Intraoral clinical examinations of pediatric patients with anticipatory anxiety and situational fear facilitated by therapy dog assistance: A pilot RCT

Objective To evaluate whether the presence of a certified therapy dog specially trained for working in a dental setting may facilitate dental care of anxious pediatric patients. Methods The Norwegian Regional Committee for Medical and Health Research Ethics approved a randomized cross-over trial with a study sample of n = 16 children aged between 6 and 12 years. The trial was registered on clinicaltrials.gov. Pediatric patients referred to specialist care at the Public Dental Service Competence Center of Northern Norway (TkNN) because of anxiety were invited to partake in the trial. Study participants met twice for an intraoral examination by a specialist pediatric dentist. Per random allocation, a therapy dog team was present in the clinic operatory during the clinical examination on the first or the second visit. The primary outcome was the assessment of patient compliance during the intraoral examination (yes/no). Secondary outcomes were measurements of child satisfaction and anxiety using the CFSS-DS scale (Dental subscale of Children's Fear Survey Schedule) completed by a parent/guardian. Supplementary outcomes were salivary cortisol level, heart rate variability, and skin conductance. Results Ten boys and six girls (mean age 8.5) were recruited. All completed both clinical visits and demonstrated full compliance while undergoing a dental examination. All study participants and guardians reported great satisfaction. The salivary cortisol level reduction during the clinical examination on the first visit decreased by 30% in the presence of the therapy dog and 20% without, while the decrease during the clinical examination on the second visit was 29% in the presence of the therapy dog and 3% without. Within the limitations of the experimental setup, the electrophysiological measurements were unreliable in the current study population. Conclusion Dog-assisted therapy in a dental care setting appears to have a positive effect on children with dental anxiety or children that avoid dental care

Prostitution, Condom Use, and Invasive Squamous Cell Cervical Cancer in Thailand

Cervical cancer is probably caused by a sexually transmitted agent. A case-control study was conducted in three hospitals in Thailand to investigate further the role of male sexual behavior, particularly regarding sexual contacts with prostitutes, in the development of this disease. Data were obtained from interviews with 225 married women with invasive squamous cell cervical carcinoma and 791 hospitalized controls, all of whom reported having only one sexual partner, and from interviews with their husbands. Risk of cervical cancer was strongly related to the women's husbands having visited prostitutes without using a condom when the husbands were less than 30 years old. A strong increasing trend in risk in relation to decreasing frequency of the husbands' condom use with prostitutes was observed, and a weaker increasing trend in risk with husbands' estimated lifetime total number of visits to prostitutes was found. The average latent period between the women's likely initial exposure to a sexually transmitted oncogenic agent and her diagnosis of invasive cervical cancer was about a quarter of a century. Regular use of condoms by customers of prostitutes could reduce the number of invasive cervical cancer cases in the general population of Thailand by at least one fourth. Am J Epidemiol 1996; 143: 779-8

A 3-year multicentre randomized controlled trial of etonogestrel- and levonorgestrel-releasing contraceptive implants, with non-randomized matched copper-intrauterine device controls

