Sensitivity and specificity of radiographic characteristics in atypical femoral fractures.

Using the American Society for Bone and Mineral Research Task Force case definition for atypical femoral fractures, sensitivity and specificity of radiographic fracture characteristics were calculated. Fracture pattern was the most sensitive and specific characteristic. This suggests that some characteristics should be weighted more heavily when identifying these fractures. INTRODUCTION: To estimate the sensitivity and specificity of each radiographic criterion in the 2013 ASBMR atypical femoral fracture (AFF) case definition for distinguishing AFF from other subtrochanteric/diaphyseal fractures (non-AFF) among women enrolled in a large integrated health care organization. METHODS: Radiographs from 55 physician-confirmed AFFs and a sample of 39 non-AFFs were reviewed by four independent expert reviewers representing four medical specialties. One image per fracture was selected for review. Using a standardized data collection tool, based on the 2013 AFF case definition, reviewers indicated the presence or absence of the following characteristics viewable on radiograph: fracture pattern, comminution, periosteal and/or endosteal thickening, and cortical thickening. Sensitivity and specificity for each characteristic was calculated for each reviewer and summarized across reviewers with the mean and range. Agreement across reviewers was quantified using Fleiss's kappa (FK) statistic. RESULTS: The most sensitive factors distinguishing AFF from non-AFF were lateral cortex transverse fracture pattern (mean 93.6 %, range 85.5-98.2 %), medial cortex transverse or oblique fracture pattern (mean 84.1 %, range 72.7-98.2 %), and minimal/non-comminution (mean 93.2 %, range 89.1-98.2 %). Specificity was the greatest for lateral cortex transverse fracture pattern (mean 95.5 %, range 92.3-97.4 %). Agreement across reviewers was the highest for lateral cortex transverse fracture pattern (FK 0.83) and incomplete fracture through the lateral cortex only (FK 0.80). CONCLUSION: Lateral cortex transverse fracture pattern was the most sensitive and specific characteristic and the most highly agreed upon across reviewers. Other characteristics were less readily agreed upon across reviewers. Measurement of discrete combinations of individual characteristics may enhance sensitivity and/or specificity.

Assessment of off-label use of denosumab 60 mg injection during the early postmarketing period using health insurance claims data.

UNLABELLED: Off-label use of denosumab 60 milligram (mg) injection was assessed within an administrative claims database. The completeness of claims to assess off-label use was investigated with medical record review. Potential denosumab 60 mg off-label use was observed based on claims, but many had evidence of on-label indications based on medical record review. INTRODUCTION: Denosumab 60 mg injection is approved in the USA to treat patients at high fracture risk due to postmenopausal osteoporosis, male osteoporosis, and hormone therapy for the treatment of prostate and breast cancers. Its RANK ligand-inhibiting effect makes it a candidate for the off-label treatment of other conditions mediated by the rate of bone resorption by osteoclasts. To better understand its utilization patterns, we assessed off-label use of denosumab 60 mg within an administrative claims database. METHODS: Definite, probable, and possible denosumab 60 mg users were identified during the early postmarketing period within a claims database of a US healthcare insurer. Medical record review confirmed a sample of these users. Off-label use among definite and probable users and all chart-confirmed users was classified using claims-derived age, dose interval, and diagnosis and treatment received relative to the administration date. Among chart-confirmed users classified as off-label, patient characteristics related to treatment indication were abstracted from medical records to investigate the completeness of claims to study off-label medication use. RESULTS: Off-label use was identified based on claims in approximately 25 % of definite and probable denosumab 60 mg users and 35 % of chart-confirmed users. Medical record review identified evidence of on-label indications in 81 % of chart-confirmed users classified as off-label in claims. CONCLUSIONS: Many of the off-label denosumab 60 mg users had diagnoses or treatment consistent with on-label indications based on medical record review, suggesting these are under-recorded in claims data. It is warranted to be cautious when using administrative databases to assess off-label medication use.

