Evidence-based dentistry: assessment to document progression to proficiency.

INTRODUCTION: The integration of evidence-based dentistry (EBD) into pre-doctoral dental curricula requires the identification of desired outcomes, development of curricular content and design of assessment strategies which guide student performance whilst documenting achievement of desired curricular outcomes. Models for developing EBD curriculums have been described in the literature; however, the logistics of designing assessment instruments to progressively document student performance have received less attention. The objective of this article is to describe the University of Iowa's College of Dentistry's development and implementation of assessment strategies to guide student learning of EBD knowledge, application and assimilation to serve as a model for other institutions developing EBD assessment protocols. ASSESSMENT DEVELOPMENT: Desired EBD knowledge and behaviour outcomes guided the development of curricular content and progressive formative and summative assessment strategies. Vertically and horizontally integrated educational activities enabling students to demonstrate EBD knowledge whilst modelling desired behaviours were identified, whilst assessment principles guided development of learning guides and assessment instruments to document achievement of desired outcomes. Consistent EBD language and educational activities are utilised throughout the 4-year interdisciplinary curriculum with stepwise assessment protocols matched to the curriculum. Examples of student learning guides and assessment instruments are provided. SUMMARY: Curricular design guides development of assessment strategies. Assessment protocols provide consistent formative and summative feedback to enable continuous student growth to become proficient EBD practitioners.

Time-lapse in the IVF-lab: how should we assess potential benefit?

Time-lapse imaging of embryos has been widely introduced to fertility laboratories worldwide with the aim of identifying the best quality embryos to transfer that will ultimately improve IVF success rates. In this opinion paper, we explore the lack of evidence of benefit of this novel intervention, analyse the methodological flaws of current studies, offer ideal study designs that assess the various features of time-lapse imaging, and discuss forthcoming studies. In particular, we emphasize the ethical aspects of hastily adopting a costly technology without current high level evidence of improved live birth rates, safety and cost effectiveness.

Minimally- and non-invasive assessment of maternal cardiac output: go with the flow!

The measurement of cardiac output may be crucial in the management of the parturient with haemodynamic instability due to critical illness or cardiac disease. Invasive haemodynamic monitoring may not be desirable due to the potential risk of complications and issues with patient compliance. Minimally- and non-invasive techniques of cardiac output measurement include those based on ultrasonic technology and pulse contour waveform analysis. This review article provides a synopsis of the literature examining currently available minimally- and non-invasive techniques for maternal cardiac output monitoring and looks at their advantages and disadvantages with respect to the parturient.

Assessment of coagulation in the obstetric population using ROTEM® thromboelastometry.

BACKGROUND: Assessment of maternal coagulation to determine suitability for neuraxial anaesthesia and management of obstetric haemorrhage remains a challenge. Thromboelastography provides point of care patient assessment of the viscoelastic properties of whole blood clotting and can assist the clinician in haemostatic decision-making. The study aim was to determine the ROTEM® thromboelastometer 95% reference limits for third trimester parturients and to compare these with non-pregnant female controls. METHODS: Following ethics committee approval and informed consent, citrated blood was sampled from 120 age-matched healthy pregnant and non-pregnant women. Thromboelastometry, using a ROTEM® point of care monitor, was performed with specific activators to measure the coagulation time (CT), clot formation time (CFT) and the maximal clot firmness (MCF) in order to evaluate the extrinsic (EXTEM® test) and intrinsic (INTEM® test) coagulation systems, as well as the fibrinogen contribution to coagulation (FIBTEM® test). RESULTS: After exclusions, data from 54 subjects in each group were analysed. Parturients had significantly lower haemoglobin values and platelet counts (P<0.01). Despite this, thromboelastometry exhibited significantly lower INTEM® CT (7.3%), INTEM® CFT (11.1%) and EXTEM® CFT (18.0%) in the pregnant group (P<0.001). MCF values were significantly higher (INTEM® (10.9%), EXTEM® (10.6%) and FIBTEM® (47.1%)) in the pregnant group compared to the non-pregnant group (P<0.0001). CONCLUSIONS: ROTEM® thromboelastometry clearly demonstrates the hypercoagulability of pregnancy. Formal reference ranges for ROTEM® that may be potentially useful in the haemostatic management of the parturient are presented.

