Pascal's Wager, infective endocarditis and the "no-lose" philosophy in medicine

Doctors and dentists have traditionally used antibiotic prophylaxis in certain patient groups in order to prevent infective endocarditis (IE). New guidelines, however, suggest that the risk to patients from using antibiotics is higher than the risk from IE. This paper analyses the relative risks of prescribing and not prescribing antibiotic prophylaxis against the background of Pascal's Wager, the infamous assertion that it is better to believe in God regardless of evidence, because of the prospective benefits should He exist. Many doctors seem to believe the parallel proposition that it is better to prescribe antibiotics, regardless of evidence, because of the prospective benefit conferred upon the patient. This has been called the "no lose philosophy" in medicine: better safe than sorry, even if the evidence inconveniently suggests that following this mantra is potentially more likely to result in sorry than safe. It transpires that, just as Pascal's Wager fails to convince because of a lack of evidence to support it and the costs incurred by trying to believe, so the "belts and braces" approach of prescribing antibiotic prophylaxis is unjustifiable given the actual evidence of potential risk and benefit to the patient. Ultimately, there is no no-lose if your clinical decisions, like Pascal's Wager, are based on faith rather than evidence

Is the Scottish population living dangerously? Prevalence of multiple risk factors: the Scottish Health Survey 2003

<b>Background:</b> Risk factors are often considered individually, we aimed to investigate the prevalence of combinations of multiple behavioural risk factors and their association with socioeconomic determinants.<p></p> <b>Methods:</b> Multinomial logistic regression was used to model the associations between socioeconomic factors and multiple risk factors from data in the Scottish Health Survey 2003. Prevalence of five main behavioural risk factors - smoking alcohol, diet, overweight/obesity, and physical inactivity, and the odds in relation to demographic, individual and area socioeconomic factors.<p></p> <b>Results:</b> Full data were available on 6,574 subjects (80.7% of the survey sample). Nearly the whole adult population (97.5%) reported to have at least one behavioural risk factor; while 55% have three or more risk factors; and nearly 20% have four or all five risk factors. The most important determinants for having four or five multiple risk factors were low educational attainment which conferred around a 3-fold increased odds compared to high education; and residence in the most deprived communities (relative to least deprived) which had greater than 3-fold increased odds.<p></p> <b>Conclusions:</b> The prevalence of multiple behavioural risk factors was high and the prevalence of absence of all risk factors very low. These behavioural patterns were socioeconomically determined. Policy to address factors needs to be joined up and better consider underlying socioeconomic circumstances.<p></p&gt

Is detecting oral cancer in general dental practices a realistic expectation? A population-based study using population linked data in Scotland

Introduction: Despite the increasing burden of oral cancer (OC) – including oral cavity (OCC) and oropharyngeal cancer (OPC) – it remains a relatively low-volume disease in Scotland, with anecdotal evidence suggesting that dentists only see between one and two cases in their practising careers. Aims: To examine, for the first time on a population-basis via data linkage, whether early detection by general dental practices (GDP) is a realistic expectation by i) estimating the number of OC cases/year a dentist in Scotland may encounter over time, accounting for the deprivation level of practice location and dental registration/attendance rates, and ii) assessing whether patients attended GDPs two years pre-diagnosis. Materials and methods: Scottish Cancer Registry data on all OC cases (2010-2012), published NHS Scotland dental workforce and registration/participation statistics, and individual patient data linked with NHS dental service activity were analysed. Results: Dentists were estimated to potentially encounter one case of OC every 10 years, OCC every 16.7 years, and OPC every 25 years. However, 53.7% of OC patients had made no dental contact two years pre-diagnosis. Conclusion: Strategies for early detection must consider the rarity of OC incidence and poor dental attendance patterns. These results highlight the importance of improving access and uptake of dental services among those at highest risk to increase the opportunities for early detection

A population-based case-control study on social factors and risk of testicular germ cell tumours

Objectives Incidence rates for testicular cancer have risen over the last few decades. Findings of an association between the risk of testicular cancer and social factors are controversial. The association of testicular cancer and different indicators of social factors were examined in this study.<p></p> Design Case–control study.<p></p> Setting Population-based multicentre study in four German regions (city states Bremen and Hamburg, the Saarland region and the city of Essen).<p></p> Participants The study included 797 control participants and 266 participants newly diagnosed with testicular cancer of which 167 cases were classified as seminoma and 99 as non-seminoma. The age of study participants ranged from 15 to 69 years.<p></p> Methods Social position was classified by educational attainment level, posteducational training, occupational sectors according to Erikson-Goldthorpe-Portocarrero (EGP) and the socioeconomic status (SES) on the basis of the International SocioEconomic Index of occupational status (ISEI). ORs and corresponding 95% CIs (95% CIs) were calculated for the whole study sample and for seminoma and non-seminoma separately.<p></p> Results Testicular cancer risk was modestly increased among participants with an apprenticeship (OR=1.7 (95% CI 1.0 to 2.8)) or a university degree (OR=1.6 (95% CI 0.9 to 2.8)) relative to those whose education was limited to school. Analysis of occupational sectors revealed an excess risk for farmers and farm-related occupations. No clear trend was observed for the analyses according to the ISEI-scale.<p></p> Conclusions Social factors based on occupational measures were not a risk factor for testicular cancer in this study. The elevated risk in farmers and farm-related occupations warrants further research including analysis of occupational exposures.<p></p&gt

