The effectiveness of marine reserve systems constructed using different surrogates of biodiversity.

Biological sampling in marine systems is often limited, and the cost of acquiring new data is high. We sought to assess whether systematic reserves designed using abiotic domains adequately conserve a comprehensive range of species in a tropical marine inter-reef system. We based our assessment on data from the Great Barrier Reef, Australia. We designed reserve systems aiming to conserve 30% of each species based on 4 abiotic surrogate types (abiotic domains; weighted abiotic domains; pre-defined bioregions; and random selection of areas). We evaluated each surrogate in scenarios with and without cost (cost to fishery) and clumping (size of conservation area) constraints. To measure the efficacy of each reserve system for conservation purposes, we evaluated how well 842 species collected at 1155 sites across the Great Barrier Reef seabed were represented in each reserve system. When reserve design included both cost and clumping constraints, the mean proportion of species reaching the conservation target was 20-27% higher for reserve systems that were biologically informed than reserves designed using unweighted environmental data. All domains performed substantially better than random, except when there were no spatial or economic constraints placed on the system design. Under the scenario with no constraints, the mean proportion of species reaching the conservation target ranged from 98.5% to 99.99% across all surrogate domains, whereas the range was 90-96% across all domains when both cost and clumping were considered. This proportion did not change considerably between scenarios where one constraint was imposed and scenarios where both cost and clumping constraints were considered. We conclude that representative reserve systems can be designed using abiotic domains; however, there are substantial benefits if some biological information is incorporated.

Oral health awareness and care preferences in patients with diabetes: a qualitative study.

BACKGROUND: People with type 2 diabetes have an increased risk of oral health problems; however, oral health is currently not included in structured diabetes reviews and education in the UK. AIM AND OBJECTIVES: This study explores the patient's experience related to oral health and diabetes, especially in relation to: • Awareness of the link between oral health and diabetes and oral self-care needs. • Interaction with health professionals in dental and general practice. • Preferences for receiving oral health information and education. Methods This nested qualitative study involved semi-structured telephone interviews with a purposive sample of 20 participants from a questionnaire study on oral health awareness in patients with diabetes. Interview transcripts were analysed using a thematic framework approach. RESULTS: Participants were mostly unaware of the link between oral health and diabetes. Those that had been made aware by a health professional were not given concrete self-care advice. Interactions with dental professionals were often limited to informing the dental practice of their diagnosis and current medication. Most participants were in favour of dentists screening for diabetes, but as their general practice was the hub for diabetes care, they felt GPs or nurses should provide oral health information and discuss oral health with patients. CONCLUSIONS: Written information regarding diabetes and its possible effects on oral health needs to be more readily available to people with diabetes, especially at diagnosis. There may be a place for introducing a structured oral health question in routine diabetes reviews.

Biological surrogacy in tropical seabed assemblages fails.

Surrogate taxa are used widely to represent attributes of other taxa for which data are sparse or absent. Because surveying and monitoring marine biodiversity is resource intensive, our understanding and management of marine systems will need to rely on the availability of effective surrogates. The ability of any marine taxon to adequately represent another, however, is largely unknown because there are rarely sufficient data for multiple taxa in the same region(s). Here, we defined a taxonomic group to be a surrogate for another taxonomic group if they possessed similar assemblage patterns. We investigated effects on surrogate performance of (1) grouping species by taxon at various levels of resolution, (2) selective removal of rare species from analysis, and (3) the number of clusters used to define assemblages, using samples for 11 phyla distributed across 1189 sites sampled from the seabed of Australia's Great Barrier Reef. This spatially and taxonomically comprehensive data set provided an opportunity for extensive testing of surrogate performance in a tropical marine system using these three approaches for the first time, as resource and data constraints were previously limiting. We measured surrogate performance as to how similarly sampling sites were divided into assemblages between taxa. For each taxonomic group independently, we grouped sites into assemblages using Hellinger distances and medoid clustering. We then used a similarity index to quantify the concordance of assemblages between all pairs of taxonomic groups. Surrogates performed better when taxa were grouped at a phylum level, compared to taxa grouped at a finer taxonomic resolution, and were unaffected by the exclusion of spatially rare species. Mean surrogate performance increased as the number of clusters decreased. Moreover, no taxonomic group was a particularly good surrogate for any other, suggesting that the use of any one (or few) group(s) for mapping seabed biodiversity patterns is imprudent; sampling several taxonomic groups appears to be essential for understanding tropical/subtropical seabed communities. Consequently, where resource constraints do not allow complete surveying of biodiversity, it may be preferable to exclude rare species to allow investment in a broader range of taxonomic groups.

