Biochemical characterisation of carious dentine zones using Raman spectroscopy.

OBJECTIVE: Carious tissue discrimination in clinical operative caries management relies traditionally on the subjective hardness of carious dentine. Biochemical alterations within the lesion have the potential to discriminate the lesion zones objectively. This study aimed to determine the correlation between the biochemical proportions of amide I and phosphate moieties as these are the most prominent peaks found in dentine with the Knoop microhardness of carious dentine zones, using non-contact Raman spectroscopy. The null hypothesis investigated was that there was no correlation between Raman peak ratios, amide I: phosphateν1, and the Knoop microhardness within specific zones of a carious lesion. METHODS: 423 scan points from 20 carious dentine lesion samples examined using high-resolution Raman spectroscopy. The peak ratio of the characteristic vibration mode of amide I (1650 cm-1) and phosphate (960 cm-1) bands were calculated, following a straight line path through the lesion to the pulp and correlated to corresponding Knoop microhardness measurements. RESULTS: Using logistic regression analysis, clear correlations were found between the Knoop microhardness and Raman peak ratio cut-off values between caries-infected and caries-affected dentine (81.5 % sensitivity / 92.7 % specificity), with a lower specificity (2.7 %) found between caries-affected and sound dentine. CONCLUSION: This study concluded that non-contact Raman spectroscopy can be used in vitro to discriminate objectively between the different zones of a carious dentine lesion at high resolution, using the Raman peak ratios, amide I : phosphate ν1. CLINICAL SIGNIFICANCE: Specific biochemical alterations have the potential to be used in-vitro and in-vivo to identify the end-point of selective carious lesion excavation.

Tracking cancer occurrence in the 5 years after referral for suspected head and neck cancer.

OBJECTIVES: Very little is known about those who receive a negative (benign) result after referral for suspected cancer, including their risk for future cancer. This service evaluation aimed to track the occurrence of cancer (of any type) in the 5 years after an appointment for suspected head and neck cancer (HNC) and compare to those referred to hospital for routine ear nose and throat reasons. MATERIALS & METHODS: Patient identifiers of referrals to one hospital Trust with either a) suspected HNC cancer on a two week wait (TWW) pathway, or b) routine ear, nose & throat problems, were linked with the National Cancer Registry data to determine the occurrence, site and stage of subsequent cancer. RESULTS: 10,314 patients were referred between 2009 and 2011. Cancer occurrence in the 5 years after their appointment for those who had initially received a negative diagnosis, was 4.0% for those referred via TWW and 2.1% for those routinely referred. Lung cancer was the most common subsequent cancer site in the TWW group. Those in higher age groups, those with previous cancer, and those referred via the TWW pathway were significantly more likely be diagnosed with subsequent cancer. CONCLUSION: Given the increased risk of subsequent cancer, it could be beneficial to improve the service provision (e.g. advice on screening attendance, ways to reduce risk, advice on timely help-seeking for symptoms of cancer) at the point of a negative diagnosis on the TWW pathway, especially in older patients and those with a previous diagnosis of cancer.

A Systematic Review and Meta-Analysis of the Role of Sugar-Free Chewing Gum in Dental Caries.

OBJECTIVE: To determine the difference in level of dental caries in adults and children who chew sugar-free gum (SFG), compared with those who do not chew SFG or use alternatives such as lozenges, candies, rinses, tablets, and other nonchewing controls. METHODS: Systematic review of published literature. RESULTS: Twelve studies of interventions of SFG for dental caries outcomes were included. SFGs were found to significantly reduce caries increment, giving a preventative fraction (PF) of 28% (95% CI, 7% to 48%). Including the 8 trials that used xylitol gum only as the basis of the intervention, the PF was 33% (95% CI, 4% to 61%). No adverse effects were recorded. There was a high level of heterogeneity among the trials included. CONCLUSION: The findings of this review provide tentative evidence that chewing SFG reduces caries increment in comparison to nonchewing controls. However, there is a considerable degree of variability in the effect and the trials included were generally of moderate quality. There is a need for future research to explore the acceptability and feasibility of the use of SFG as a public health intervention (PROSPERO 2018 CRD42018094676). KNOWLEDGE TRANSFER STATEMENT: The results of this study can be used by clinicians when deciding how best to implement dental caries prevention regimes for their patients. With consideration of cost and patient preference, this information could help to develop national policy directives on caries prevention and dictate the direction of future clinical research.