STUDY QUESTION Is there any difference in the clinical performance of the 3-year one-rod etonogestrel (ENG)- and the 5-year two-rod levonorgestrel (LNG)-releasing contraceptive implants during 3 years of insertion, and between implant and intrauterine device (IUD) contraception, in particular complaints possibly related to hormonal contraceptives? SUMMARY ANSWER The cumulative contraceptive effectiveness after 3 years and method continuation through 2.5 years were not significantly different between ENG and LNG implants, but both outcomes were significantly worse in the non-randomized age-matched group of IUD users than in the combined implant group. WHAT IS KNOWN ALREADY ENG- and LNG-releasing implants are safe and highly efficacious contraceptives with pregnancy rates reported to be 0.0-0.5 per 100 women-years (W-Y). No head-to-head comparative study of the two implants has been undertaken, and little information is available on comparisons of complaints of side effects of implant and copper IUD users. STUDY DESIGN, SIZE, DURATION This was an open parallel group RCT with 1:1 allocation ratio of the ENG and the LNG implants with non-randomized control group of women choosing TCu380A IUD to address lack of reliable data on common side effects typically attributed to the use of progestogen-only contraceptives. After device(s) placement, follow-ups were at 2 weeks, 3 and 6 months, and semi-annually thereafter for 3 years or until pregnancy, removal or expulsion of the implant/IUD occurred. PARTICIPANTS, SETTING, METHODS The study took place in family planning clinics in Brazil, Chile, Dominican Republic, Hungary, Thailand, Turkey and Zimbabwe. Women seeking long-term contraception were enlisted after an eligibility check and informed consent, and 2982 women were enrolled: 1003, 1005 and 974 in the ENG-implant, LNG-implant and IUD groups, respectively; 995, 997 and 971, respectively, were included in the per protocol analysis reported here. MAIN RESULTS AND THE ROLE OF CHANCE ENG and LNG implants each had the same 3-year cumulative pregnancy rate of 0.4 per 100 W-Y [95% confidence interval (CI) 0.1-1.4]. A weight of ≥70 kg at admission was unrelated to pregnancy. Method continuation rates for ENG and LNG implants at 2.5 years were 69.8 (95% CI 66.8-72.6) and 71.8 per 100 W-Y (68.8-74.5), and at 3 years 12.1 (95% CI 5.2-22.0) and 52.0 per 100 W-Y (95% CI 41.8-61.2), respectively. Bleeding disturbances, the most frequent reason for method discontinuation, were significantly more common in the ENG group [16.7 (95% CI 14.4-19.3)] than in the LNG group [12.5 (95% CI 10.5-14.9)] (P 0.019). The 3-year cumulative loss to follow-up was lower in the ENG- than in the LNG-implant group, 8.1 (95% CI 6.4-10.2) and 14.4 per 100 W-Y (95% CI 12.1-17.1), respectively. The median duration of implant removal was 50 s shorter among women with ENG than among women with LNG implant (P < 0.0001). In the observational comparison between IUD and implant users, the 3-year relative risk for pregnancy in IUD group compared with the combined implant group was 5.7 per 100 W-Y (95% CI 4.4-7.3) (P = 0.0003). The 3-year expulsion rate of the IUD was 17.8 per 100 W-Y (95% CI 14.5-21.9), while the discontinuation rate for bleeding disturbances was 8.5 (95% CI 6.7-10.9). Frequency of complaints of headache and dizziness was not significantly different between implant and IUD users (P = 0.16 and 0.77, respectively), acne and bleeding irregularities were more frequent among implant users (P < 0.0001), while heavy bleeding and lower abdominal pain occurred more often among IUD than implant users (P < 0.0001). LIMITATIONS, REASONS FOR CAUTION Few women were ≤19 years old or nulligravida, the proportion of implant users ≥70 kg was <20% and <8% were obese. WIDER IMPLICATIONS OF THE FINDINGS Findings of the study can inform policy makers and clinicians about choice of implant, but also about TCu380A IUD in relation to implants. STUDY FUNDING/COMPETING INTEREST(S) UNDP/UNFPA/WHO/UNICEF/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR), World Health Organization (WHO). This report contains the views of an international expert group and does not necessarily represent the decisions or the stated policy of the WHO. TRIAL REGISTRATION ISRCTN33378571 registered on 22 March 2004. The first participant was enrolled on 12 May 200

Menopausal hormone use and ovarian cancer risk: individual participant meta-analysis of 52 epidemiological studies