Identifying latent tuberculosis in high-risk populations: systematic review and meta-analysis of test accuracy.

BACKGROUND: The relative accuracy of interferon-gamma release assays (IGRAs) and the tuberculin skin test (TST) in identifying latent tuberculosis infection (LTBI) is uncertain.OBJECTIVE: To perform a systematic review and meta-analysis to compare the sensitivity and specificity of IGRAs and TST for the prediction of progression to clinical tuberculosis (TB).METHODS: We searched electronic databases (e.g., MEDLINE and EMBASE) from December 2009 to September 2018 for prospective studies that followed up individuals who had undergone testing with commercial IGRAs and/or TST but had not received treatment based on the test result. The sensitivity and specificity estimates were pooled using a Bayesian bivariate random-effects model.RESULTS: Twenty-five studies, mostly with moderate to high risk of bias and a mean follow-up time ranging from 1 to 5 years were included. TST (10-15 mm) tended to have lower sensitivity and higher specificity than QuantiFERON® Gold In-Tube, T-SPOT®.TB and TST (5 mm). The evidence did not indicate that any test outperformed the others due to wide and overlapping 95% credible intervals.CONCLUSION: The evidence following individuals who had undergone testing for LTBI and had progressed to clinical TB is sparse. We did not find that IGRAs were superior to TST or vice versa; however, as our findings are based on a small number of studies with methodological limitations and great uncertainty around the pooled estimates, the results should be interpreted with caution.

The use of irinotecan, oxaliplatin and raltitrexed for the treatment of advanced colorectal cancer: systematic review and economic evaluation.