Comorbidities, bone-sparing agent prescription history and their determinants among postmenopausal women in UK primary care settings: a retrospective database study.

SUMMARY: Distinguishing oral bisphosphonates from other bone-sparing therapies, this retrospective observational study, first, characterized treated osteoporosis patients in the UK, and secondly, explored factors associated with the risk of discontinuation or switching between therapies. The latter should be considered when evaluating real-world data. PURPOSE: This retrospective observational study evaluated the characteristics of women with postmenopausal osteoporosis, including comorbidities and determinants of treatment patterns with bone-sparing agents. METHODS: The UK Clinical Practice Research Datalink was used to identify postmenopausal women (aged ≥50 years) treated with a bone-sparing agent or diagnosed with osteoporosis between 1 January 1993 and 31 December 2008. Two non-mutually-exclusive subpopulations were defined: (1) patients active in the database on 31 December 2008; (2) patients treated with a bone-sparing agent since 1 January 1993. Subpopulation 1 was used to describe patient comorbidities and osteoporosis treatment history, and subpopulation 2 was used to explore the characteristics associated with bone-sparing treatment patterns use via multivariable regression for repeated multinomial responses. RESULTS: A total of 62,657 individuals met the inclusion criteria; subpopulation 1 comprised 38,469 women (61.4%), of whom 21,687 received a bone-sparing agent in 2008 (99.7% oral bisphosphonates and the remainder other agents). Those receiving other agents were more likely to have had previous treatment with bone-sparing agents, to have experienced previous fractures, and to have visited their doctor more frequently. Analyses also identified several comorbidities associated with an increased risk of discontinuation of bone-sparing agents, including heart disease, gastrointestinal disease, and renal failure. Anticonvulsant use was associated with a dramatic increase in the risk of switching. CONCLUSIONS: Several patient characteristics were associated with discontinuation of, or switching between, bone-sparing treatments. Patients receiving bone-sparing medication other than oral bisphosphonates were more likely to have comorbid conditions and a history of fracture and to have taken an oral bisphosphonate previously.

HIV prevalence, previous HIV testing, and condom use with clients and regular partners among Senegalese commercial sex workers.

OBJECTIVES: To assess HIV prevalence and risk factors for HIV infection, to investigate condom use among registered female commercial sex workers (CSWs) in Senegal, West Africa, and to examine the association between previous HIV testing, knowledge of HIV serostatus and condom use with both regular sex partners and clients within this population. METHODS: A cross-sectional study was conducted at three sexually transmitted disease clinics among 1052 Senegalese registered CSWs between 2000 and 2004. Inperson interviews soliciting information concerning demographic characteristics, medical history, sexual behaviour with clients and regular partners, and previous HIV testing history were performed. Blood samples were collected for determination of HIV-1 and/or HIV-2 serostatus. Multivariable, Poisson and log-binomial models were used to calculate prevalence ratios. RESULTS: The overall HIV prevalence was 19.8%. Over 95% of CSWs reported always using a condom with clients, but only 18% reported always using a condom with their regular partners. A history of previous HIV testing was not associated with condom use with clients (adjusted prevalence ratio (APR) = 0.98, 95% confidence intervals, CI: 0.90 to 1.06). However, prior HIV testing was associated with decreased condom use with their regular partners (APR = 0.44, 95% CI: 0.28 to 0.69), especially in women who tested HIV negative (APR = 0.17, 95% CI: 0.08 to 0.36). CONCLUSIONS: CSWs in Senegal have a high HIV prevalence; therefore preventing HIV transmission from this population to the general population is important. Condom use with regular partners is low among registered CSWs in Senegal, and a prior HIV negative test is associated with even less condom use with regular partners. Intervention efforts to increase condom use with regular sexual partners are needed.

Comparison of human immunodeficiency virus (HIV)-specific T-cell responses in HIV-1- and HIV-2-infected individuals in Senegal.

