Is dentistry the orphaned field of medicine? Ethical consideration for evidence-based dentistry.

It was a watershed moment when Archie Cochrane published his work on Effectiveness and efficiency: random reflections on health services which was considered the start of evidence-based healthcare as we now know it. From there onward, evidence-based dentistry (EBD) has developed and evolved and there has been little attention to the interlink between EBD and ethics. The aim of this paper is to explore some of the ethical basis of evidence-based approach to healthcare utilising Beauchamp and Childress' four principles. EBD will be examined in relation to a variety of ethical theories. The case will be made that dentistry can, at times, be considered the orphaned field of medicine and an examination will be presented about how this may affect the uptake of EBD in practice. While exploring the strengths and weaknesses of EBD from an ethical viewpoint, we will highlight some of the challenges facing many dental practitioners in judging what is considered high-quality evidence and examine ways in which this could be improved with links to patient outcomes from an ethical perspective.

Reduction in interval cancer rates following the introduction of two-view mammography in the UK breast screening programme.

BACKGROUND: The introduction of two-view mammography at incident (subsequent) screens in the National Health Service Breast Screening Programme (NHSBSP) has led to an increased number of cancers detected at screen. However, the effect of two-view mammography on interval cancer rates has yet to be assessed. METHODS: Routine screening and interval cancer data were collated from all screening programmes in the United Kingdom for women aged 50-64, screened between 1 April 2003 and 31 March 2005. Interval cancer rates were compared based on whether two-view mammography was in use at the last routine screen. RESULTS: The reduction in interval cancers following screening using two-view mammography compared with one view was 0.68 per 1,000 women screened. Overall, this suggests the introduction of two-view mammography at incident screen was accompanied by a 15-20% reduction in interval cancer rates in the NHSBSP. CONCLUSION: The introduction of two-view mammography at incident screens is associated with a reduction in incidence of interval cancers. This is consistent with previous publications on a contemporaneous increase in screen-detected cancers. The results provide further evidence of the benefit of the use of two-view mammography at incident screens.

An observational study to evaluate the performance of units using two radiographers to read screening mammograms.

AIM: To examine the performance of screening units in which a proportion of mammograms were double read using "non-discordant radiographer only (double) reading" (NDROR). MATERIALS AND METHODS: NDROR was used by seven pilot units between 2006 and 2009, and six further units in 2009 only. There were 51 comparison units. Screening performance outcome measures were calculated, and logistic regression was used to compare performance between the pilot and comparison units. RESULTS: Phase 1 pilot units read between on average 15 and 48% of mammograms per year using NDROR between 2006 and 2009 (median, 33%) and in 2009, phase 2 pilot units used NDROR to read between 4 and 77% of mammograms (median, 34%). The results showed an increase in recall rates in the phase 1 pilot units relative to the comparison units at both prevalent and incident screens (adjusted OR 1.09, 95% CI 1.05, 1.14; and adjusted OR 1.10, 95% CI 1.07, 1.14, respectively). There were also increases in the phase 2 pilot units relative to the comparison units; adjusted OR 1.08 (95% 1.00, 1.17) at prevalent screens, and adjusted OR 1.07 (95% CI 1.02, 1.14) at incident screens. There was no evidence to suggest a difference in cancer-detection rates between the pilot units and the comparison units. CONCLUSIONS: Evidence from the present study suggests that recall rates may increase as a result of units using radiographers to double read a proportion of their mammograms. However, there is little evidence to suggest that NDROR, as practiced by the pilot units in the present study, is likely to have major impacts on performance in the UK National Health Service Breast Screening Programme (NHSBSP), particularly if it is fully supported and closely monitored (particularly recall rates).

Artemisia annua extracts, artemisinin and 1,8-cineole, prevent fruit infestation by a major, cosmopolitan pest of apples.

CONTEXT: Extracts of Artemisia annua (L.) (Asteraceae) and artemisinins are used for treatment of malaria, parasitic infections and have potent anticancer properties in cell lines. Eucalyptus oil and 1,8-cineole have antimicrobial, immune-stimulatory, anti-inflammatory, antioxidant, analgesic, and spasmolytic effects. Codling moth, Cydia pomonella, (L.) (Tortricidae), is a major cosmopolitan pest of the apple, potentially causing damage translating to 40 billion US dollars per year, globally. Currently used control measures are either hazardous to agricultural workers and harmful to environment, or ineffective. The potential of plant-derived semiochemicals for codling moth control is heavily understudied. OBJECTIVE: This study evaluated the potential of A. annua extracts, and two chemicals that this plant contains, artemisinin and 1,8-cineole, for preventing apple feeding and infestation by neonate Cydia pomonella larvae. METHODS: We studied effects of A. annua extracts, artemisinin and 1,8-cineole on apple infestation by neonate codling moth larvae using fruit choice assay in laboratory experiments. Preference of fruit treated with test solutions versus fruit treated with solvent was recorded and analyzed. RESULTS: Crude A. annua extracts prevented fruit feeding at 1, 3, and 10 mg/ml. Artemisinin had feeding deterrent effects at 10 and 30 mg/ml, and 1,8-cineole at 100 and 300 mg/ml. DISCUSSION AND CONCLUSIONS: A. annua contains chemicals that prevent apple infestation by codling moth neonates. Artemisinin and 1,8-cineole are among them, but there are other, polar constituents of A. annua, which have similar effects. There is a potential of using our findings in codling moth control and production of codling moth-resistant apples.