OBJECTIVES: To evaluate three technologies for the management of advanced colorectal cancer: (1) first-line irinotecan combination [with 5-fluorouracil (5-FU)] or second-line monotherapy; (2) first- or second-line oxaliplatin combination (again, with 5-FU); and (3) raltitrexed, where 5-FU is inappropriate. To examine the role of irinotecan and oxaliplatin in reducing the extent of incurable disease before curative surgery (downstaging). SOURCES: Ten electronic bibliographic databases covering the period up to August 2004. METHODS: Searches identified existing studies of the effectiveness and economics of the technologies and any studies that evaluated any of the indications outlined above were included. Data were extracted and assessed generic components of methodological quality. Survival outcomes were meta-analysed. RESULTS: Seventeen trials were found, of varying methodological quality. Compared with 5-FU, first-line irinotecan improved overall survival (OS) by 2-4 months (p=0.0007), progression-free survival (PFS) by 2-3 months (p<0.00001) and response rates (p<0.001). It offered a different toxicity profile and no quality of life (QoL) advantage. However, second-line irinotecan compared with 5-FU improved OS by 2 months (p=0.035) and PFS by 1 month (p=0.03), and provided a better partial response rate, but with more toxicities and no QoL advantage. Compared with second-line best supportive care, irinotecan improved OS by 2 months (p=0.0001), had a different toxicity profile and maintained baseline QoL longer, but with no overall difference. The addition of oxaliplatin to second-line 5-FU is associated with a borderline significant improvement in overall survival (p<0.07); a significantly higher response rate (<0.0001); and more serious toxicities. There is no evidence for a significant difference in QoL. Schedules with treatment breaks may not reduce clinical effectiveness but reduce toxicity. The addition of oxaliplatin to second-line 5-FU also saw no improvement in OS (p<0.07), better PFS (by 2.1 months, p=0.0001), an 8.9% higher response rate (p<0.0001), more toxicities and no QoL advantage. There was no significant difference in OS or PFS between first-line irinotecan and oxaliplatin combinations except when 5-FU was delivered by bolus injection, when oxaliplatin provided better OS (p=0.032) and response rates (p=0.032), but not PFS (p=0.169). The regimens had different toxicity profiles and neither conferred a QoL advantage. When compared to 5-FU, raltitrexed is associated with no significant difference in overall or progression-free survival; no significant difference in response rates; more vomiting and nausea, but less diarrhoea and mucositis; no significant difference in, or worse QoL. Raltitrexed treatment was cut short in two out of four included trials due to excess toxic deaths. 5-FU followed by irinotecan was inferior to any other sequence. First-line irinotecan/5-FU combination improved OS and PFS, although further unplanned therapy exaggerated the OS effect size. Staged combination therapy (combination oxaliplatin followed by combination irinotecan or vice versa) provided the best OS and PFS, although there was no head-to-head comparison against other treatment plans. In the only trial to use three active chemotherapies in any staged combination, median OS was over 20 months. In another study, the longest median OS from a treatment plan using two active agents was 16.2 months. Where irinotecan or oxaliplatin were used with 5-FU to downstage people with unresectable liver metastases, studies consistently showed response rates of around 50%. Resection rates ranged from 9 to 35% with irinotecan and from 7 to 51% with oxaliplatin. In the one study that compared the regimens, oxaliplatin enabled more resections (p=0.02). Five-year OS rates of 5-26% and disease-free survival rates of 3-11% were reported in studies using oxaliplatin. Alone or in combination, 5-FU was more effective and less toxic when delivered by continuous infusion. Existing economic models were weak because of the use of unplanned second-line therapies in their trial data: the survival benefits in patients on such trials cannot be uniquely attributed to the allocated therapy. Consequently, the economic analyses are either limited to the use of PES (at best, a surrogate outcome) or are subject to confounding. Weaknesses in cost components, the absence of direct in-trial utility estimates and the limited use of sensitivity analysis were identified. Improvements to the methodologies used in existing economic studies are presented. Using data from two trials that planned treatment sequences, an independent economic evaluation of six plans compared with first-line 5-FU followed on progression by second-line irinotecan monotherapy (NHS standard treatment) is presented. 5-FU followed on progression by irinotecan combination cost 13,174 pounds per life-year gained (LYG) and 10,338 pounds per quality-adjusted life-year (QALY) gained. Irinotecan combination followed on progression by additional second-line therapies was estimated to cost 12,418 pounds per LYG and 13,630 pounds per QALY gained. 5-FU followed on progression by oxaliplatin combination was estimated to cost 23,786 pounds per LYG and 31,556 pounds per QALY gained. Oxaliplatin combination followed on progression by additional second-line therapies was estimated to cost 43,531 pounds per LYG and 67,662 pounds per QALY gained. Evaluations presented in this paragraph should be interpreted with caution owing to missing information on the costs of salvage therapies in the trial from which data were drawn. Irinotecan combination followed on progression by oxaliplatin combination cost 12,761 pounds per LYG and 16,663 pounds per QALY gained. Oxaliplatin combination followed on progression by irinotecan combination cost 16,776 pounds per LYG and 21,845 pounds per QALY gained. The evaluation suggests that these two sequences have a cost-effectiveness profile that is favourable in comparison to other therapies currently funded by the NHS. However, the differences in OS observed between the two trials from which data were taken may be a result of heterogeneous patient populations, unbalanced protocol-driven intensity biases or other differences between underlying health service delivery systems. CONCLUSIONS: Treatment with three active therapies appears most clinically effective and cost-effective. NHS routine data could be used to validate downstaging findings and a meta-analysis using individual patient-level data is suggested to validate the optimal treatment sequence.

Cost-effectiveness analysis of different embryo transfer strategies in England.

