Effectiveness, safety and acceptability of self-assessment of the outcome of first-trimester medical abortion: a systematic review and meta-analysis.

BACKGROUND: For many women, the need for multiple clinical visits is a barrier to medical abortion. OBJECTIVES: We assessed the effectiveness, safety, and acceptability of self-assessment of the outcome of medical abortion completed at home versus routine clinic follow up after medical abortion. SEARCH STRATEGY: We searched databases such as MEDLINE, Embase, and CENTRAL to find studies published in 1991-2018. SELECTION CRITERIA: Eligible studies included women of reproductive age who had undergone a medical abortion that was completed at home. The intervention and self-assessment of the outcome of medical abortion done by urine pregnancy tests kits by women at home was compared with routine medical follow up at a clinic. DATA COLLECTION AND ANALYSIS: Two researchers completed the study selection, data extraction, critical appraisal, and assessment of the evidence. The outcomes were successful complete abortions, side effects and complications, and acceptability. We performed meta-analyses when possible and GRADE to ascertain the certainty of the evidence. The protocol was registered in PROSPERO (CRD42017055316). MAIN RESULTS: Four randomised controlled trials (RCTs; n = 5493) met our inclusion criteria. The pooled analysis from all studies showed no significant difference in complete abortion rates between self-assessment and routine clinic follow up: RR = 1.00, 95% CI 0.99-1.01. The ongoing pregnancy rates were similar and the pooled results for the safety outcomes showed no significant differences between the groups. There was a significantly greater preference for self-assessment as the follow-up method. CONCLUSIONS: The effectiveness, safety, and acceptability of self-assessment of the outcome of medical abortion completed at home are not inferior to routine clinic follow up. TWEETABLE ABSTRACT: The effectiveness, safety, and acceptability of self-assessment of the outcome of medical abortion are not inferior to routine clinic follow up.

Primary sedimentation as a sustainability measure for newly built municipal wastewater treatment plants: too expensive?

A study was performed based on the design of a new wastewater treatment plant (WWTP) to be built in Weesp, The Netherlands (about 46,000 Population Equivalents (PE)). The conventional activated sludge plant was considered among the alternatives, with and without primary sedimentation. This pre-treatment technique is considered a sustainability measure as it improves the energy balance of the WWTP. However, at the same time, the question arose about the cost effectiveness of this measure. The scope of the study was to assess whether other sustainability measures (like solar panels) can realise the same level of sustainability with lower costs. The outcome of the study indeed shows that, for a new WWTP, it is considerably cheaper to avoid primary sedimentation and focus on other measures like solar panels instead. This appeared not only to be the case for the scale of WWTP Weesp, but also for WWTPs with capacities higher than 500,000 PE. For existing WWTPs with primary sedimentation, the choice can be different as customisation is necessary.

Comparison of Outcomes Following a Switch From a Brand to an Authorized Versus Independent Generic Drug.

Authorized generics are identical in formulation to brand drugs, manufactured by the brand company but marketed as a generic. Generics, marketed by generic manufacturers, are required to demonstrate pharmaceutical and bioequivalence to the brand drug, but repetition of clinical trials is not required. This retrospective cohort study compared outcomes for generics and authorized generics, which serves as a generic vs. brand proxy that minimizes bias against generics. For the seven drugs studied between 1999 and 2014, 5,234 unique patients were on brand drugs prior to generic entry and 4,900 (93.6%) switched to a generic. During the 12 months following the brand-to-generic switch, patients using generics vs. authorized generics were similar in terms of outpatient visits, urgent care visits, hospitalizations, and medication discontinuation. The likelihood of emergency department (ED) visits was slightly higher for authorized generics compared with generics. These data suggest that generics were clinically no worse than their proxy brand comparators.

Barebacking among men who have sex with men recruited through a Swedish website: associations with sexual activities at last sexual encounter.