Influenza vaccine uptake among staff in care homes in Nottinghamshire: a random cluster sample survey.

OBJECTIVES: To establish uptake of influenza vaccine amongst care home clinical staff in Greater Nottingham, and to investigate what could be done to improve vaccine uptake in this group. STUDY DESIGN: Postal questionnaire surveys were used. In the first instance, a total sample survey was used. In the second instance, a sample of care home staff was surveyed, randomized at the care home level. METHODS: A postal questionnaire completed by care home matrons was used to obtain a preliminary estimate of staff vaccine uptake. Individual staff questionnaires were then used to validate this finding, and measure attitudes, beliefs and behaviours associated with vaccination. RESULTS: Vaccine uptake among those working in care homes with nursing was found to be low. Vaccine uptake was higher in homes with a policy recommending vaccination of staff. Most respondents who had received vaccination reported that they had done so because of an existing medical condition, rather than because of being a healthcare worker. A statistically significant relationship (P=0.02) was found between individuals' reported beliefs on how well they could resist influenza and their vaccination status. CONCLUSIONS: All care homes for the elderly should have a vaccination policy which recommends staff vaccination. Educational campaigns, vaccination in the workplace and free provision of the influenza vaccine may help to improve vaccine uptake in this group.

MLL-AF9 and FLT3 cooperation in acute myelogenous leukemia: development of a model for rapid therapeutic assessment.

Human leukemias harboring chromosomal translocations involving the mixed lineage leukemia (MLL, HRX, ALL-1) gene possess high-level expression, and frequent activating mutations of the receptor tyrosine kinase FLT3. We used a murine bone marrow transplant model to assess cooperation between MLL translocation and FLT3 activation. We demonstrate that MLL-AF9 expression induces acute myelogenous leukemia (AML) in approximately 70 days, whereas the combination of MLL-AF9 and FLT3-ITD does so in less than 30 days. Secondary transplantation of splenic cells from diseased mice established that leukemia stem cells are present at a very high frequency of approximately 1:100 in both diseases. Importantly, prospectively isolated granulocyte macrophage progenitors (GMPs) coinfected with MLL-AF9 and FLT3-ITD give rise to a similar AML, with shorter latency than from GMP transduced with MLL-AF9 alone. Cooperation between MLL-AF9 and FLT3-ITD was further verified by real-time assessment of leukemogenesis using noninvasive bioluminescence imaging. We used this model to demonstrate that MLL-AF9/FLT3-ITD-induced leukemias are sensitive to FLT3 inhibition in a 2-3 week in vivo assay. These data show that activated FLT3 cooperates with MLL-AF9 to accelerate onset of an AML from whole bone marrow as well as a committed hematopoietic progenitor, and provide a new genetically defined model system that should prove useful for rapid assessment of potential therapeutics in vivo.

To freeze or not to freeze: a cost-effectiveness analysis of wart treatment.

BACKGROUND: Several general practitioner (GP)-prescribed and over-the-counter therapies for warts and verrucae are available. However, the cost-effectiveness of these treatments is unknown. OBJECTIVES: To compare the cost-effectiveness of different treatments for cutaneous warts. METHODS: We designed a decision-analytic Markov simulation model based on systematic review evidence to estimate the cost-effectiveness of various treatments. The outcome measures studied are percentage of patients cured, cost of treatment and incremental cost-effectiveness ratio for each treatment, compared with no treatment, after 18 weeks. RESULTS: Duct tape was most cost-effective but published evidence of its effectiveness is sparse. Salicylic acid was the most cost-effective over-the-counter treatment commonly used. Cryotherapy administered by a GP was less cost-effective than GP-prescribed salicylic acid and less cost-effective than cryotherapy administered by a nurse. CONCLUSIONS: Duct tape could be adopted as the primary treatment for cutaneous warts if its effectiveness is verified by further rigorous trials. Nurse-administered cryotherapy is likely to be more cost-effective than GP-administered cryotherapy.

Wireless connectivity for health and sports monitoring: a review.