Background Half the epidemiological studies with information about menopausal hormone therapy and ovarian cancer risk remain unpublished, and some retrospective studies could have been biased by selective participation or recall. We aimed to assess with minimal bias the effects of hormone therapy on ovarian cancer risk. Methods Individual participant datasets from 52 epidemiological studies were analysed centrally. The principal analyses involved the prospective studies (with last hormone therapy use extrapolated forwards for up to 4 years). Sensitivity analyses included the retrospective studies. Adjusted Poisson regressions yielded relative risks (RRs) versus never-use. Findings During prospective follow-up, 12 110 postmenopausal women, 55% (6601) of whom had used hormone therapy, developed ovarian cancer. Among women last recorded as current users, risk was increased even with <5 years of use (RR 1·43, 95% CI 1·31–1·56; p<0·0001). Combining current-or-recent use (any duration, but stopped <5 years before diagnosis) resulted in an RR of 1·37 (95% CI 1·29–1·46; p<0·0001); this risk was similar in European and American prospective studies and for oestrogen-only and oestrogen-progestagen preparations, but differed across the four main tumour types (heterogeneity p<0·0001), being definitely increased only for the two most common types, serous (RR 1·53, 95% CI 1·40–1·66; p<0·0001) and endometrioid (1·42, 1·20–1·67; p<0·0001). Risk declined the longer ago use had ceased, although about 10 years after stopping long-duration hormone therapy use there was still an excess of serous or endometrioid tumours (RR 1·25, 95% CI 1·07–1·46, p=0·005). Interpretation The increased risk may well be largely or wholly causal; if it is, women who use hormone therapy for 5 years from around age 50 years have about one extra ovarian cancer per 1000 users and, if its prognosis is typical, about one extra ovarian cancer death per 1700 users

Alcohol, tobacco and breast cancer – collaborative reanalysis of individual data from 53 epidemiological studies, including 58 515 women with breast cancer and 95 067 women without the disease

Alcohol and tobacco consumption are closely correlated and published results on their association with breast cancer have not always allowed adequately for confounding between these exposures. Over 80% of the relevant information worldwide on alcohol and tobacco consumption and breast cancer were collated, checked and analysed centrally. Analyses included 58 515 women with invasive breast cancer and 95 067 controls from 53 studies. Relative risks of breast cancer were estimated, after stratifying by study, age, parity and, where appropriate, women's age when their first child was born and consumption of alcohol and tobacco. The average consumption of alcohol reported by controls from developed countries was 6.0 g per day, i.e. about half a unit/drink of alcohol per day, and was greater in ever-smokers than never-smokers, (8.4 g per day and 5.0 g per day, respectively). Compared with women who reported drinking no alcohol, the relative risk of breast cancer was 1.32 (1.19–1.45, P<0.00001) for an intake of 35–44 g per day alcohol, and 1.46 (1.33–1.61, P<0.00001) for ⩾45 g per day alcohol. The relative risk of breast cancer increased by 7.1% (95% CI 5.5–8.7%; P<0.00001) for each additional 10 g per day intake of alcohol, i.e. for each extra unit or drink of alcohol consumed on a daily basis. This increase was the same in ever-smokers and never-smokers (7.1% per 10 g per day, P<0.00001, in each group). By contrast, the relationship between smoking and breast cancer was substantially confounded by the effect of alcohol. When analyses were restricted to 22 255 women with breast cancer and 40 832 controls who reported drinking no alcohol, smoking was not associated with breast cancer (compared to never-smokers, relative risk for ever-smokers=1.03, 95% CI 0.98–1.07, and for current smokers=0.99, 0.92–1.05). The results for alcohol and for tobacco did not vary substantially across studies, study designs, or according to 15 personal characteristics of the women; nor were the findings materially confounded by any of these factors. If the observed relationship for alcohol is causal, these results suggest that about 4% of the breast cancers in developed countries are attributable to alcohol. In developing countries, where alcohol consumption among controls averaged only 0.4 g per day, alcohol would have a negligible effect on the incidence of breast cancer. In conclusion, smoking has little or no independent effect on the risk of developing breast cancer; the effect of alcohol on breast cancer needs to be interpreted in the context of its beneficial effects, in moderation, on cardiovascular disease and its harmful effects on cirrhosis and cancers of the mouth, larynx, oesophagus and liver

"..men det er MITT fag!" - Hvordan forholder norske sykehusleger seg til ”pasientens helsetjeneste”?