OBJECTIVE: The objective of this study was to assess the cost-effectiveness of different embryo transfer strategies for a single cycle when two embryos are available, and taking the NHS cost perspective. DESIGN: Cost-effectiveness model. SETTING: Five in vitro fertilisation (IVF) centres in England between 2003/04 and 2004/05. POPULATION: Women with two embryos available for transfer in three age groups (<30, 30-35 and 36-39 years). METHODS: A decision analytic model was constructed using observational data collected from a sample of fertility centres in England. Costs and adverse outcomes are estimated up to 5 years after the birth. Incremental cost per live birth was calculated for different embryo transfer strategies and for three separate age groups: less than 30, 30-35 and 36-39 years. MAIN OUTCOME MEASURES: Premature birth, neonatal intensive care unit admissions and days, cerebral palsy and incremental cost-effectiveness ratios. RESULTS: Single fresh embryo transfer (SET) plus frozen single embryo transfer (fzSET) is the more costly in terms of IVF costs, but the lower rates of multiple births mean that in terms of total costs, it is less costly than double embryo transfer (DET). Adverse events increase when moving from SET to SET+fzSET to DET. The probability of SET+fzSET being cost-effective decreases with age. When SET is included in the analysis, SET+fzSET no longer becomes a cost-effective option at any threshold value for all age groups studied. CONCLUSIONS: The analyses show that the choice of embryo transfer strategy is a function of four factors: the age of the mother, the relevance of the SET option, the value placed on a live birth and the relative importance placed on adverse outcomes. For each patient group, the choice of strategy is a trade-off between the value placed on a live birth and cost.

Short- and long-term clinical outcomes of use of beta-interferon or glatiramer acetate for people with clinically isolated syndrome: a systematic review of randomised controlled trials and network meta-analysis.

BACKGROUND: Beta-interferon (IFN-ß) and glatiramer acetate (GA) have been evaluated in people with clinically isolated syndrome (CIS) with the aim to delay a second clinical attack and a diagnosis of clinically definite multiple sclerosis (CDMS). We systematically reviewed trials evaluating the short- and long-term clinical effectiveness of these drugs in CIS. METHODS: We searched multiple electronic databases. We selected randomised controlled studies (RCTs) conducted in CIS patients and where the interventions were IFN-ß and GA. Main outcomes were time to CDMS, and discontinuation due to adverse events (AE). We compared interventions using random-effect network meta-analyses (NMA). We also reported outcomes from long-term open-label extension (OLE) studies. RESULTS: We identified five primary studies. Four had open-label extensions following double-blind periods comparing outcomes between early vs delayed DMT. Short-term clinical results (double-blind period) showed that all drugs delayed CDMS compared to placebo. Indirect comparisons did not suggest superiority of any one active drug over another. We could not undertake a NMA for discontinuation due to AE. Long-term clinical results (OLE studies) showed that the risk of developing CDMS was consistently reduced across studies after early DMT treatment compared to delayed DMT (HR = 0.64, 95% CI 0.55, 0.74). No data supported the benefit of DMTs in reducing the time to, and magnitude of, disability progression. CONCLUSIONS: Meta-analyses confirmed that IFN-ß and GA delay time to CDMS compared to placebo. In the absence of evidence that early DMTs can reduce disability progression, future research is needed to better identify patients most likely to benefit from long-term DMTs.

The clinical and cost-effectiveness of oxaliplatin and capecitabine for the adjuvant treatment of colon cancer: systematic review and economic evaluation.