Human immunodeficiency virus type 2 (HIV-2) infection is typically less virulent than HIV-1 infection, which may permit the host to mount more effective, sustained T-cell immunity. We investigated antiviral gamma interferon-secreting T-cell responses by an ex vivo Elispot assay in 68 HIV-1- and 55 HIV-2-infected Senegalese patients to determine if differences relate to more efficient HIV-2 control. Homologous HIV-specific T cells were detected in similar frequencies (79% versus 76%, P = 0.7) and magnitude (3.12 versus 3.08 log(10) spot-forming cells/10(6) peripheral blood mononuclear cells) in HIV-1 and HIV-2 infection, respectively. Gag-specific responses predominated in both groups (>/=64%), and significantly higher Nef-specific responses occurred in HIV-1-infected (54%) than HIV-2-infected patients (22%) (P < 0.001). Heterologous responses were more frequent in HIV-1 than in HIV-2 infection (46% versus 27%, P = 0.04), but the mean magnitude was similar. Total frequencies of HIV-specific responses in both groups did not correlate with plasma viral load and CD4(+) T-cell count in multivariate regression analyses. However, the magnitude of HIV-2 Gag-specific responses was significantly associated with lower plasma viremia in HIV-1-infected patients (P = 0.04). CD4(+) T-helper responses, primarily recognizing HIV-2 Gag, were detected in 48% of HIV-2-infected compared to only 8% of HIV-1-infected patients. These findings indicate that improved control of HIV-2 infection may relate to the contribution of T-helper cell responses. By contrast, the superior control of HIV-1 replication associated with HIV-2 Gag responses suggests that these may represent cross-reactive, higher-avidity T cells targeting epitopes within Gag regions of functional importance in HIV replication.

Risk factors for diagnostic subgroups of painful temporomandibular disorders (TMD).

Temporomandibular Disorders (TMD) encompass several entities, which may have differing etiologies. To test this hypothesis, we investigated risk factors for three diagnostic subgroups of painful TMD. Ninety-seven subjects with myofascial pain only, 20 with arthralgia only, 157 with both myofascial pain and arthralgia, and 195 controls without TMD pain met criteria for study eligibility. Investigated risk factors included both physical and psychological variables. Adjusted odds ratios were calculated by multiple logistic regression analyses. Myofascial pain occurring alone was significantly associated with trauma (Odds Ratio [OR] = 2.0), clenching (OR = 4.8), third molar removal (OR = 3.2), somatization (OR = 3.7), and female gender (OR = 4.2). Myofascial pain with arthralgia was significantly associated with trauma (OR = 2.1), clenching (OR = 3.3), third molar removal (OR = 4.0), somatization (OR = 5.1), and female gender (OR = 4.7). No significant associations were found for the small-arthralgia-only group.

The effect of sequential use of vacuum and forceps for assisted vaginal delivery on neonatal and maternal outcomes.

OBJECTIVE: To determine the risk of neonatal and maternal disease associated with the sequential use of vacuum and forceps compared with spontaneous vaginal delivery. STUDY DESIGN: Using Washington state birth certificate data linked to hospital discharge records, we compared 3741 vaginal deliveries by both vacuum and forceps, 3741 vacuum deliveries, and 3741 forceps deliveries to 11,223 spontaneous vaginal deliveries. RESULTS: Compared with spontaneous vaginal deliveries, deliveries by sequential use of vacuum and forceps had significantly higher rates of intracranial hemorrhage (relative risk [RR], 3.9; 95% confidence interval [CI], 1.5 to 10.1), brachial plexus (RR, 3.2; 95% CI, 1.6 to 6.4), facial nerve injury (RR, 13.3; 95% CI, 4.7 to 37.7), seizure (RR, 13.7; 95% CI, 2.1 to 88.0), depressed 5-minute Apgar score (RR, 3.0; 95% CI, 2.2 to 4.0), assisted ventilation (RR, 4.8; 95% CI, 2.1 to 11.0), fourth-degree (RR, 11.4; 95% CI, 6.4 to 20.1 among multiparous women) and other lacerations, hematoma (RR, 6.2; 95% CI, 2.1 to 18.1 among multiparous women), and postpartum hemorrhage (RR, 1.6; 95% CI, 1.3 to 2.0). The relative risk of sequential vacuum and forceps use was greater than the sum of the individual relative risks of each instrument for intracranial hemorrhage, facial nerve injury, seizure, hematoma, and perineal and vaginal lacerations. CONCLUSION: Sequential use of vacuum and forceps is associated with increased risk of both neonatal and maternal injury.