Influenza vaccine effectiveness against hospitalisation due to laboratory-confirmed influenza in children in England in the 2015-2016 influenza season - a test-negative case-control study.

England has recently started a new paediatric influenza vaccine programme using a live-attenuated influenza vaccine (LAIV). There is uncertainty over how well the vaccine protects against more severe end-points. A test-negative case-control study was used to estimate vaccine effectiveness (VE) in vaccine-eligible children aged 2-16 years of age in preventing laboratory-confirmed influenza hospitalisation in England in the 2015-2016 season using a national sentinel laboratory surveillance system. Logistic regression was used to estimate the VE with adjustment for sex, risk-group, age group, region, ethnicity, deprivation and month of sample collection. A total of 977 individuals were included in the study (348 cases and 629 controls). The overall adjusted VE for all study ages and vaccine types was 33.4% (95% confidence interval (CI) 2.3-54.6) after adjusting for age group, sex, index of multiple deprivation, ethnicity, region, sample month and risk group. Risk group was shown to be an important confounder. The adjusted VE for all influenza types for the live-attenuated vaccine was 41.9% (95% CI 7.3-63.6) and 28.8% (95% CI -31.1 to 61.3) for the inactivated vaccine. The study provides evidence of the effectiveness of influenza vaccination in preventing hospitalisation due to laboratory-confirmed influenza in children in 2015-2016 and continues to support the rollout of the LAIV childhood programme.

Burden of hospital admissions caused by respiratory syncytial virus (RSV) in infants in England: A data linkage modelling study.

OBJECTIVES: Current national estimates of respiratory syncytial virus (RSV)-associated hospital admissions are insufficiently detailed to determine optimal vaccination strategies for RSV. We employ novel methodology to estimate the burden of RSV-associated hospital admissions in infants in England, with detailed stratification by patient and clinical characteristics. METHODS: We used linked, routinely collected laboratory and hospital data to identify laboratory-confirmed RSV-positive and RSV-negative respiratory hospital admissions in infants in England, then generate a predictive logistic regression model for RSV-associated admissions. We applied this model to all respiratory hospital admissions in infants in England, to estimate the national burden of RSV-associated admissions by calendar week, age in weeks and months, clinical risk group and birth month. RESULTS: We estimated an annual average of 20,359 (95% CI 19,236-22,028) RSV-associated admissions in infants in England from mid-2010 to mid-2012. These admissions accounted for 57,907 (95% CI 55,391-61,637) annual bed days. 55% of RSV-associated bed days and 45% of RSV-associated admissions were in infants <3 months old. RSV-associated admissions peaked in infants aged 6 weeks, and those born September to November. CONCLUSIONS: We employed novel methodology using linked datasets to produce detailed estimates of RSV-associated admissions in infants. Our results provide essential baseline epidemiological data to inform future vaccine policy.

Significant spike in excess mortality in England in winter 2014/15 - influenza the likely culprit.

Significant increases in excess all-cause mortality, particularly in the elderly, were observed during the winter of 2014/15 in England. With influenza A(H3N2) the dominant circulating influenza A subtype, this paper determines the contribution of influenza to this excess controlling for weather. A standardised multivariable Poisson regression model was employed with weekly all-cause deaths the dependent variable for the period 2008-2015. Adjusting for extreme temperature, a total of 26 542 (95% CI 25 301-27 804) deaths in 65+ and 1942 (95% CI 1834-2052) in 15-64-year-olds were associated with influenza from week 40, 2014 to week 20, 2015. This is compatible with the circulation of influenza A(H3N2). It is the largest estimated number of influenza-related deaths in England since prior to 2008/09. The findings highlight the potential health impact of influenza and the important role of the annual influenza vaccination programme that is required to protect the population including the elderly, who are vulnerable to a severe outcome.

