventions remains unclear. This review is an update of one first published in 2006 and last updated in 2010. OBJECTIVES: Primary objective • To evaluate the relative effectiveness of fissure sealants compared with fluoride varnishes, or fissure sealants together with fluoride varnishes compared with fluoride varnishes alone, for preventing dental caries in the occlusal surfaces of permanent teeth of children and adolescents. Secondary objectives • To evaluate whether effectiveness is influenced by sealant material type and length of follow-up.• To document and report on data concerning adverse events associated with sealants and fluoride varnishes. SEARCH METHODS: We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 18 December 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 11), MEDLINE via Ovid (1946 to 18 December 2015) and EMBASE via Ovid (1980 to 18 December 2015). We also searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the World Health Organization (WHO) Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on language or date of publication when searching electronic databases. We screened the reference lists of identified trials and review articles for additional relevant studies. SELECTION CRITERIA: We included randomised controlled trials with at least 12 months of follow-up comparing fissure sealants, or fissure sealants together with fluoride varnishes, versus fluoride varnishes for preventing caries in the occlusal surfaces of permanent premolar or molar teeth, in participants younger than 20 years of age at the start of the study. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results, extracted data and assessed risk of bias of included studies. We attempted to contact study authors to obtain missing or unclear information.We grouped and analysed studies on the basis of sealant material type (resin-based sealant and glass ionomer-based sealant: glass ionomer and resin-modified glass ionomer) and different follow-up periods. We calculated the odds ratio (OR) for caries or no caries on occlusal surfaces of permanent molar teeth. For trials with a split-mouth design, we used the Becker-Balagtas odds ratio. For continuous outcomes and data, we used means and standard deviations to obtain mean differences. We presented all measures with 95% confidence intervals (CIs).We assessed the quality of the evidence using GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods.We conducted meta-analysis using the fixed-effect model, as data from only two studies were combined. We had planned to conduct meta-analyses using a random-effects model when more than three trials were included in the meta-analysis. MAIN RESULTS: In this review, we included eight trials with 1746 participants (four of the trials were new since the 2010 update). Seven trials (1127 participants) contributed to the analyses, and children involved were five to 10 years of age at the start of the trial. Sealant versus fluoride varnish Resin-based fissure sealants compared with fluoride varnishes Four trials evaluated this comparison (three of them contributing to the analyses). Compared with fluoride varnish, resin-based sealants prevented more caries in first permanent molars at two-year follow-up (two studies in the meta-analysis with pooled odds ratio (OR) 0.69, 95% confidence interval (CI) 0.50 to 0.94; P value = 0.02; I(2) = 0%; 358 children evaluated). We assessed the body of evidence as low quality. The caries-preventive benefit for sealants was maintained at longer follow-up in one trial at high risk of bias: 26.6% of sealant teeth and 55.8% of fluoride-varnished teeth had developed caries when 75 children were evaluated at nine years of follow-up. Glass ionomer-based sealants compared with fluoride varnishes Three trials evaluated this comparison: one trial with chemically cured glass ionomer and two with resin-modified glass ionomer. Researchers reported similar caries increment between study groups regardless of which glass ionomer material was used in a trial. Study designs were clinically diverse, and meta-analysis could not be conducted. The body of evidence was assessed as of very low quality. Sealant together with fluoride varnish versus fluoride varnish alone One split-mouth trial analysing 92 children at two-year follow-up found a significant difference in favour of resin-based fissure sealant together with fluoride varnish compared with fluoride varnish only (OR 0.30, 95% CI 0.17 to 0.55). The body of evidence was assessed as low quality. Adverse events Three trials (two with resin-based sealant material and one with resin-modified glass ionomer) reported that no adverse events resulted from use of sealants or fluoride varnishes. The other five studies did not mention adverse events. AUTHORS' CONCLUSIONS: Currently, scarce and clinically diverse data are available on the comparison of sealants and fluoride varnish applications; therefore it is not possible to draw clear conclusions about possible differences in effectiveness for preventing or controlling dental caries on occlusal surfaces of permanent molars. The conclusions of this updated review remain the same as those of the last update (in 2010). We found some low-quality evidence suggesting the superiority of resin-based fissure sealants over fluoride varnish applications for preventing occlusal caries in permanent molars, and other low-quality evidence for benefits of resin-based sealant and fluoride varnish over fluoride varnish alone. Regarding glass ionomer sealant versus fluoride varnish comparisons, we assessed the quality of the evidence as very low and could draw no conclusions.

Maternal pain influences her evaluation of recurrent pain in 6- to 11-year-old healthy children.