HLA class II DR-DQ and increased risk of cervical cancer among Senegalese women.

To examine Senegalese women to confirm and extend associations between HLA class II types and cervical cancer previously observed among African-American, Caucasian, Hispanic, and Japanese ethnic populations, 55 Senegalese women with invasive cervical carcinoma were compared with age-matched (human papillomavirus) HPV-positive (n = 83) and HPV-negative (n = 107) control women. PCR-based HPV and HLA typing methods were used. Data were analyzed using a global randomization test and conditional logistic regression. Although this study failed to confirm a previously reported association between cervical cancer and DQB1*03 alleles, the DRB1*1101-DQB1*0301 haplotype was detected more frequently among cervical carcinoma cases than among controls (adjusted odds ratio, 2.6; 95% confidence interval, 1.0-7.1). Furthermore, as reported by others, we observed a negative association of borderline statistical significance between DRB1*13 and cervical carcinoma (adjusted odds ratio, 0.5; 95% confidence interval, 0.2-1.1). Observations from this study confirm earlier findings of a negative association between DRB1*13 and cervical cancer and suggest that specific DRB1-DQB1 haplotype combinations, rather than individual DQB1*03 alleles, increase the risk for cervical cancer.

Predictors of accidental fatal drug overdose among a cohort of injection drug users.

OBJECTIVES: This study evaluated factors associated with accidental fatal drug overdose among a cohort of injection drug users (IDUs). METHODS: In a prospective cohort study of 2849 IDUs in King County, Washington, deaths were identified by electronically merging subject identifiers with death certificate records. Univariate and multivariate Cox regression analyses were performed to identify predictors of overdose mortality. RESULTS: Thirty-two overdoses were observed. Independent predictors of overdose mortality were bisexual sexual orientation (relative risk [RR] = 4.86; 95% confidence interval [CI] = 2.30, 13.2), homelessness (RR = 2.30; 95% CI = 1.06, 5.01), infrequent injection of speedballs (RR = 5.36; 95% CI = 1.58, 18.1), daily use of powdered cocaine (RR = 4.84; 95% CI = 1.13, 20.8), and daily use of poppers (RR = 22.0; 95% CI = 1.74, 278). CONCLUSIONS: Sexual orientation, homelessness, and drug use identify IDUs who may benefit from targeted interventions.

Human papillomavirus and long-term oral contraceptive use increase the risk of adenocarcinoma in situ of the cervix.

We examined United States Surveillance, Epidemiology, and End Results incidence data and conducted a population-based case-control study to examine the role of human papillomavirus (HPV) and oral contraceptive (OC) use in the etiology of adenocarcinoma in situ of the cervix (ACIS). One hundred and fifty women diagnosed with ACIS and 651 randomly selected control women completed in-person interviews. The presence of HPV DNA in archival ACIS specimens was determined by E6 and L1 consensus PCR. Serum samples from case and control subjects were collected at interview, and antibodies to HPV-16 L1 and HPV-18 L1 were detected by virus-like particle capture assays. The overall prevalence of HPV DNA was 86.6%, with 39.0% positive for HPV-16 DNA, 52.4% positive for HPV-18 DNA, and 13.4% positive for more than one HPV type. The age-adjusted relative risk of ACIS associated with HPV-18 seropositivity was 3.3 (95% confidence interval 2.2-4.9). No increased risk was associated with antibodies to HPV-16 L1. Among women born after 1945, the relative risk increased with duration of OC use, with the highest risk for 12 or more years of use (odds ratio, 5.5; 95% confidence interval, 2.1-14.6) relative to nonusers. The detection of HPV DNA in 86.6% of ACIS and the strong association of ACIS with HPV-18 L1 seropositivity underscore the importance of HPV, particularly HPV-18, in the etiology of ACIS. In addition, long-term OC use may contribute to the pathogenesis of these tumors in some women.