Population-level factors predicting variation in influenza vaccine uptake among adults and young children in England, 2015/16 and 2016/17.

England's influenza vaccination programme targets persons with clinical risk factors, pregnant women, those aged 65 years and older and children. Low vaccine uptake amongst primary school children was previously found to be significantly associated with increasing deprivation, Black or Minority Ethnic (BME) and certain religions. It is unknown whether these population predictors are associated with vaccine uptake in other groups. GP level data for target groups during the 2015/16 and 2016/17 seasons were linearly regressed against various factors to determine potential predictors associated with variation in uptake. Adjusted uptake for 2-4 year olds during both seasons was more than 11% lower in the most deprived decile and more than 3% lower in 34%+ BME populations compared to the least deprived and non-BME populations. Pregnant women in deprived areas had significantly lower vaccine uptake than in non-deprived areas. Patients 16-64 years old at risk showed no significant variation in uptake by deprivation, whereas patients 65 years and older had more than 3% higher vaccine uptake in the least deprived populations than the most deprived populations. Areas with the highest Muslim and BME populations had a significantly higher vaccine uptake among patients ages 16 to under 65 years old in a clinical risk group than non-Muslim and non-BME populations during both seasons. Population-factors have different effects on vaccine uptake for the various target groups. These findings support segmenting public health activities to improve vaccine uptake and reduce inequalities.

Using data linkage to improve surveillance methods for acute hepatitis E infections in England and Wales 2010-2016.

Indigenous, foodborne transmission of hepatitis E has been increasing across industrialised countries. Public Health England has conducted enhanced surveillance in England and Wales since 2003.This report gives an account of acute infections from 2010 to 2016 and describes modification made to the methods of surveillance to account for changes in reporting behaviours and improve ascertainment.

Pork products associated with human infection caused by an emerging phylotype of hepatitis E virus in England and Wales.

Since 2010, human hepatitis E infections have increased in England and Wales. Most cases are locally acquired and caused by hepatitis E virus genotype 3 (HEV G3). HEV G3 is linked to the consumption of pork products. The increase is associated with the emergence of a new phylotype, HEV G3-group 2 (G3-2, also known as G3abcdhij). Sixty individuals with confirmed hepatitis E infection and no history of travel outside the UK were recruited: 19 were infected with HEV G3-group 1 (G3-1 or G3efg) and 41 with G3-2. Epidemiological data relating to usual shopping habits and consumption of ham and sausages were analysed together with typing data to identify any associations with HEV phylotype. Study participants who purchased ham and/or sausage from a major supermarket were more likely to have HEV G3-2 infection (Relative risks 1·85, P = 0·06, CI 0·97-3·53). The HEV G3-2 phylotype has not been detected in indigenous UK pigs and it is suggested that human infections could be the result of consumption of products made from pork originating outside the UK. This does not infer blame on the supermarket but the epidemiology of HEV is dynamic and reflects complex animal husbandry practices which need to be explored further.

Investigation of a national outbreak of STEC Escherichia coli O157 using online consumer panel control methods: Great Britain, October 2014.

In October 2014, Public Health England (PHE) identified cases of Shiga toxin-producing Escherichia coli (STEC) serogroup O157 sharing a multiple locus variable-number tandem repeat analysis (MLVA) profile. We conducted a case-control study using multivariable logistic regression to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) testing a range of exposures. Cases were defined as laboratory-confirmed STEC O157 with the implicated MLVA profile, were UK residents aged ⩾18 years with symptom onset between 25 September and 30 October 2014, and had no history of travel abroad within 5 days of symptom onset. One hundred and two cases were identified. Cases were mostly female (65%; median age 49, range 2-92 years). It was the second largest outbreak seen in England, to date, and a case-control study was conducted using market research panel controls and online survey methods. These methods were instrumental in the rapid data collection and analysis necessary to allow traceback investigations for short shelf-life products. This is a new method of control recruitment and this is the first in which it was a standalone recruitment method. The case-control study suggested a strong association between consumption of a ready-to-eat food and disease (aOR 28, 95% CI 5·0-157) from one retailer. No reactive microbiological testing of food items during the outbreak was possible due to the short shelf-life of the product. Collaboration with industrial bodies is needed to ensure timely traceback exercises to identify contamination events and initiate appropriate and focused microbiological testing and implement control measures.