This is a review of health and sports monitoring research that uses or could benefit from wireless connectivity. New, enabling wireless connectivity standards are evaluated for their suitability, and an assessment of current exploitation of these technologies is summarised. An example of the application is given, highlighting the capabilities of a network of wireless sensors. Issues of timing and power consumption in a battery-powered system are addressed to highlight the benefits networking can provide, and a suggestion of how monitoring different biometric signals might allow one to gain additional information about an athlete or patient is made.

Effectiveness and cost-effectiveness of salicylic acid and cryotherapy for cutaneous warts. An economic decision model.

OBJECTIVES: To estimate the costs of commonly used treatments for cutaneous warts, as well as their health benefits and risk. To create an economic decision model to evaluate the cost-effectiveness of these treatments, and, as a result, assess whether a randomised controlled trial (RCT) would be feasible and cost-effective. DATA SOURCES: Focus groups, structured interviews and observation of practice. Postal survey sent to 723 patients. A recently updated Cochrane systematic review and published cost and prescribing data. REVIEW METHODS: Primary and secondary data collection methods were used to inform the development of an economic decision model. Data from the postal survey provided estimates of the effectiveness of wart treatments in a primary care setting. These estimates were compared with outcomes reported in the Cochrane review of wart treatment, which were largely obtained from RCTs conducted in secondary care. A decision model was developed including a variety of over-the-counter (OTC) and GP-prescribed treatments. The model simulated 10,000 patients and adopted a societal perspective. RESULTS: OTC treatments were used by a substantial number of patients (57%) before attending the GP surgery. By far the most commonly used OTC preparation was salicylic acid (SA). The results of the economic model suggested that of the treatments prescribed by a GP, the most cost-effective treatment was SA, with an incremental cost-effectiveness ratio (ICER) of 2.20 pound/% cured. The ICERs for cryotherapy varied widely (from 1.95 to 7.06 pound/% cured) depending on the frequency of applications and the mode of delivery. The most cost-effective mode of delivery was through nurse-led cryotherapy clinics (ICER = 1.95 pound/% cured) and this could be a cost-effective alternative to GP-prescribed SA. Overall, the OTC therapies were the most cost-effective treatment options. ICERs ranged from 0.22 pound/% cured for OTC duct tape and 0.76 pound/% cured for OTC cryotherapy to 1.12 pound/% cured for OTC SA. However, evidence in support of OTC duct tape and OTC cryotherapy is very limited. Side-effects were commonly reported for both SA and cryotherapy, particularly a burning sensation, pain and blistering. CONCLUSIONS: Cryotherapy delivered by a doctor is an expensive option for the treatment of warts in primary care. Alternative options such as GP-prescribed SA and nurse-led cryotherapy clinics provide more cost-effective alternatives, but are still expensive compared with self-treatment. Given the minor nature of most cutaneous warts, coupled with the fact that the majority spontaneously resolve in time, it may be concluded that a shift towards self-treatment is warranted. Although both duct tape and OTC cryotherapy appear promising new self-treatment options from both a cost and an effectiveness perspective, more research is required to confirm the efficacy of these two methods of wart treatment. If these treatments are shown to be as cost-effective as or more cost-effective than conventional treatments, then a shift in service delivery away from primary care towards more OTC treatment is likely. A public awareness campaign would be useful to educate patients about the self-limiting nature of warts and the possible alternative OTC treatment options available. Two future RCTs are recommended for consideration: a trial of SA compared with nurse-led cryotherapy in primary care, and a trial of home treatments. Greater understanding of the efficacy of these home treatments will give doctors a wider choice of treatment options, and may help to reduce the overall demand for cryotherapy in primary care.

Randomised controlled trial of short bursts of a potent topical corticosteroid versus prolonged use of a mild preparation for children with mild or moderate atopic eczema.