The research topic of barebacking emerged in the mid-1990s. Since then, a multitude of studies, largely from the United States, have produced invaluable knowledge of factors that help explain the behaviour among men who have sex with men (MSM), and that may contribute to HIV risk reduction programming and advice to counsellors working with barebackers. Given the scant empirical research about barebacking among European MSM, we conducted a survey among 3,634 MSM recruited through a web community in Nordic countries. The objectives of the study were twofold: to describe the sexual activities associated with barebacking behaviour at last sexual encounter, and to evaluate the relationship of barebacking with relevant variables. Men who reported barebacking (n=356) and men who did not (n=3,278) were compared. On the basis of the results of the analyses, the socio-sexual profile of barebackers drawn was one that is at increased risk of acquiring human immunodeficiency virus (HIV) and other sexually transmitted infections due to their sexual practices, particularly unprotected anal intercourse, but also group sex and rimming. In a multivariate logistic regression analysis, the likelihood of engaging in barebacking was higher for MSM who reported more frequent HIV testing (odds ratio (OR)=5.16), a higher number of female sex partners (OR=16.80), using gay cruising places (OR=1.51) and gay chat rooms (OR=2.11).

The predictive value of 3D time-of-flight MR angiography in assessment of brain arteriovenous malformation obliteration after radiosurgery.

BACKGROUND AND PURPOSE: The purpose of radiosurgery of bAVMs is complete angiographic obliteration of its nidus. We assessed the diagnostic accuracy of 1.5T T2-weighted MR imaging and TOF-MRA images for detecting nidus obliteration after radiosurgery. MATERIALS AND METHODS: The pre- and postradiosurgery MR images and DSA images from 120 patients who were radiosurgically treated for a bAVM were re-evaluated by 2 observers for patency of the nidus (preradiosurgery) and obliteration (postradiosurgery: final follow-up MR imaging), by using a 3-point scale of confidence. Consensus reading of the DSA after radiosurgery was considered the criterion standard for obliteration. Sensitivity, specificity, PPVs, and NPVs, and overall diagnostic performance by using ROC were determined. RESULTS: Mean bAVM volume during radiosurgery was 3.4 mL (95% CI, 2.6-4.3 mL). Sixty-six patients (55%) had undergone previous endovascular embolization. The mean intervals between radiosurgery and follow-up MR imaging and for DSA, respectively, were 35.6 months (95% CI, 32.3-38.9 months) and 42.1 months (95% CI, 40.3-44.0 months). With ROC, an area under curve of 0.81-0.83 was found. PPVs of final follow-up MR-imaging for definitive obliteration varied between 0.89 [corrected] and 0.95. NPV was 0.52 [corrected] . An average false-positive rate, meaning overestimation of nidus obliteration of 0.10 [corrected] and an average false-negative rate, meaning underestimation of nidus obliteration of 0.42 [corrected] were found. CONCLUSIONS: MRA is insufficient to diagnose obliteration in the follow-up of bAVMs after radiosurgery. A remaining nidus diameter <10 mm seems to be the major limiting factor for reliable assessment of obliteration. We highly recommend follow-up DSA for definitive diagnosis of complete obliteration.

Performance of semiautomatic assessment of carotid artery stenosis on CT angiography: clarification of differences with manual assessment.

BACKGROUND AND PURPOSE: Semiautomated methods for ICA stenosis measurements have the potential to reduce interobserver variability and to speed up its analysis. In this study, we estimate the precision and accuracy of a semiautomated measurement for carotid artery stenosis degree and identify and explain differences compared with the manual method. MATERIALS AND METHODS: In this retrospective study involving 90 patients, 2 observers determined the stenosis degree twice, with both the semiautomated and the manual method. Intra- and interobserver correlations were calculated for both methods. The accuracy was estimated by comparing average semiautomated with manual measurements. The semiautomated stenosis calculations were performed using either the minimal or maximal intersection at the reference site. Individual cases with large differences in measurement were retrospectively inspected by 3 observers. RESULTS: Intra- (R = 0.93, 0.96) and interobserver (R = 0.98) correlations for the semiautomated method were excellent and exceeded the manual performance correlations (R = 0.87, 0.86). The semiautomated measurements correlated well with the manual measurements (R = 0.87), with high specificity of 96% and lower sensitivity of 63%. Large differences were caused by misinterpretations of the semiautomated method associated with calcified plaques, resulting in overestimations of the minimal diameter, underestimation of stenosis degree, and incorrect centerlines. The effect of using the minimal diameter at the reference position resulted in a small, but significant, underestimation of the stenosis degree by the semiautomated method. CONCLUSIONS: The semiautomated method showed an excellent reproducibility and good correlation with manual measurements with a high specificity and lower sensitivity for detecting a significant stenosis. Erroneous semiautomatic stenosis measurements were associated with the presence of calcium.