Slow diffusion of home HIV-specimen collection: provider concerns at odds with client preferences.

BACKGROUND: Home specimen collection and telephone counseling (HSCTC) may be a convenient new method for detection of HIV infection among cohorts at high-risk for HIV. GOAL: To evaluate attitudes about HSCTC among participants, HIV counselors, and community advisory board members associated with a national multisite study of persons at high risk for HIV. STUDY DESIGN: Twelve focus groups and surveys were conducted at six sites among 126 counselors, community advisory board members, and cohort participants. RESULTS: Staff and community advisory board members raised concerns about the acceptability, feasibility, safety, and effectiveness of HSCTC. In contrast, participants (92%) reported a willingness to collect blood and oral samples on a frequent basis, and preferred telephone (73%) to office-based counseling. CONCLUSION: Home specimen collection and telephone counseling appear to be preferred by study participants at high risk of HIV infection. Staff and community advisory board members had stronger reservations than prospective users.

Maternal and neonatal outcomes after induction of labor without an identified indication.

OBJECTIVE: This study was undertaken to examine associations between induction of labor and maternal and neonatal outcomes among women without an identified indication for induction. STUDY DESIGN: This was a population-based cohort study of 2886 women with induced labor and 9648 women with spontaneous labor who were delivered at 37 to 41 weeks' gestation, all without identified medical and obstetric indications for induction. RESULTS: Among nulliparous women 19% of women with induced labor versus 10% of those with spontaneous labor underwent cesarean delivery (adjusted relative risk, 1.77; 95% confidence interval, 1.50-2.08). No association was seen in multiparous women (relative risk, 1.07; 95% confidence interval, 0. 81-1.39). Among all women induction was associated with modest increases in instrumental delivery (19% vs 15%; relative risk, 1.20; 95% confidence interval, 1.09-1.32) and shoulder dystocia (3.0% vs 1. 7%; relative risk, 1.32; 95% confidence interval, 1.02-1.69). CONCLUSION: Among women who lacked an identified indication for induction of labor, induction was associated with increased likelihood of cesarean delivery for nulliparous but not multiparous women and with modest increases in the risk of instrumental delivery and shoulder dystocia for all women.

Home collection for frequent HIV testing: acceptability of oral fluids, dried blood spots and telephone results. HIV Early Detection Study Group.

OBJECTIVE: To assess the feasibility and acceptability of bimonthly home oral fluid (OF) and dried blood spot (DBS) collection for HIV testing among high-risk individuals. DESIGN: A total of 241 participants [including men who have sex with men (MSM), injecting drug users (IDU), and women at heterosexual risk] were recruited from a randomly selected subset of study participants enrolled at four sites in the HIV Network for Prevention Trials (HIVNET) cohort, and assigned at random to bimonthly home collection of OF or DBS specimens over a 6 month interval. Participants could select telephone calls or clinic visits to receive HIV test results. METHODS: Bimonthly specimens were tracked for adherence to the schedule, were evaluated for adequacy for testing, and tested using antibody assays and polymerase chain reaction (PCR) for DBS. The acceptability of bimonthly home OF and DBS collection and telephone counseling was assessed in an end-of-study questionnaire. RESULTS: The laboratory received 96 and 90% of expected OF and DBS specimens, respectively; 99% of each specimen type was adequate for testing. Almost all (95%) participants chose results disclosure by telephone. The majority of participants (85%) reported that bimonthly testing did not make them worry more about HIV, and almost all (98%) judged that with bimonthly testing their risk behavior remained the same (77%) or became less risky (21%). CONCLUSION: Bimonthly home specimen collection of both OF and DBS with telephone counseling is acceptable and feasible among study participants at high risk. These methods will be useful for the early detection of HIV infection and remote follow-up of research cohort participants in HIV vaccine and prevention trials.