OBJECTIVES: To assess the clinical and cost-effectiveness of oxaliplatin in combination with 5-fluorouracil/leucovorin (5-FU/LV), and capecitabine monotherapy (within their licensed indications), as adjuvant therapies in the treatment of patients with Stage III (Dukes' C) colon cancer after complete surgical resection of the primary tumour, as compared with adjuvant chemotherapy with an established fluorouracil-containing regimen. DATA SOURCES: Ten electronic bibliographic databases were searched from inception to January 2005. Searches were supplemented by hand searching relevant articles, sponsor and other submissions of evidence to the National Institute of Health and Clinical Excellence and conference proceedings. REVIEW METHODS: A systematic review and meta-analysis (where appropriate) of clinical efficacy evidence and a cost-effectiveness review and economic modelling were carried out. Marginal costs, life years gained and cost-effectiveness acceptability curves were estimated. Probabilistic sensitivity analysis was used to generate information on the likelihood that each of the interventions was optimal. RESULTS: Three randomised active-controlled trials, of varying methodological quality, were included in the review. The MOSAIC trial and NSABP C-07 study considered the addition of oxaliplatin to adjuvant treatment (albeit administered in different 5-FU/LV regimens) and the X-ACT study compared oral capecitabine with bolus 5-FU/LV alone. A review of the available evidence indicated that in patients with Stage III colon cancer, oxaliplatin in combination with an infusional de Gramont schedule of 5-FU/LV (FOLFOX4) was more effective in preventing and delaying disease recurrence than infusional 5-FU/LV alone (de Gramont regimen). Serious adverse events and treatment discontinuations due to toxicity were more evident with oxaliplatin-based regimens (FOLFOX4 and FLOX regimen) than infusional or bolus 5-FU/LV alone (de Gramont and Roswell Park regimen). Oral capecitabine was at least equivalent in disease-free survival to the bolus Mayo Clinic 5-FU/LV regimen for patients with resected Stage III colon cancer. Although, the safety and tolerability profile of capecitabine was superior to that of the Mayo Clinic 5-FU/LV regimen, it has not been evaluated in comparison with other less toxic 5-FU/LV regimens currently in common use in the UK. Based on the assumptions and survival analysis methods used, the cost-effectiveness analysis using economic modelling estimated that capecitabine was a dominating strategy and resulted in a cost-saving of approximately pound 3320 per patient in comparison with the Mayo Clinic 5-FU/LV regimen, while also providing an additional 0.98 quality-adjusted life-years (QALYs) over a 50-year model time horizon. Oxaliplatin in combination with 5-FU/LV (FOLFOX4 regimen) is estimated to cost an additional pound 2970 per QALY gained when compared with the de Gramont 5-FU/LV regimen and demonstrated superior survival outcomes with marginal costs. The uncertainty analysis suggests that both interventions have a high probability of being cost-effective at a threshold of both pound 20,000 and pound 30,000. An indirect comparison of the FOLFOX4 and Mayo Clinic 5-FU/LV regimens suggests that the use of FOLFOX4 in place of the Mayo Clinic 5-FU/LV regimen would cost an additional pound 5777 per QALY gained. An incremental cost-effectiveness ratio (ICER) is estimated to be approximately pound 13,000 per QALY gained from treatment with FOLFOX4 compared with capecitabine. However, if the Mayo Clinic and the de Gramont 5-FU/LV regimens are assumed to be equivalent in terms of effectiveness, the ICER of FOLFOX4 in comparison with capecitabine may be greater than pound 30,000 per QALY. CONCLUSIONS: The evidence suggests that both capecitabine and FOLFOX4 are clinically effective and cost-effective in comparison with 5-FU/LV regimens (Mayo Clinic and de Gramont schedules). Further research is suggested into the effectiveness, tolerability, patient acceptability and costs of different oxaliplatin/fluoropyrimidine schedules in the adjuvant setting; the effects of treatment duration on efficacy; adverse events; resource data collection strategies and reporting of summary statistics; subgroups benefiting most from adjuvant chemotherapy; and methods for estimating mean survival.

Computerised cognitive behaviour therapy for depression and anxiety update: a systematic review and economic evaluation.