AIM: Children with recurrent pain rely on their parents to acknowledge it. We compared pain reported by healthy children and their mothers, to evaluate their agreement, and also looked at the effect of maternal health on children's pain. METHODS: This was a cross-sectional questionnaire-based survey in Danish public schools. The participants were 131 healthy children aged 6-11 years and their mothers. The main outcome measures were the prevalence of recurrent pain reported by the mother and child, agreements between their reports and any associations between the child's pain, socio-demographic characteristics and maternal health factors. RESULTS: Recurrent pain was reported by nearly one-third (31%) of the children and their mothers. A quarter (25%) of the mother-child pairs disagreed on the existence of pain in the child, and a third (33%) disagreed on the frequency and duration. When the data were adjusted for child characteristics and socio-demographic parameters, mothers who had chronic pain were five times more likely to report frequent pain in their children than mothers without pain. This is a new finding. CONCLUSION: Maternal health factors may influence her evaluation of her child's pain. Family health and pain behaviour should be considered when recurrent pain is suspected in a child.

[Implementation in Finnish]. / Implementointia suomeksi.

Implementation research examines and promotes the uptake of research findings in various operational environments. The concepts of implementation research in Finnish are not yet established. In support of the research field we describe the Finnish equivalents of the central terms related to knowledge translation in healthcare and the frame of reference of Implementation research, with the national Current Care Guidelines as the starting point. The frame of reference is based on literature, experiences of the authors, iterative modification of the frame of reference on the basis of discussions, and results of expert inquiry. The frame of reference describes seven objects of evaluation, examples of research set-ups and methods as well as tools.

Prescribing style and variation in antibiotic prescriptions for sore throat: cross-sectional study across six countries.

BACKGROUND: Variation in prescription of antibiotics in primary care can indicate poor clinical practice that contributes to the increase of resistant strains. General Practitioners (GPs), as a professional group, are expected to have a fairly homogeneous prescribing style. In this paper, we describe variation in prescribing style within and across groups of GPs from six countries. METHODS: Cross-sectional study with the inclusion of 457 GPs and 6394 sore throat patients. We describe variation in prescribing antibiotics for sore throat patients across six countries and assess whether variation in "prescribing style"--understood as a subjective tendency to prescribe--has an important effect on variation in prescription of antibiotics by using the concept of prescribing style as a latent variable in a multivariable model. We report variation as a Median Odds Ratio (MOR) which is the transformation of the random effect variance onto an odds ratio; Thus, MOR = 1 means similar odds or strict homogeneity between GPs' prescribing style, while a MOR higher than 1 denotes heterogeneity in prescribing style. RESULTS: In all countries some GPs always prescribed antibiotics to all their patients, while other GPs never did. After adjusting for patient and GP characteristics, prescribing style in the group of GPs from Russia was about three times more heterogeneous than the prescribing style in the group of GPs from Denmark--Median Odds Ratio (6.8, 95% CI 3.1;8.8) and (2.6, 95% CI 2.2;4.4) respectively. CONCLUSION: Prescribing style is an important source of variation in prescription of antibiotics within and across countries, even after adjusting for patient and GP characteristics. Interventions aimed at influencing the prescribing style of GPs must encompass context-specific actions at the policy-making level alongside GP-targeted interventions to enable GPs to react more objectively to the external demands that are in place when making the decision of prescribing antibiotics or not.

Antibiotics for acute maxillary sinusitis in adults.