OBJECTIVE: To determine whether a three day burst of a potent corticosteroid is more effective than a mild preparation used for seven days in children with mild or moderate atopic eczema. DESIGN: Randomised, double blind, parallel group study of 18 weeks' duration. SETTING: 13 general practices and a teaching hospital in the Nottingham area. PARTICIPANTS: 174 children with mild or moderate atopic eczema recruited from general practices and 33 from a hospital outpatient clinic. INTERVENTIONS: 0.1% betamethasone valerate applied for three days followed by the base ointment for four days versus 1% hydrocortisone applied for seven days. MAIN OUTCOME MEASURES: Primary outcomes were total number of scratch-free days and number of relapses. Secondary outcomes were median duration of relapses, number of undisturbed nights, disease severity (six area, six sign atopic dermatitis severity scale), scores on two quality of life measures (children's life quality index and dermatitis family impact questionnaire), and number of patients in whom treatment failed in each arm. RESULTS: No differences were found between the two groups. This was consistent for all outcomes. The median number of scratch-free days was 118.0 for the mild group and 117.5 for the potent group (difference 0.5, 95% confidence interval -2.0 to 4.0, P=0.53). The median number of relapses for both groups was 1.0. Both groups showed clinically important improvements in disease severity and quality of life compared with baseline. CONCLUSION: A short burst of a potent topical corticosteroid is just as effective as prolonged use of a milder preparation for controlling mild or moderate atopic eczema in children.

Use of a fibrous dressing in exuding leg ulcers.

In a multicentre, prospective, randomised trial of 44 patients with exuding leg ulcers, a new hydrofibre dressing was compared with an alginate dressing in terms of dressing performance, patient comfort, safety and cost-effectiveness. The groups were well matched with regard to sex and age. A statistically significant difference between treatment groups was observed in mean wear time, with a longer wear time of four days observed in the hydrofibre dressing group compared to three days in the alginate group. The hydrofibre dressing group therefore demonstrated a significantly lower frequency of dressing changes required per week. Significantly more patients achieved a seven-day wear time with the hydrofibre dressing than with the alginate dressing. There was no difference with regard to percentage change in ulcer area. Cost-effectiveness was based on the cost of dressings, compression therapy and nursing time to achieve a healed wound. However, because of small patient numbers, it was difficult to make an accurate comparison. This study suggests that the hydrofibre dressing may have clinical benefits that merit further investigation with larger patient numbers.

Rape in South Africa: an invisible part of apartheid's legacy.

PIP: Male dominated power systems in South Africa coupled with a culture of aggression and domination have not allowed for the mainstream emergence of qualities such as trust, compassion, and gentleness, frequently associated with female virtues. Rape under such circumstances is the assertion of male power, and, as expected, the numbers of rape cases and other forms of gender violence have increased. Under an apartheid system, where only the rape of white women was prosecuted, and gender and race issues could diffuse the black struggle, there were difficulties in mobilizing support to end violence against black women. There was social acceptance that rape of black women was part of life. Police statistics on the incidence of rape were notoriously unreliable, because only a small percentage of cases are reported to police, and many women would be ashamed to admit to marital abuse, including rape. In women's groups, it was reported that 1 out of every 4 women had been raped, and raped at early ages, such as 14 years of age. In impoverished communities, there is widespread poverty, injustice, prejudice, alcohol abuse, and other conditions impacting on women. The rapists may be school classmates, or street fighters, or political activists. The sexual initiation of women worldwide and in South Africa frequently is accompanied by coercion. Abduction and forced sex is considered legitimate for young men, who believe that mental health is deleteriously affected by lack of sex. Girls may even be abducted from the classroom, as a way of preventing women's power and control over assets and resources and diminishing the potential threat to gender power relations. School girls who become pregnant are often forced to leave school. Victims of rape may be excluded from family life and forced to seek prostitution as a means of support. Rape is reportedly experienced among older women with bottles, tins, or other devices which inflict injury. Only rape with penal penetration is an official offense. HIV infection is an increased risk for raped women, who are likely to suffer from bleeding. With an end to apartheid, it is up to the new government to enforce more equitable laws. Improvements are evident in Soweto at Baragwanath Hospital and in some police precincts, but the best protection is to teach nonviolence and respect for women.^ieng

Psychiatric managed care at a rural MEDDAC.