OBJECTIVES: To evaluate computerised cognitive behaviour therapy (CCBT) for the treatment of anxiety, depression, phobias, panic and obsessive-compulsive behaviour (OCD). The software packages to be considered include Beating the Blues (BtB), Overcoming Depression: a five areas approach, FearFighter (FF), Cope and BT Steps. Other packages or programmes incorporating CCBT were also considered. DATA SOURCES: Electronic databases from 1966 to March 2004. Evidence submitted by sponsors for CCBT products. REVIEW METHODS: A systematic review was a review of the literature and the evidence submitted by sponsors for each of the products. A series of cost-effectiveness models was developed and run by the project team for the five CCBT products across the three mental health conditions. RESULTS: Twenty studies were identified in the clinical effectiveness review. The analysis of these results showed some evidence that CCBT is as effective as therapist-led cognitive behaviour therapy (TCBT) for the treatment of depression/anxiety and phobia/panic and is more effective than treatment as usual (TAU) in the treatment of depression/anxiety. CCBT also appears to reduce therapist time compared with TCBT. When reviewing cost-effectiveness studies, only one published economic evaluation of CCBT was found. This was an economic evaluation of the depression software BtB alongside a randomised controlled trial (RCT), which found that BtB was cost-effective against TAU in terms of cost per quality-adjusted life-year (QALY) (less than 2000 pounds), however it contained weaknesses that were then addressed in the cost-effectiveness model developed for the study. The results of the model for the depression software packages in terms of incremental cost per QALY compared with TAU and the chance of being cost-effective at 30,000 pounds per QALY were for BtB 1801 pounds and 86.8%, for Cope 7139 pounds and 62.6% and for Overcoming Depression 5391 pounds and 54.4%. The strength of the BtB software being that it has been evaluated in the context of an RCT with a control group. The subgroup analysis found no differences across the severity groupings. For phobia/panic software, the model showed an incremental cost per QALY of FF over relaxation was 2380 pounds. Its position compared with TCBT is less clear. When modelling OCD packages, using the practice-level licence cost meant that BT Steps was dominated by TCBT, which had significantly better outcomes and was cheaper. However, the cheaper PCT licence resulted in the incremental cost-effectiveness of BT Steps over relaxation being 15,581 pounds and TCBT over BT Steps being 22,484 pounds. CONCLUSIONS: The study findings are subject to substantial uncertainties around the organisational level for purchasing these products and the likely throughput. This is in addition to concerns with the quality of evidence on response to therapy, longer term outcomes and quality of life. The position of CCBT within a stepped care programme needs to be identified, as well as its relationship to other efforts to increase access to CBT and psychological therapies. Research is needed to compare CCBT with other therapies that reduce therapist time, in particular bibliotherapy and to explore the use of CCBT via the Internet. Independent research is needed, particularly RCTs, that examine areas such as patient preference and therapist involvement within primary care.

Cost effectiveness of total hip arthroplasty in osteoarthritis: comparison of devices with differing bearing surfaces and modes of fixation.

Many different designs of total hip arthroplasty (THA) with varying performance and cost are available. The identification of those which are the most cost-effective could allow significant cost-savings. We used an established Markov model to examine the cost effectiveness of five frequently used categories of THA which differed according to bearing surface and mode of fixation, using data from the National Joint Registry for England and Wales. Kaplan-Meier analyses of rates of revision for men and women were modelled with parametric distributions. Costs of devices were provided by the NHS Supply Chain and associated costs were taken from existing studies. Lifetime costs, lifetime quality-adjusted-life-years (QALYs) and the probability of a device being cost effective at a willingness to pay £20 000/QALY were included in the models. The differences in QALYs between different categories of implant were extremely small (< 0.0039 QALYs for men or women over the patient's lifetime) and differences in cost were also marginal (£2500 to £3000 in the same time period). As a result, the probability of any particular device being the most cost effective was very sensitive to small, plausible changes in quality of life estimates and cost. Our results suggest that available evidence does not support recommending a particular device on cost effectiveness grounds alone. We would recommend that the choice of prosthesis should be determined by the rate of revision, local costs and the preferences of the surgeon and patient.

Elderly drivers and their accidents: the Aging Driver Questionnaire.