Interval cancers in the NHS breast cancer screening programme in England, Wales and Northern Ireland.

BACKGROUND: The United Kingdom NHS Breast Screening Programme was established in 1988, and women aged between 50 and 70 are routinely invited at three yearly intervals. Expected United Kingdom interval cancer rates have been calculated previously, but this is the first publication from an exercise to collate individual-based interval cancer data at a national level. METHODS: Interval cancer case ascertainment is achieved by the regular exchange of data between Regional Breast Screening Quality Assurance Reference Centres and Cancer Registries. The present analysis includes interval cancers identified in women screened between 1st April 1997 and 31st March 2003, who were aged between 50 and 64 at the time of their last routine screen. RESULTS: In the periods >0-<12 months, 12-<24 months and 24-<36 months after a negative screen, we found overall interval cancer rates and regional ranges of 0.55 (0.43-0.76), 1.13 (0.92-1.47) and 1.22 (0.93-1.57) per 1000 women screened, respectively. Rates in the period 33-<36 months showed a decline, possibly associated with early re-screening or delayed presentation. CONCLUSIONS: Interval cancer rates were higher than the expected rates in the 24-month period after a negative screen, but were similar to published results from other countries. Increases in background incidence may mean that the expected rates are underestimated. It is also possible that, as a result of incomplete case ascertainment, interval cancers rates were underestimated in some regions in which rates were less than the expected.

Inverted papilloma: a review of 53 cases.

OBJECTIVE: To assess the surgical management of patients with inverted nasal papilloma over a 14-year period. STUDY DESIGN: Retrospective study. SETTING: Tertiary health care center. RESULTS: Fifty-three patients (38 males, 15 females) with an average age of 49.8 years were treated. Overall recurrence rate was 28% and a malignant association of 9% was shown. Recurrence rates varied from 27% in patients with more extensive disease involvement treated by lateral rhinotomy and medial maxillectomy, to 30% in patients with less extensive disease treated conservatively. Of the 5 patients with associated malignancy, 3 (6% of all patients) are likely to have undergone malignant transformation. CONCLUSION: Aggressive initial management remains the therapeutic aim in this condition.

Autosomal dominant craniometaphyseal dysplasia is caused by mutations in the transmembrane protein ANK.

Craniometaphyseal dysplasia (CMD) is a rare skeletal disorder characterized by progressive thickening and increased mineral density of craniofacial bones and abnormally developed metaphyses in long bones. Linkage studies mapped the locus for the autosomal dominant form of CMD to an approximately 5-cM interval on chromosome 5p, which is defined by recombinations between loci D5S810 and D5S1954. Mutational analysis of positional candidate genes was performed, and we describe herein three different mutations, in five different families and in isolated cases, in ANK, a multipass transmembrane protein involved in the transport of intracellular pyrophosphate into extracellular matrix. The mutations are two in-frame deletions and one in-frame insertion caused by a splicing defect. All mutations cluster within seven amino acids in one of the six possible cytosolic domains of ANK. These results suggest that the mutated protein has a dominant negative effect on the function of ANK, since reduced levels of pyrophosphate in bone matrix are known to increase mineralization.

Tonsillectomy and tonsillitis in Cape Town--age and sex of patients.

OBJECTIVES: To assess the sex and age of patients undergoing tonsillectomy in the Cape Town metropolitan area. METHODOLOGY: A retrospective audit was conducted from 1991 to 1995 comparing the sex and age of patients undergoing tonsillectomy with patients admitted to hospital for acute tonsillitis and the general population. RESULTS: A total of 7,250 tonsillectomies were performed for recurrent tonsillitis, and 111 adult patients were admitted with acute tonsillitis. When the data for the adult tonsillectomy patients were isolated, the female/male ratio was 3.22:1, which is highly significant when compared with the data for the general population (Cornfield's 95% confidence limit: 2.82, 3.68) and for patients with acute tonsillitis (Cornfield's 95% confidence limit: 1.14, 2.65). CONCLUSION: Recurrent tonsillitis requiring tonsillectomy occurs more commonly in female than male patients.