BACKGROUND: Sinusitis is one of the most common diagnoses among adults in ambulatory care, accounting for 15% to 21% of all adult outpatient antibiotic prescriptions. However, the role of antibiotics for sinusitis is controversial. OBJECTIVES: To assess the effects of antibiotics in adults with acute maxillary sinusitis by comparing antibiotics with placebo, antibiotics from different classes and the side effects of different treatments. SEARCH METHODS: We searched CENTRAL 2013, Issue 2, MEDLINE (1946 to March week 3, 2013), EMBASE (1974 to March 2013), SIGLE (OpenSIGLE, later OpenGrey (accessed 15 January 2013)), reference lists of the identified trials and systematic reviews of placebo-controlled studies. We also searched for ongoing trials via ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP). We imposed no language or publication restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing antibiotics with placebo or antibiotics from different classes for acute maxillary sinusitis in adults. We included trials with clinically diagnosed acute sinusitis, confirmed or not by imaging or bacterial culture. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results, extracted data and assessed trial quality. We calculated risk ratios (RRs) for differences between intervention and control groups in whether the treatment failed or not. All measures are presented with 95% confidence intervals (CIs). We conducted the meta-analyses using either the fixed-effect or random-effects model. In meta-analyses of the placebo-controlled studies, we combined data across antibiotic classes. Primary outcomes were clinical failure rates at 7 to 15 days and 16 to 60 days follow-up. We used GRADEpro to assess the quality of the evidence. MAIN RESULTS: We included 63 studies in this updated review; nine placebo-controlled studies involving 1915 participants (seven of the studies clearly conducted in primary care settings) and 54 studies comparing different classes of antibiotics (10 different comparisons). Five studies at low risk of bias comparing penicillin or amoxicillin to placebo provided information on the main outcome: clinical failure rate at 7 to 15 days follow-up, defined as a lack of full recovery or improvement, for participants with symptoms lasting at least seven days. In these studies antibiotics decreased the risk of clinical failure (pooled RR of 0.66, 95% CI 0.47 to 0.94, 1084 participants randomised, 1058 evaluated, moderate quality evidence). However, the clinical benefit was small. Cure or improvement rates were high in both the placebo group (86%) and the antibiotic group (91%) in these five studies. When clinical failure was defined as a lack of full recovery (n = five studies), results were similar: antibiotics decreased the risk of failure (pooled RR of 0.73, 95% CI 0.63 to 0.85, high quality evidence) at 7 to 15 days follow-up.Adverse effects in seven of the nine placebo-controlled studies (comparing penicillin, amoxicillin, azithromycin or moxicillin to placebo) were more common in antibiotic than in placebo groups (median of difference between groups 10.5%, range 2% to 23%). However, drop-outs due to adverse effects were rare in both groups: 1.5% in antibiotic groups and 1% in control groups.In the 10 head-to-head comparisons, none of the antibiotic preparations were superior to another. However, amoxicillin-clavulanate had significantly more drop-outs due to adverse effects than cephalosporins and macrolides. AUTHORS' CONCLUSIONS: There is moderate evidence that antibiotics provide a small benefit for clinical outcomes in immunocompetent primary care patients with uncomplicated acute sinusitis. However, about 80% of participants treated without antibiotics improved within two weeks. Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual and general population levels.

[General practice research in Finland]. / Yleislääketieteen tutkimus Suomessa.

Researchers within our largest specialty, general practice, are above all interested in the contents and quality of their own work, organizing the work and treatment practices. Clinical research is conducted to a limited extent only. Primary health care is being studied in the universities and research institutes in a multidisciplinary manner, but only a small proportion of the authors of peer-reviewed studies are working in community health centers. The volume of research dealing with or being conducted within primary care is somewhat smaller in Finland than in the other Nordic countries, the Netherland or Great Britain. Research should be utilized much more actively than is being done today in the development of our primary health care.

[General practice research units in Denmark: multidisciplinary research in support of practical work]. / Yleislääketieteen tutkimusyksiköt Tanskassa.

In Denmark the general practice research units operating in connection with universities provide a home base, training and methodology support for researchers in the field from medical students to general practitioners carrying out practical work. Research issues frequently require a multidisciplinary approach and use of different kinds of materials. Problems arising from the practical work of general practitioners take priority in the wide selection of topics. The units have networked efficiently with organizations of general practitioners and medical education. The combination of research environments has created synergy benefiting everybody and increased the scientific productivity and visibility of the field.

Sealants for preventing dental decay in the permanent teeth.