The Manchester Driver Behavior Questionnaire (DBQ) was included as part of a questionnaire survey of 1989 drivers aged 50 or over. Previous research has differentiated three main types of aberrant driver behavior: errors, lapses and violations. Each of these has different psychological origins, and different implications for road safety interventions [Reason et al., 1990. Ergonomics 33, 1315-1312]. It has also been shown that, using a full age-range sample of drivers, reported violations were statistically associated with accident involvement, whereas errors and lapses were not [Parker et al., 1995a. Ergonomics 38, 1036-1048; Parker et al., 1995b. Accident Analysis and Prevention 27, 571-581]. Although factor analysis of the DBQ responses of this sample produced five factors, the original three-way distinction was preserved. However the pattern of relationships between factor scores and accident involvement was different. Relatively high scores on the error factor and the lapse factor were predictive of involvement in an active accident, while passive accident involvement was associated with high scores on the lapse factor.

Factors influencing lead concentrations in shed deciduous teeth.

Data collected for the Edinburgh Lead Study have been used to investigate lead concentrations in children's naturally shed deciduous teeth. A within-child multiple-regression analysis has shown that the upper jaw has a higher concentration of lead than the lower, and that there is a gradient of decreasing concentration from the front to the back of the mouth. Even after the effects of jaw and tooth type have been allowed for, the concentration is still found to be negatively correlated with the weight of the tooth and with the age at which the tooth was shed. No statistically significant effects could be attributed to caries, fillings, or the incomplete resorption of roots. A single-valued index of tooth lead has been derived for each child, taking into account the fact that children gave different types of teeth.

Caries experience and oral cleanliness of 3- and 4-year-old children from deprived and non-deprived areas in Edinburgh, Scotland.

Caries experience and oral cleanliness were measured in 1,453 3- and 4-year-old Edinburgh nursery schoolchildren living in areas of multiple urban deprivation and of non-deprivation in the city of Edinburgh. Children with poor oral cleanliness had a mean dmf value of 3.6 teeth compared with 1.6 teeth in those with good oral cleanliness. The greatest relative increases in caries experience were seen in the incisor and canine teeth and upon the occlusal and approximal surfaces. Children living in deprived city areas had a mean dmf value of 3.0 teeth compared with 2.0 teeth in those from non-deprived areas. This difference in caries experience was partially accounted for by the different standards of oral cleanliness found between the deprived and non-deprived areas. In the deprived areas there was a trend towards a high caries experience which was independent of the standard of oral cleanliness. The children were in considerable need of dental care. Only 23 percent of dmf teeth had been either extracted or restored.

Comparative study of oral health status between Scottish and Japanese schoolchildren aged 6-11 years.

This study was carried out to examine and compare the differences in oral health status between Scottish (Fife) and Japanese (Motoyoshi) primary schoolchildren, and also to analyse some factors concerned with the differences found. It was observed that caries experience is higher in Motoyoshi than in Fife, despite Fife schoolchildren having poorer oral cleanliness and consuming snacks more frequently. However, Fife children had more fissure sealants and brushed their teeth more frequently with fluoridated dentifrice than did Motoyoshi children. The sugar content of snacks consumed by Motoyoshi children was higher than that of the Scots. Gingivitis (PMA positive rate) was higher in Fife than in Motoyoshi, and it was also noted that Fife children were less independent than Motoyoshi children in their daily behaviour.

A 2-year retrospective study of demand for dental care from Scottish school leavers.

After leaving school young adults in the United Kingdom are no longer eligible to receive care from the School Dental Service. Patients who have previously been treated by the Service are obliged to seek care elsewhere. The aim of the study was to see how effectively a group of Scottish school leavers coped with the change. The study population was 912 school leavers. The method depended upon a retrospective study of clinical records relating to the year before leaving school and the following year. During the last year at school, 48% of the subjects received treatment from three sources: 30% were treated by a general practitioner, 19% by the school service and 2% by the hospital service. During the 2nd year of the study, 69% of those who had earlier been treated by a general practitioner again requested dental care compared with only 40% of those who had earlier been treated by the school service and 30% of those who had not sought dental care during their last year at school. Recommendations are made for encouraging an increased demand for care from those who have formerly been treated by the school service.

Dental caries experience and prevalence of children afraid of dental treatment.