Evaluation of a policy to reduce youth tractor crashes on public roads.

OBJECTIVE: Evaluate the effectiveness of a United States state law, Wisconsin Act 455, in reducing highway tractor crashes involving youth operators. DESIGN: Policy outcome evaluation involving review of a retrospective case series. SETTING: Youth highway tractor crashes from Wisconsin for the years 1994-2003 that resulted in a fatality, injury, and/or property damage. SUBJECTS: One hundred and forty six tractor crash cases involving operators younger than 16 years. METHODS: Describe and model the tractor crash patterns before and after enactment of the law, and examine the relation between the contributing circumstances identified in the crash reports and the content covered in the mandated tractor certification course. RESULTS: There was neither a significant change in the number of youth tractor crashes after the law was passed, nor any reduction in the proportion of crashes where the youth operator was designated at fault. The tractor certification course did not cover the major factors contributing to youth tractor crashes on public roads. CONCLUSIONS: No significant effect of the law was detected and crash rates at the end of the study period were similar to those before Wisconsin Act 455. The authors'findings should not be construed to suggest that public policy, in general, is an ineffective strategy for the prevention of pediatric agricultural injuries. Negotiating a balance in public policy debates will be a challenge, but it is clear that future policy initiatives need to identify and implement the right policy for the right problem.

Economic and environmental effects of the manure policy in The Netherlands: synthesis of integrated ex-post and ex-ante evaluation.

This paper summarises the results of both an ex-post evaluation of the Dutch Mineral Accounting System (MINAS) and an ex-ante evaluation of the effect of different levy-free surplus values. The MINAS system has been introduced in 1998 in order to reduce nitrate and phosphate leaching from agricultural soils. MINAS resulted in a reduction of the N surplus on dairy farms of approximately 50 kg ha(-1) to limited or no costs to the farms involved. MINAS resulted in higher costs for manure removal for intensive livestock farmers. Though emissions of N and P have decreased significantly during the last five years effects of this reduction in environmental quality cannot be observed, except for a small decrease in nitrate concentration of the upper groundwater. The ex-ante evaluation of different variants for possible future levy-free surplus levels indicated that under the lowest variant, the nitrate concentration in groundwater will exceed 50 mg per litre on 14% of the area. The environmental effect of the different variants for P were not distinguished. The lowering of the levy-free surplus for P will have a drastic effect on the intensive livestock farms. The incorporation of fertiliser P under the MINAS system would be a cheap option to reduce the P surplus.

Geriatric oral health issues in the United States.

Of the more than 270 million people in the United States, about 13 per cent are aged 65 years or older. As in most other countries throughout the world, this proportion of the population is projected to increase in the coming years. To care for this ageing and racially/ethnically diverse population, health care professionals, especially dentists, must initiate changes in public policies, available resources and access to services. The dental profession especially must improve awareness among the general public and health care professionals of the link between oral health and general health. Immediate improvements should be made to increase the proportion of dentists who are willing and qualified to treat these patient groups. Increasing the reimbursement rates available through the Medicaid programme and expanding the types of services Medicaid recipients can seek are critical. Dental education programmes must continue to provide more training opportunities to prepare professionals to meet the needs of these patients.

A critical assessment of some biomarker approaches linked with dietary intake.