Visepresident i Legeforeningen Christer Mjåset skriver 23.5.2018 at arbeidspresset for norske leger er altfor høyt, og at de opplever at deres autonomi er på et lavmål (Mjåset, 2018). Innlegget føyer seg inn i en internasjonal debatt om økende utbrenthet og misnøye blant leger (Crosson & Casalino, 2015, Wyller, et al., 2013). Pasientene er mer komplekse, det er økende krav til rapportering og kvalitetssikring, datasystemene er tungrodde. Det oppleves å stadig komme ”pålegg ovenfra” som legene kan streve med å se noen nytte av. Som yrkesgruppe er ikke legene alene om å påpeke trangere økonomiske rammer, mer komplekse arbeidsoppgaver og økte krav til dokumentasjon. Dette gjelder for eksempel også skoleverket (Garbo & Raugland, 2017). For legene har det imidlertid også skjedd en annen grunnleggende endring av arbeidssituasjonen som de selv ikke snakker så mye om; Pasientene har fått mer makt. Dette er en villet utvikling. Helseminister Bent Høie beskriver selve poenget med å endre helsetjenesten til å bli ”pasientens helsetjeneste” er økt makt til pasienten. I hans Sykehustale 2015 refereres det til en historie fra en ansatt som ble konfrontert av en lege som var grundig lei ”alle disse styringssignalene ovenfra”. Svaret var: ”Det er ikke et styringssignal ovenfra, det er et styringssignal nedenfra – fra pasienten”. I denne mastergraden er 10 sykehusleger intervjuet om hvordan de forholder seg til ”pasientens helsetjeneste”. De er spurt både hva de tenker om dette som en ide til forbedring av helsevesenet, og hva de ser som fordeler og ulemper med økt brukermedvirkning og brukerinnflytelse. Legene har fra åtte til nesten førti års erfaring etter turnustjeneste. De reflekterer over hvordan både de selv og helsevesenet har endret holdning til brukermedvirkning. De er enige at det er viktig å informere pasientene bedre. Men de holder de fast på at beslutninger om behandlingstiltak skal ligge hos legen. Derav sitatet i tittelen; ”det er MITT fag!”. Leger som i daglig virke møter pasienter som er opptatt av brukermedvirkning er markant mer positive til å ta med pasienten i beslutninger om egen helse. Leger som jobber med pasienter som ikke ønsker, eller er for syke, til å medvirke, er mer skeptiske til ideen om økt makt til pasienten. For alle leger synes det å være en grense for hvor langt brukermedvirkning bør gå. Denne grensen kan man spekulere i trekkes ved det den enkelte lege definerer som sin profesjonelle kjerne. Hva denne kjernen består i ser ut til å variere i mellom medisinske spesialiteter. Den praktiske tilretteleggingen for ”pasientens helsetjeneste” vil også være forskjellig avhengig av medisinsk spesialitet. I oppgaven beskrives eksempler på hvordan slike endringer er forsøkt innført. Som politisk budskap har ”pasientens helsetjeneste” i liten praktisk konsekvens for sykehuslegene. Avstanden er for lang imellom de politiske signalene som gis og virkeligheten på sykehuset. Politiske budskap har liten legitimitet hos legene. Det skjer likevel endringer i tråd med målsettingene i ”pasientens helsevesen”. Dette ser ut til å handle om kohortendringer der yngre leger har med seg andre holdninger, ikke minst fra endringer i medisinstudiet. Men en endring i retning ”pasientens helsetjeneste” skjer raskest der pasientene går i direkte dialog med legene. Som det sies i brukernes innledning til Nasjonal Helse- og sykehusplan 2016-2019; ”Pasientar er ofte dei mest radikale endringsagentane”