Is the onset of influenza in the community age-related?

We studied the spread of influenza in the community between 1993 and 2009 using primary-care surveillance data to investigate if the onset of influenza was age-related. Virus detections [A(H3N2), B, A(H1N1)] and clinical incidence of influenza-like illness (ILI) in 12·3 million person-years in the long-running Royal College of General Practitioners-linked clinical-virological surveillance programme in England & Wales were examined. The number of days between symptom onset and the all-age peak ILI incidence were compared by age group for each influenza type/subtype. We found that virus detection and ILI incidence increase, peak and decrease were in unison. The mean interval between symptom onset to peak ILI incidence in virus detections (all ages) was: A(H3N2) 20·5 [95% confidence interval (CI) 19·7-21·6] days; B, 18·8 (95% CI 15·8·0-21·7) days; and A(H1N1) 17·0 (95% CI 15·6-18·4) days. Differences by age group were examined using the Kruskal-Wallis test. For A(H3N2) and A(H1N1) viruses the interval was similar in each age group. For influenza B there were highly significant differences by age group (P = 0·0001). Clinical incidence rates of ILI reported in the 8 weeks preceding the period of influenza virus activity were used to estimate a baseline incidence and threshold value (upper 95% CI of estimate) which was used as a marker of epidemic progress. Differences between the age groups in the week in which the threshold was reached were small and not localized to any age group. In conclusion we found no evidence to suggest that influenza A(H3N2) and A(H1N1) occurs in the community in one age group before another. For influenza B, virus detection was earlier in children aged 5-14 years than in persons aged ⩾25 years.

Risk factors for Group B Streptococcus colonisation and disease in Gambian women and their infants.

OBJECTIVES: To determine risk factors for GBS colonisation in Gambian mothers and in their infants from birth to day 60-89 of age. METHODS: Swabs and breastmilk from mothers/infant pairs were collected and cultured on selective agar. Negative samples were analysed for GBS DNA via real-time PCR. Positive isolates were serotyped using multiplex PCR and gel-agarose electrophoresis. RESULTS: Seven hundred and fifty women/infant pairs were recruited. 253 women (33.7%) were GBS-colonised at delivery. The predominant serotypes were: V (55%), II (16%), III (10%), Ia (8%) and Ib (8%). 186 infants were colonised (24.8%) at birth, 181 (24.1%) at 6 days and 96 at day 60-89 (14%). Infants born before 34 weeks of gestation and to women with rectovaginal and breastmilk colonisation at delivery had increased odds of GBS colonisation at birth. Season of birth was associated with increased odds of persistent infant GBS colonisation (dry season vs. wet season AOR 2.9; 95% CI 1.6-5.2). CONCLUSION: GBS colonisation is common in Gambian women at delivery and in their infants to day 60-89 and is dominated by serotype V. In addition to maternal colonisation, breastmilk and season of birth are important risk factors for infant GBS colonisation.

Cancer symptom awareness and barriers to symptomatic presentation in England--are we clear on cancer?