In this review many examples are given of the complexities involved in using some biomarkers in relation to assessing the effects of dietary exposure, when there is frequently a need to determine changes following long-term low level exposure to dietary components. These range from understanding why the biomarker might be valuable and how best it can be measured, to the pitfalls which can occur in the interpretation of data. Analytical technique is considered in relation to folate and selenium, and flavonoid and carotenoid species are used to illustrate how the metabolism of a compound may alter the validity or adequacy of a marker. Vitamin A is discussed in relation to the difficulties which can arise when there are several biomarkers that may be available to assess exposure to one nutrient. Vitamin B12 is discussed in relation to the dietary choices made by individuals. Possible interactions and the role of measuring total antioxidant capacity is considered in some detail. In contrast to most nutrients, there is a marked lack of biomarkers of either exposure or effect for most non-nutrients. The role of biological effect monitoring is considered for dietary contaminants, fumonisins and polyhalogenated aromatic hydrocarbons. Aflatoxins are discussed to exemplify food contaminants for which the biomarker approach has been extensively studied. Finally some compounds which are deliberately added to foods and some which appear as processing contaminants are each considered briefly in relation to the requirement for a biomarker of exposure to be developed.

Impact of older adults on private dental practices, 1988-1998.

BACKGROUND: A 1988 study indicated that older adults made up a substantial portion of regular patients seen in private dental practices. A follow-up study was conducted in 1998 to track changes over the decade in the participating practices. METHODS: The authors collected data from respondents to the 1988 survey again in 1998. The authors received complete data from 41.7 percent of the original respondents who still were practicing at their 1988 addresses. Dentists kept a log of all procedures provided in their practices in one day. The authors attributed values of services in both years, using a 1997 national estimate of fees. RESULTS: The authors found that the percentage of office visits, services provided and patient expenditures attributed to patients 65 years of age or older exceeded the percentage of the population in that age group. In four of the five age groups in which patients had the highest mean expenditures, patients were 60 years of age or older. Patients 60 years of age or older accounted for 28.8 percent of all patient expenditures, a 12.1 percent increase from 1988. Longitudinal analyses indicated that between 1988 and 1998, dentists 40 years of age or older experienced increases of 30.3 to 64.3 percent in the proportion of visits, services and expenditures by patients 65 years of age or older. CONCLUSIONS: The results of this investigation illustrate the importance of older adults to dental practices. Data from the practices of dentists who participated in both surveys show increases in the percentage of total dental visits, total services provided and total patient expenditures attributed to older adults. CLINICAL IMPLICATIONS: Older adults continue to have a disproportionate and positive impact on the surveyed dental practices and their financial well-being. Dentists should reevaluate the accessibility of their practices to this population. Rather than waiting for the practice to "age," dentists may want to structure their practices in ways that appeal directly to older adults and work to even better understand the needs and preferences of older patients already in their practices.

Spectrum of care treatment planning: application of the model in older adults.

A model for treatment planning is presented to help emphasize the most important elements of the clinical decision-making process for older adult patients. The patient's concerns and needs in the domains of function, symptoms, pathology, and esthetics are the central elements of the process. With sophisticated assessment methods and creative interventions, the dentist can work with each patient to identify and successfully address his or her needs and concerns. This model is applied to two clinical cases which illustrate the importance of considering innovative treatment plans, even when the patient is advanced in years.

Orthodontics at the turn of the century. A discussion of some relevant aspects.

Some changing paradigms, that might influence orthodontics in the future, are being discussed: economic problems related to our welfare systems; development of the media societies; concepts of normality; future changes as regards the type of treatment records; evaluation of treatment outcome; "exaggerated orthodontics?"; orthodontics and facial aesthetics; Newtonian paradigms and scientific revolution; the growth of knowledge; phenomenology; tacit knowledge; decision making.

The receiving simplification partnership: a win-win approach to better service and higher profitability.

To achieve competitive advantage, customers and suppliers are increasingly forming logistics partnerships to improve supply chain performance and reduce costs. The partnerships are typically motivated by the need to solve a particular problem, but with attention and open communication, new program ideas can develop, sometimes even breakthrough concepts. During the course of their partnership, Avery Dennison and United Stationers created a program that dramatically simplifies and speeds receiving and put-away of shipments with the aim of reducing workloads, improving service, and increasing profitability. The program involves optimizing order quantity increments to full-pallet, layer, and case volumes based on demand and warehouse configurations. Within six weeks, the results included a 50 percent reduction in shipment line items and 92 percent fewer put-away pieces, despite unchanged inventory levels.