BACKGROUND: Dental sealants were introduced in the 1960s to help prevent dental caries in the pits and fissures of mainly the occlusal tooth surfaces. Sealants act to prevent the growth of bacteria that can lead to dental decay. There is evidence to suggest that fissure sealants are effective in preventing caries in children and adolescents when compared to no sealants. Their effectiveness may be related to the caries prevalence in the population. OBJECTIVES: To compare the effects of different types of fissure sealants in preventing caries in permanent teeth in children and adolescents. SEARCH METHODS: We searched the Cochrane Oral Health Group's Trials Register (to 1 November 2012); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); MEDLINE via OVID (1946 to 1 November 2012); EMBASE via OVID (1980 to 1 November 2012); SCISEARCH, CAplus, INSPEC, NTIS and PASCAL via STN Easy (to 1 September 2012); and DARE, NHS EED and HTA (via the CAIRS web interface to 29 March 2012 and thereafter via Metaxis interface to September 2012). There were no language or publication restrictions. We also searched for ongoing trials via ClinicalTrials.gov (to 23 July 2012). SELECTION CRITERIA: Randomised or quasi-randomised controlled trials of at least 12 months duration comparing sealants for preventing caries of occlusal or approximal surfaces of premolar or molar teeth with no sealant or different type of sealant in children and adolescents under 20 years of age. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results, extracted data and assessed trial quality. We calculated the odds ratio (OR) for caries or no caries on occlusal surfaces of permanent molar teeth. For trials with a split-mouth design, the Becker-Balagtas odds ratio was used. For mean caries increment we used the mean difference. All measures are presented with 95% confidence intervals (CI). The quality of the evidence was assessed using GRADE methods. We conducted the meta-analyses using a random-effects model for those comparisons where there were more than three trials in the same comparison, otherwise the fixed-effect model was used. MAIN RESULTS: Thirty-four trials are included in the review. Twelve trials evaluated the effects of sealant compared with no sealant (2575 participants) (one of those 12 trials stated only number of tooth pairs); 21 trials evaluated one type of sealant compared with another (3202 participants); and one trial evaluated two different types of sealant and no sealant (752 participants). Children were aged from 5 to 16 years. Trials rarely reported the background exposure to fluoride of the trial participants or the baseline caries prevalence.- Resin-based sealant compared with no sealant: Compared to control without sealant, second or third or fourth generation resin-based sealants prevented caries in first permanent molars in children aged 5 to 10 years (at 2 years of follow-up odds ratio (OR) 0.12, 95% confidence interval (CI) 0.07 to 0.19, six trials (five published in the 1970s and one in 2012), at low risk of bias, 1259 children randomised, 1066 children evaluated, moderate quality evidence). If we were to assume that 40% of the control tooth surfaces were decayed during 2 years of follow-up (400 carious teeth per 1000), then applying a resin-based sealant will reduce the proportion of the carious surfaces to 6.25% (95% CI 3.84% to 9.63%); similarly if we were to assume that 70% of the control tooth surfaces were decayed  (700 carious teeth per 1000), then applying a resin-based sealant will reduce the proportion of the carious surfaces to 18.92% (95% CI 12.28% to 27.18%). This caries preventive effect was maintained at longer follow-up but both the quality and quantity of the evidence was reduced (e.g. at 48 to 54 months of follow-up OR 0.21, 95% CI 0.16 to 0.28, four trials (two studies at low risk of bias and two studies at high risk of bias), 482 children evaluated; risk ratio (RR) 0.24, 95% CI 0.12 to 0.45, one study at unclear risk of bias, 203 children evaluated).- Glass ionomer sealant compared with no sealant: There is insufficient evidence to make any conclusions about whether glass ionomer sealants, prevent caries compared to no sealant at 24-month follow-up (mean difference in DFS -0.18, 95% CI -0.39 to 0.03, one trial at unclear risk of bias, 452 children randomised, 404 children evaluated, very low quality evidence).- Sealant compared with another sealant: The relative effectiveness of different types of sealants remained inconclusive in this review. Twenty-one trials directly compared two different sealant materials. Several different comparisons were made according to type of sealant, outcome measure and duration of follow-up. There was great variation with regard to comparisons, outcomes, time of outcomes reported and background fluoride exposure if this was reported.Fifteen trials compared glass ionomer with resin sealants and there is insufficient evidence to make any conclusions about the superiority of either of the two materials. Although there were 15 trials the event rate was very low in many of these which restricted their contribution to the results.Three trials compared resin-modified glass ionomer with resin sealant and reported inconsistent results.Two small low quality trials compared polyacid-modified resin sealants with resin sealants and found no difference in caries after 2 years.- Adverse effects: Only two trials mentioned adverse effects and stated that no adverse effects were reported by participants. AUTHORS' CONCLUSIONS: The application of sealants is a recommended procedure to prevent or control caries. Sealing the occlusal surfaces of permanent molars in children and adolescents reduces caries up to 48 months when compared to no sealant, after longer follow-up the quantity and quality of the evidence is reduced. The review revealed that sealants are effective in high risk children but information on the magnitude of the benefit of sealing in other conditions is scarce. The relative effectiveness of different types of sealants has yet to be established.

Clinical decision support must be useful, functional is not enough: a qualitative study of computer-based clinical decision support in primary care.

BACKGROUND: Health information technology, particularly electronic decision support systems, can reduce the existing gap between evidence-based knowledge and health care practice but professionals have to accept and use this information. Evidence is scant on which features influence the use of computer-based clinical decision support (eCDS) in primary care and how different professional groups experience it. Our aim was to describe specific reasons for using or not using eCDS among primary care professionals. METHODS: The setting was a Finnish primary health care organization with 48 professionals receiving patient-specific guidance at the point of care. Multiple data (focus groups, questionnaire and spontaneous feedback) were analyzed using deductive content analysis and descriptive statistics. RESULTS: The content of the guidance is a significant feature of the primary care professional's intention to use eCDS. The decisive reason for using or not using the eCDS is its perceived usefulness. Functional characteristics such as speed and ease of use are important but alone these are not enough. Specific information technology, professional, patient and environment features can help or hinder the use. CONCLUSIONS: Primary care professionals have to perceive eCDS guidance useful for their work before they use it.