BACKGROUND: Low cancer awareness may contribute to delayed diagnosis and poor cancer survival. We aimed to quantify socio-demographic differences in cancer symptom awareness and barriers to symptomatic presentation in the English population. METHODS: Using a uniquely large data set (n=49 270), we examined the association of cancer symptom awareness and barriers to presentation with age, gender, marital status and socio-economic position (SEP), using logistic regression models to control for confounders. RESULTS: The youngest and oldest, the single and participants with the lowest SEP recognised the fewest cancer symptoms, and reported most barriers to presentation. Recognition of nine common cancer symptoms was significantly lower, and embarrassment, fear and difficulties in arranging transport to the doctor's surgery were significantly more common in participants living in the most deprived areas than in the most affluent areas. Women were significantly more likely than men to both recognise common cancer symptoms and to report barriers. Women were much more likely compared with men to report that fear would put them off from going to the doctor. CONCLUSIONS: Large and robust socio-demographic differences in recognition of some cancer symptoms, and perception of some barriers to presentation, highlight the need for targeted campaigns to encourage early presentation and improve cancer outcomes.

Risk factors for delay in symptomatic presentation: a survey of cancer patients.

BACKGROUND: Delay in symptomatic presentation leading to advanced stage at diagnosis may contribute to poor cancer survival. To inform public health approaches to promoting early symptomatic presentation, we aimed to identify risk factors for delay in presentation across several cancers. METHODS: We surveyed 2371 patients with 15 cancers about nature and duration of symptoms using a postal questionnaire. We calculated relative risks for delay in presentation (time from symptom onset to first presentation >3 months) by cancer, symptoms leading to diagnosis and reasons for putting off going to the doctor, controlling for age, sex and deprivation group. RESULTS: Among 1999 cancer patients reporting symptoms, 21% delayed presentation for >3 months. Delay was associated with greater socioeconomic deprivation but not age or sex. Patients with prostate (44%) and rectal cancer (37%) were most likely to delay and patients with breast cancer least likely to delay (8%). Urinary difficulties, change of bowel habit, systemic symptoms (fatigue, weight loss and loss of appetite) and skin symptoms were all common and associated with delay. Overall, patients with bleeding symptoms were no more likely to delay presentation than patients who did not have bleeding symptoms. However, within the group of patients with bleeding symptoms, there were significant differences in risk of delay by source of bleeding: 35% of patients with rectal bleeding delayed presentation, but only 9% of patients with urinary bleeding. A lump was a common symptom but not associated with delay in presentation. Twenty-eight percent had not recognised their symptoms as serious and this was associated with a doubling in risk of delay. Embarrassment, worry about what the doctor might find, being too busy to go to the doctor and worry about wasting the doctor's time were also strong risk factors for delay, but were much less commonly reported (<6%). INTERPRETATION: Approaches to promote early presentation should aim to increase awareness of the significance of cancer symptoms and should be designed to work for people of the lowest socioeconomic status. In particular, awareness that rectal bleeding is a possible symptom of cancer should be raised.

Differences in cancer awareness and beliefs between Australia, Canada, Denmark, Norway, Sweden and the UK (the International Cancer Benchmarking Partnership): do they contribute to differences in cancer survival?

BACKGROUND: There are wide international differences in 1-year cancer survival. The UK and Denmark perform poorly compared with other high-income countries with similar health care systems: Australia, Canada and Sweden have good cancer survival rates, Norway intermediate survival rates. The objective of this study was to examine the pattern of differences in cancer awareness and beliefs across these countries to identify where these might contribute to the pattern of survival. METHODS: We carried out a population-based telephone interview survey of 19079 men and women aged ≥ 50 years in Australia, Canada, Denmark, Norway, Sweden and the UK using the Awareness and Beliefs about Cancer measure. RESULTS: Awareness that the risk of cancer increased with age was lower in the UK (14%), Canada (13%) and Australia (16%) but was higher in Denmark (25%), Norway (29%) and Sweden (38%). Symptom awareness was no lower in the UK and Denmark than other countries. Perceived barriers to symptomatic presentation were highest in the UK, in particular being worried about wasting the doctor's time (UK 34%; Canada 21%; Australia 14%; Denmark 12%; Norway 11%; Sweden 9%). CONCLUSION: The UK had low awareness of age-related risk and the highest perceived barriers to symptomatic presentation, but symptom awareness in the UK did not differ from other countries. Denmark had higher awareness of age-related risk and few perceived barriers to symptomatic presentation. This suggests that other factors must be involved in explaining Denmark's poor survival rates. In the UK, interventions that address barriers to prompt presentation in primary care should be developed and evaluated.