Association of antiretroviral therapy with detection of HIV-1 RNA and DNA in the anorectal mucosa of homosexual men.

OBJECTIVE: To determine whether combination antiretroviral therapy is associated with reduced detection of HIV-1 RNA and DNA in the anorectal mucosa of men who have sex with men (MSM). DESIGN: Cross-sectional study of 233 MSM recruited from community and clinic sites in Seattle, Washington between July 1996 and December 1997. METHODS: HIV-1 RNA and HIV-1 DNA were detected in anorectal swab specimens by polymerase chain reaction amplification assays. RESULTS: HIV-1 RNA was detected significantly less often in anorectal specimens from users of combination antiretroviral therapies, whether a protease inhibitor was received (15/89; 17%) or not (16/53; 30%), than in men not receiving therapy (43/88; 49%) (P < 0.001, P = 0.03, respectively). In contrast, HIV-1 DNA was detected only slightly less frequently in anorectal specimens obtained from men receiving protease inhibitors (35/81; 43%) or reverse transcriptase inhibitors alone (22/48; 46%) than in specimens from men not receiving therapy (45/78; 58%) (P = 0.07, P = 0.20, respectively). Among men with < 50 copies HIV-1 RNA/ml plasma, detection of HIV-1 RNA in anorectal specimens was rare (1/54; 2%) but detection of HIV-1 DNA was common (14/50; 28%). CONCLUSIONS: Combination antiretroviral therapy is associated with reductions in HIV-1 RNA, but HIV-1 DNA remains detectable in the anorectal canal of almost half of MSM receiving such therapy. Condom use during anal intercourse should be encouraged, regardless of plasma viral load response to potent antiretroviral therapy.

Secretor polymorphism and human immunodeficiency virus infection in Senegalese women.

The FUT2 gene encodes the enzyme alpha (1,2) fucosyltransferase, which determines expression of blood-group antigens on mucosal epithelial cell surfaces and in secretions. Homozygotes for a specific stop mutation in FUT2 (nonsecretors) cannot produce this enzyme and thus are unable to express blood group antigens. Nonsecretor status is associated with a decreased risk of several respiratory viral infections. By use of molecular genotyping, 2 populations of Senegalese women were examined for polymorphisms of the FUT2 gene. Among Senegalese commercial sex workers, absence of FUT2 (nonsecretor genotype) was associated with reduced risk of human immunodeficiency virus (HIV) type 1 infection (odds ratio [OR] adjusted for cervical and vaginal infection, 0.18; 95% confidence interval [CI], 0.04-0.90) and HIV-2 infection (adjusted OR, 0.43; 95% CI, 0.13-1.39), although the latter was not statistically significant. Modification of cell surface carbohydrates at mucosal surfaces determined by the FUT2 gene may underlie the protective association against heterosexual HIV infection.

Is there a doctor in the house?