Angiocentric T-cell lymphoma: an extensive lesion involving the posterior tongue, hypopharynx and supraglottis.

Angiocentric T-cell lymphoma, which in the past has been grouped with a variety of granulomatous diseases, occur uncommonly as a destructive condition of the posterior nasal space and midface. We report on a patient with a chronic granular ulcerative lesion involving the posterior tongue, hypopharynx and supraglottis.

Familial streptomycin ototoxicity in a South African family: a mitochondrial disorder.

The vestibular and ototoxic effects of the aminoglycoside antibiotics (streptomycin, gentamycin, kanamycin, tobramycin, neomycin) are well known; streptomycin, in particular, has been found to cause irreversible, profound, high frequency sensorineural deafness in hypersensitive persons. Aminoglycoside ototoxicity occurs both sporadically and within families and has been associated with a mitochondrial DNA (mtDNA) 1555A to G point mutation in the 12S ribosomal RNA gene. We report on the molecular analysis of a South African family with streptomycin induced sensorineural deafness in which we have found transmission of this same predisposing mutation. It is now possible to identify people who are at risk of hearing loss if treated with aminoglycosides in the future and to counsel them accordingly. In view of the fact that aminoglycoside antibiotics remain in widespread use for the treatment of infections, in particular for tuberculosis, which is currently of epidemic proportions in South Africa, this finding has important implications for the family concerned. In addition, other South African families may potentially be at risk if they carry the same mutation.

Postlaryngectomy voice restoration--a 2-year review.

We present a 2-year (1991/92) review of tracheo-oesophageal speech following total laryngectomy with tracheo-oesophageal fistula formation and subsequent use of a voicing prosthesis. Thirty-five primary fistulas and four secondary fistulas were created. Initially, 86% of patients obtained daily use of intelligible, fluent voice with few extraneous stomal sounds. Over a 2-3-month period following surgery, approximately one-third of these lost their fistula speech. The reasons for this were mainly related to psychological and socio-economic factors. Patient selection, surgical technique and postoperative management are described. Although a successful outcome requires a consolidated team approach, primary health care workers also need to know about postlaryngectomy prosthetic (fistula) speech and its management.

Bismuth subgallate: a safe means to a faster adenotonsillectomy.

Tonsillectomy, with or without adenoidectomy, is one of the most commonly performed surgical procedures and as such contributes significantly to the surgery performed by GPs and ENT surgeons. In this randomized controlled study we compared the use of a compound bismuth subgallate (BSG) during adeno-tonsillectomy with the standard operations. Two hundred and two tonsillectomies were randomized into two groups. BSG was used in 90 patients while the other 112 patients were used as controls. The mean operating time was reduced from 11.5 to 9.9 minutes, the number of swabs from 4.5 to 3.7 and number of ties from 3.4 to 2.1. All these reductions were significant (p-values all < 0.05). There were no post-operative complications in either group. Thus the use of BSG during adeno-tonsillectomy or tonsillectomy alone significantly decreases the operating time and results in less intraoperative haemorrhage with fewer ties and swabs being required.

Rod-cone dystrophy, sensorineural deafness, and renal dysfunction: an autosomal recessive syndrome?

An autosomal recessive syndrome of progressive rod-cone dystrophy, sensorineural deafness, and renal dysfunction was identified in 14 children in 9 Afrikaner families in South Africa. The renal involvement, which is of the Fanconi type, leads to rickets-like skeletal changes and kidney failure. Each of the children was initially misdiagnosed as having retinitis pigmentosa or Usher syndrome, on a basis of minor retinal pigmentation. This condition, which appears to be a hitherto undocumented entity, warrants differentiation from these disorders.

Congenital cerebrospinal fluid fistula through the inner ear and meningitis.

Congenital deformities of the labyrinth of the inner ear can be associated with a fistulous communication between the intracranial subarachnoid space and the middle ear cavity. We describe seven such cases, six confirmed by high resolution CT and one by postmortem histological section. The seven patients all presented with meningitis although a cerebrospinal fluid fistula was demonstrated at subsequent surgery or postmortem. The lesions were bilateral in three patients, unilateral in three and probably bilateral in the postmortem case although only one temporal bone was obtained. In every case there was a dilated sac instead of the normal two and a half turn cochlea on the affected side and this was confirmed at surgery. The demonstration of the basal cochlear turn is of paramount importance in any deaf child presenting with meningitis. A true Mondini deformity with a normal basal turn and some hearing is not at risk of developing a fistula.