The autonomic response to human esophageal acidification and the development of hyperalgesia.

BACKGROUND: Distal esophageal acidification induces variable hyperalgesia in the non-acid exposed proximal esophagus. As the autonomic nervous system (ANS) modulates nociception, the aim was to determine whether autonomic reactivity to acid infusion predicted inter-individual differences in hyperalgesia. METHODS: In 25 healthy volunteers (18 women, age range 22-58, mean 36.5 years), using a double-blind, placebo-controlled crossover design, pain thresholds to electrical stimulation were determined in the proximal esophagus and foot (control) pre and post a 30-min distal esophageal infusion of 0.15 mol L(-1) HCl or saline with autonomic monitoring. Sympathetic Cardiac Sympathetic Index and Skin Conductance Response and parasympathetic Cardiac Vagal Tone and Cardiac Sensitivity to Baroreflex measures were derived. Plasma cortisol was measured pre and post infusion as were anxiety and unpleasantness. KEY RESULTS: Acid infusion reduced group pain threshold in the proximal esophagus (adjusted mean change -5.0 mA vs saline +3.4 mA, P < 0.001), and raised sympathetic measures (Cardiac Sympathetic Index, Skin Conduction Response) and cortisol levels, but reduced parasympathetic measures (cardiac vagal tone and cardiac sensitivity to Baroreflex) (all P < 0.05). Acid infusion also increased anxiety and unpleasantness scores (both P < 0.05). In 16 acid-sensitizers, the degree of hyperalgesia correlated with increasing heart rate (r = -0.66, P = 0.005), and fall in cardiac vagal tone (r = 0.54, P = 0.03) and Cardiac Sensitivity to Baroreflex (r = 0.54, P = 0.03). CONCLUSIONS & INFERENCES: Acid-induced esophageal hyperalgesia correlated with reduced parasympathetic tone, suggesting that the parasympathetic nervous system may have anti hyperalgesic properties. Additional studies on the autonomic modulation of esophageal hyperalgesia are required.

A methodological study to compare survey-based and observation-based evaluations of organisational and safety cultures and then compare both approaches with markers of the quality of care.

BACKGROUND: Patient safety concerns have focused attention on organisational and safety cultures, in turn directing attention to the measurement of organisational and safety climates. OBJECTIVES: First, to compare levels of agreement between survey- and observation-based measures of organisational and safety climates/cultures and to compare both measures with criterion-based audits of the quality of care, using evidence-based markers drawn from national care standards relating to six common clinical conditions. (This required development of an observation-based instrument.) Second, to examine whether observation-based evaluations could replace or augment survey measurements to mitigate concerns about declining response rates and increasing social desirability bias. Third, to examine mediating factors in safety and organisational climate scores. DESIGN: The study had three strands: (A) a postal questionnaire survey to elicit staff perceptions of organisational and safety climates, using six prevalidated scales; (B) semistructured non-participant observation of clinical teams; and (C) a retrospective criterion-based audit carried out by non-clinical auditors to minimise hindsight bias. Standardised summary scores were created for each strand, and pairs of measurements were compared (strand A with strand B, strand A with strand C, and strand B with strand C) using Bland-Altman plots to evaluate agreement. Correlations were also examined. Multilevel modelling of Strand A scores explored mediating factors. SETTING AND PARTICIPANTS: Eight emergency departments and eight maternity units in England, UK. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Examination of feasibility, correlation and agreement. RESULTS: Strand A: the overall response rate was 27.6%, whereas site-specific rates ranged from 9% to 47%. We identified more mediating factors than previous studies; variable response rates had little effect on the results. Organisational and safety climate scores were strongly correlated (r = 0.845) and exhibited good agreement [standard deviation (SD) differences 0.449; 14 (88%) within ± 0.5; one large difference]. Two commonly used scales had high levels of positive responses, suggesting positive climates or social desirability bias. Strand B: scoring on a four-point scale was feasible. Observational evaluation of teamwork culture was good but too limited for evaluating organisational culture. Strand C: a total of 359-399 cases were audited per condition. The results varied widely between different markers for the same condition, so selection matters. Each site performed well on some markers but not others, with few consistent patterns. Some national guidelines were contested. Comparisons: the comparison of safety climate (survey) and teamwork culture (observation) revealed a moderately low correlation (r = 0.316) and good agreement [SD differences 1.082; 7 (44%) within ±0.5; one large difference]. The comparison of safety climate (survey) and performance (audit) revealed lower correlation (r = 0.150, i.e. relationship not linear) but reasonably good agreement [SD differences 0.992; 9 (56%) within ± 0.5; two large differences]. Comparisons between performance (audit) and both organisational climate (survey) and teamwork culture (observation) showed negligible correlations (< 0.1) but moderately good agreement [SD differences 1.058 and 1.241; 6 (38%) and 7 (44%) within ± 0.5; each with two large differences (at different sites)]. Field notes illuminated large differences. CONCLUSIONS: Climate scores from staff surveys are not unduly affected by survey response rates, but increasing use risks social desirability bias. Safety climate provides a partial indicator of performance, but qualitative data are needed to understand discrepant results. Safety climate (surveys) and, to a lesser degree, teamwork culture (observations) are better indicators of performance than organisational climate (surveys) or attempts to evaluate organisational culture from time-limited observations. Scoring unobtrusive, time-limited observations to evaluate teamwork culture is feasible, but the instrument developed for this study needs further testing. A refined observation-based measure would be useful to augment or replace surveys. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Hearing and ossicular chain preservation in cholesteatoma surgery.