Mental health costs at General Leonard Wood Army Community Hospital (GLWACH) have risen every year. In 1990, $2.7 million had been spent on CHAMPUS mental health costs, 58% of the entire CHAMPUS costs for the hospital's catchment area. Gateway to Care, a plan of coordinated managed care conceived by Health Services Command, was initiated at GLWACH to give the commander and providers more flexibility to control costs and improve access to care. Five major changes were made under GLWACH's mental health coordinated care project. In the first full year of the project, CHAMPUS net costs were reduced to $1.4 million while more comprehensive care was provided to beneficiaries. Cost reduction came primarily from dramatically increasing the size and scope of outpatient care to reduce inpatient admissions.

Clinical and hemodynamic assessment of the Hancock II bioprosthesis.

The Hancock II bioprosthesis was used for heart valve replacement in 614 patients from 1982 to 1990. Aortic valve replacement (AVR) was performed in 376 patients, mitral valve replacement (MVR) in 195, and aortic and mitral valve replacement (DVR) in 43. The mean age was 62.7 years, and 78% of all patients were in New York Heart Association functional class III or IV before operation. Coronary artery bypass graft was necessary in 232 patients and replacement of ascending aorta in 55. There were 31 operative deaths (AVR, 4%; MVR, 6%; DVR, 9%). Follow-up was complete in 98.5% of the patients and extended from 12 to 103 months, with a mean of 49 months. At the last follow-up, 85% of the patients were in New York Heart Association class I or II. The actuarial survival at 8 years was 79% +/- 3% for AVR, 68% +/- 4% for MVR, and 65% +/- 10% for DVR. The freedom from stroke at 8 years was 93% +/- 2% for AVR, 83% +/- 5% for MVR, and 90% +/- 5% for DVR. At the end of 8 years 96% +/- 1% of all patients were free from endocarditis, 92% +/- 1% were free from primary tissue failure, and 89% +/- 3% were free from reoperation. The actuarial freedom from valve-related death at 8 years was 98% +/- 1% for AVR, 86% +/- 5% for MVR, and 91% +/- 6% for DVR. Hemodynamic assessment was obtained by Doppler echocardiography in all operative survivors and demonstrated satisfactorily effective valve orifices and transvalvular gradients. The clinical results obtained with the Hancock II bioprosthesis have been gratifying, particularly in the aortic position. This bioprosthesis is our biological valve of choice.

The cost of needle-stick injuries: the impact of safer medical devices.

The cost of needle-stick injuries significantly impacts health care workers and their institutions. Safer medical devices can reduce both direct and indirect costs associated with these injuries.

The cost of nursing excellence in critical care.

The results of the American Association of Critical-Care Nurses Demonstration Project support the contention that high quality critical care nursing can be provided to patients at a reasonable cost. In addition, the data refute the notion that elements influenced by nurses--supplies and nursing care--are the most costly portion of the total hospital charge.

Influence of variations in biological and economical parameters on beef production net returns.

Net returns were defined as a function of the monetary returns (revenue) generated by the outputs less the monetary costs generated by the variable inputs. Outputs included total weaning weights of steers and heifers, weight of cull cows and weight of open heifers. Inputs included both feed and nonfeed costs. The net returns equation was incorporated as the objective function in a linear programming model. By maximizing the objective function, the breeding system that generated the highest net returns could be identified considering certain resource constraints. Breeding systems included purebred Herefords; small rotational dual purpose (SR), utilizing the breeds Angus, Pinzgauer, Gelbvieh and Tarentaise; large rotational (LR), a three-way rotational cross with the breeds Charolais, Simmental and Maine-Anjou; and Angus-sired terminal (AL) utilizing Angus as the sire breed and LR heifers as the maternal breed. Large rotational generally produced the greatest net returns, followed by SR and either AL or HE, depending on specific resource constraints (limited feed supply or herd size), calving rates, management systems, environment, beef to feed price ratios and purchased or farm-produced (inexpensive) feed utilized. Only under the conditions of a herd size constraint and farm-produced feed did AL exceed SR in net returns. Hereford had larger net returns than LR only when the two breeding systems were evaluated in an environment assumed to be reproductively stressful to LR. Ranking of breeding systems were dependent on specific conditions and indicated that one must consider each resource constraint and environment in which cattle are expected to produce before making breeding system recommendations.