The two cases presented deal with urgent situations experienced by persons unknown to the dentist in the area. It is likely that dentists, physicians, nurses, and other medical professionals will encounter persons in urgent need of medical attention in other venues. Certainly, it is possible for someone to experience an emergency in a ballpark, grocery store, church, or other public gathering. While these settings may not offer the advantage of a medical emergency kit, they do pose the same ethical requirement for those trained in medical management of urgent problems to step forward, identify themselves, and attempt to help the ill person. Fortunately, most non-air settings usually allow for contacting emergency medical help and prompt transport to hospitals. The public may never reach a general understanding of the extent to which doctors other than physicians are trained to handle medical emergencies. Similarly, when someone in a crowded theater yells, "Is there a doctor in the house?" he or she most likely is thinking about a physician. This does not mean that a dentist is excused from acting as a medically trained Good Samaritan. The ethical obligation of specific beneficence requires dentists to minister to the ill in medical emergencies unless a more qualified health care provider is present and identifies himself or herself. The ethical obligation of general beneficence requires dentists and other citizens to assist those in urgent circumstances whose needs do not call upon specialized knowledge or training. Fortunately, the law in this country is designed to protect those who do attempt to help those in need.

Risk factors for urinary tract infection in the postpartum period.

OBJECTIVE: We sought to examine risk factors for urinary tract infection in postpartum women. STUDY DESIGN: Subjects (n = 931) with maternal urinary tract infections and control subjects (n = 1862) were identified by using a linked Washington State birth certificate and Birth Events Records Database for the years 1987-1993; stratified analysis was performed by using Mantel-Haenszel procedures. RESULTS: Increased risk for postpartum urinary tract infection was associated with black, Native American, or Hispanic race-ethnicity (odds ratio, 1.30; 95% confidence interval, 1.03-1.64) and unmarried status (odds ratio, 1.33; 95% confidence interval, 1.11-1.58). Cesarean delivery (odds ratio, 2.70; 95% confidence interval, 2.27-3.20) and tocolysis (odds ratio, 3.30; 95% confidence interval, 2.15-5.06) also contributed to maternal risk of acquiring a urinary tract infection. Maternal risk factors included renal disease (adjusted odds ratio, 3.89; 95% confidence interval, 1.80-8.41) and preeclampsia-eclampsia (adjusted odds ratio, 3.21; 95% confidence interval, 2.36-4.38). Among women undergoing vaginal delivery, renal disease (odds ratio, 5.47; 95% confidence interval, 2.04-14.64) and abruptio placentae (odds ratio, 5.02; 95% confidence interval, 1.84-13.64) were risk factors. Length of hospital stay was significantly associated with urinary tract infection. CONCLUSION: Maternal medical conditions and procedures that predispose to urinary tract infections are those that also are associated with urethral catheterization. In addition, maternal urinary tract infections may contribute significantly to duration of postpartum hospital stay.

Disclosure of mistakes.

In the course of professional practice, errors will occur and patients may be harmed because of them. The ethical obligation to respect patients' autonomy requires that dentists reveal mistakes to patients if the mistake significantly affects the patient's health and well-being. Answering the question, "would most people think they have a right to know of this type of mistake if it happened to them?" may be helpful in determining the significance of an error. An open disclosure and examination of professional mistakes will be beneficial to patients, doctors, and the practice. Fear of legal reprisals or thoughts that the mistake could be effectively concealed from the patient cannot justify failing to inform the patient of an error and may put the dentist in greater legal peril. Dentists who attempt to hide errors from patients violate the patient's autonomy and risk implicating the profession as one which cannot be trusted.

Sexual boundaries in dental practice: Part 2.

Sexual harassment in the workplace is harmful to employees and disruptive. While the ethical obligations arising from the doctor-patient relationship do not address a dentist's ethical obligations toward his or her employees, the more general ethical obligations to the profession and those of business ethics would mediate against the creating or tolerance of sexual harassment in the workplace. The legal implications of participating in sexual harassment or allowing it to persist in the dental office are significant and dentists should be aware that employees enjoy legal protections against this inappropriate and potentially unlawful behavior. While any gender in any position may be the victim of sexual harassment, women who occupy subordinate positions are the most likely targets of these overtures. Dentist-employers are wise to be proactive in providing an appropriate protocol for employees to use when they perceive sexual harassment in the workplace.