OBJECTIVE: To assess the hearing changes associated with sacrificing an intact ossicular chain during cholesteatoma surgery. METHODS: We reviewed the operation notes of surgical procedures performed by the senior author between October 2000 and April 2006. Thirty-three cases were identified in which cholesteatoma surgery had been performed in the presence of a mobile, intact ossicular chain. One set of case notes was missing; therefore, 32 cases were included in the analysis. The ossicular chain was preserved in 17 cases (14 males and three females) and sacrificed in 15 (eight males and seven females). RESULTS: At the first post-operative assessment, a median air-bone gap deterioration of 3.3 dB was seen in patients in whom the ossicular chain had been sacrificed, while a median air-bone gap improvement of 3.3 dB was seen in those in whom the chain had been preserved. However, multivariable logistic regression analysis suggested that this difference in hearing outcomes was due to pre-operative hearing status, and that preservation of the ossicular chain did not lead to a better outcome. CONCLUSIONS: In cholesteatoma surgery, there is at most a marginal benefit in preserving the ossicular chain. In the current study, the better hearing outcomes associated with preservation of the ossicular chain were accounted for by patients' better pre-operative hearing status. This study did not demonstrate a difference in residual disease rate, but was underpowered to do so.

An evaluation of the performance of OraQuick ADVANCE Rapid HIV-1/2 Test in a high-risk population attending genitourinary medicine clinics in East London, UK.

To date, no data have been published on the use of OraQuick ADVANCE Rapid HIV-1/2 Test (OraQuick) in the UK. We report preliminary findings of an ongoing evaluation of OraQuick in UK genitourinary (GU) medicine clinics. A total of 820 samples from patients in high-risk groups for HIV were tested with OraQuick and results were compared with standard HIV antibody testing. HIV prevalence (enzyme immunoassay [EIA]) was 5.73%, sensitivity of OraQuick was 93.64% (95% CI 82.46-98.66%), specificity 99.87% (99.28-100%), positive predictive value 97.78% (88.27-99.94%) and negative predictive value 99.61% (98.87-99.92%). This includes three false-negatives considered to be due to observer error and now rectified by further training. This has increased test sensitivity to 100%. Our observed test performance of OraQuick compares well with EIA and with other rapid tests. We believe that simple, non-invasive antibody detection tests such as OraQuick can increase HIV testing and diagnosis in UK GU medicine and community settings.