The aim of this study was to examine the clinical outcome with regard to dental caries of high self reported dental anxiety in a group of Scottish secondary schoolchildren. 1103 children participated in the study, mean age 14 yr (sd 0.35 yr), and the prevalence of high dental anxiety was 7.1% (95% CI = 5.6%, 8.6%). When these children were compared with their contemporaries their DMFT and all its components were higher but only the mean MT reached statistical significance after adjusting for gender and social class. Children with a high dental anxiety were 62% more likely to have at least 1 missing tooth due to caries. In addition this group when compared to the rest of the study population, had a significantly lower mean number of teeth fissure sealed and a lower proportion of children with sealants. No similar trend was obvious for children who had a high general fear. The dentally anxious more accurately perceived their treatment need and were more likely to defer, cancel or not turn up for dental appointments.

Public health in Canada: a comparative study of six provinces.

PURPOSE: To describe the public health systems and their projected futures in six provinces in the context of two developments: 1) the emerging discourse on population health and 2) the trend toward regionalization of the health care system. METHODS: Telephone interviews with key informants and key document review. RESULTS AND CONCLUSIONS: Communicable disease control and health protection are currently the "core businesses" of public health; the population health discourse has not resulted in mandated programming. The reality is a retrenchment of public health scope during a time that should be considered conducive to expansion. Only Ontario has not regionalized its health care system, although public health is already delivered regionally. Alberta, Saskatchewan and Manitoba have either evolved or are evolving toward an integrated health system. There were concerns about the potential impact on public health identity and funding of this "vertical integration". Regionalization of public health may result in units that are too small to support adequate local expertise and may jeopardize development and enforcement of province-wide programs.

Incidence and prevalence of end-stage renal disease among Ontario's James Bay Cree.

End-stage renal disease (ESRD) and chronic renal failure (CRF) among Canadian natives is more common than among the general Canadian population. The results of this study show the James Bay Cree in Northern Ontario in 1989 experienced ESRD prevalence rates 3.2 times greater than the national rate. The average annual incidence rates for 1981-1989 were 1.6 times the national rate. Methodological difficulties inherent in incidence and prevalence studies of native Canadians are examined. With tertiary treatment care facilities available only in southern urban centres, native Canadians in remote northern communities face considerable psychosocial disruption when seeking out medical assistance for ESRD such as renal dialysis services.

Changes in the characteristics of patients attending an out-of-hours emergency dental service in Edinburgh.

A daily out-of-hours emergency dental service was established in Edinburgh in 1977. An analysis of some recent annual surveys carried out by the service shows that there has been an increasing trend for the patients to have experienced their dental problem for more than three days, to have travelled more than 10 miles to attend the clinic and not to have attended the dentist for more than a year. This analysis also reveals an increasing trend for people who seek treatment at the emergency service to have received routine treatment rather than emergency treatment on their last dental visit. There is evidence that the Lothian emergency dental service is developing its own clientele.

Dental health related behaviour of Scottish and English secondary schoolchildren.

The purpose of this investigation was to compare the dental health related behaviour of groups of 13-14-year-old English and Scottish schoolchildren, in order to explain the differences in caries experience demonstrated by the 1983 national children's dental health survey. The data-bank of health-reported behaviour of schoolchildren in the United Kingdom held by the Schools Health Education Unit (SHEU), Exeter University was used. Seventy-four secondary schools in England and 8 secondary schools in Scotland participated in the study. The information obtained from the questionnaires of 2283 children in England and 259 children in Scotland was examined. The daily intake of sweets, sugary fizzy drinks and a 'sugary' carbohydrate index were analysed from a 24-hour recall dietary record. There was a general consistency between the findings from the SHEU data and the 1983 United Kingdom children dental health survey (Todd & Dodd 1985) with regard to toothbrushing behaviour and dental attendance. Therefore, as dietary information was not gathered in the 1983 survey, exploration of the SHEU data bank allowed a comparison of the dietary habits between Scottish and English schoolchildren. Scottish schoolchildren consumed more sugar-containing items than English schoolchildren. Children from lower social groups in both countries consumed more sugar; however, the major dietary difference between the two countries was not in the mean number of sweets consumed or the daily sugary carbohydrate index, but in the mean number of sugary fizzy drinks consumed.