Linking routinely collected social work, education and health data to enable monitoring of the health and health care of school-aged children in state care (‘looked after children’) in Scotland: a national demonstration project

Background and objectives: Children in state care (‘looked after children’) have poorer health than children who are not looked after. Recent developments in Scotland and elsewhere have aimed to improve services and outcomes for looked after children. Routine monitoring of the health outcomes of looked after children compared to those of their non-looked after peers is currently lacking. Developing capacity for comparative monitoring of population based outcomes based on linkage of routinely collected administrative data has been identified as a priority. To our knowledge there are no existing population based data linkage studies providing data on the health of looked after and non-looked after children at national level. Smaller scale studies that are available generally provide very limited information on linkage methods and hence do not allow scrutiny of bias that may be introduced through the linkage process. Study design and methods: National demonstration project testing the feasibility of linking routinely collected looked after children, education, and health data. Participants: All children in publicly funded school in Scotland in 2011/12. Results: Linkage between looked after children data and the national pupil census classified 10,009 (1.5%) and 1,757 (0.3%) of 670,952 children as, respectively, currently and previously looked after. Recording of the unique pupil identifier (Scottish Candidate Number, SCN) on looked after children returns is incomplete, with 66% of looked after records for 2011/12 for children of possible school age containing a valid SCN. This will have resulted in some under-ascertainment of currently and, particularly, previously looked after children within the general pupil population. Further linkage of the pupil census to the NHS Scotland master patient index demonstrated that a safe link to the child’s unique health service (Community Health Index, CHI) number could be obtained for a very high proportion of children in each group (94%, 95%, and 95% of children classified as currently, previously, and non-looked after respectively). In general linkage rates were higher for older children and those living in more affluent areas. Within the looked after group, linkage rates were highest for children with the fewest placements and for those in permanent fostering. Conclusions: This novel data linkage demonstrates the feasibility of monitoring population based health outcomes of school aged looked after and non-looked after children using linked routine administrative data. Improved recording of the unique pupil identifier number on looked after data returns would be beneficial. Extending the range of personal identifiers on looked after children returns would enable linkage to health data for looked after children who are not in publicly funded schooling (i.e. those who are pre- or post-school, home schooled, or in independent schooling)

The current state of peek implant osseointergration and future perspectives: a systematic review

Polyetheretherketone (PEEK) has been considered as an alternative to replace surgical metal implants. Several medical applications, including dental and orthopaedic implants, need confirmed osseointegration before functional loading. The present study aims at providing a comprehensive systematic review of the evidence on PEEK implants' osseointegration. A systematic search was conducted using Cochrane library, MEDLINE (PubMed), Ovid MEDLINE, Web of Science and EMBASE databases. Publications were identified in accordance with specific inclusion and exclusion criteria. Eligibility screening, data extraction and quality assessment were performed. The review protocol was registered in PROSPERO (CRD42018116061). A total of 55 articles were reviewed and 29 of the most relevant that met the inclusion criteria were selected. Heterogeneity was identified among the included studies. Several approaches have been applied to enhance PEEK osseointegration, with most in vivo studies conducted on small-scale animal models but no study evaluating the osseointegration of PEEK under cyclic loading. However, PEEK modifications are demonstrated to enhance osseointegration preclinically. Collectively, the present review shows a shortage of evidence, including a lack of comprehensive assessment of osseointegration, the need for large-animal-model tests, the need to assess the effect of loading on the implants and the lack of randomised controlled clinical trials

A prospective cohort study of human papillomavirus-driven oropharyngeal cancers: implications for prognosis and immunisation

Aims: Oropharyngeal cancer (OPC) is increasing on a global scale, including the component driven by high-risk human papillomavirus (HR-HPV); contemporary data that provides insight into the prognosis of this disease in addition to the fraction attributable to HR-HPV are essential to inform primary and secondary disease management strategies. Materials and methods: A population-based cohort of 235 patients diagnosed with OPC between 2013 and 2015 in Scotland was assessed for HPV status using molecular genotyping. Associations between HR-HPV status and key clinical and demographic variables were estimated using the Pearson chi-squared test. Rates of overall survival and progression-free survival were estimated and visualised using Kaplan–Meier curves. Results: HPV DNA (largely HPV 16) was identified in 60% of cases. After adjustment for age, gender, deprivation, smoking, alcohol consumption and tumour stage, patients with HR-HPV-positive OPC had an 89% reduction in the risk of death (hazard ratio = 0.11, 95% confidence interval 0.05–0.25) and an 85% reduction in the risk of disease progression (hazard ratio = 0.15, 95% confidence interval 0.07–0.30). HPV positivity was not associated with age, deprivation or smoking status, whereas those who reported excess alcohol consumption were less likely to be positive for HR-HPV. Conclusions: The prevalence of HR-HPV-associated OPC is high in Scotland and strongly associated with dramatically improved clinical outcomes, including survival. Demographic/behavioural variables did not reliably predict HPV positivity in this cohort, which underlines the importance of laboratory confirmation. Finally, the dominance of HPV 16 in OPC indicates the significant impact of prophylactic immunisation on this disease

Spectral extension of the quantum group cotangent bundle

The structure of a cotangent bundle is investigated for quantum linear groups GLq(n) and SLq(n). Using a q-version of the Cayley-Hamilton theorem we construct an extension of the algebra of differential operators on SLq(n) (otherwise called the Heisenberg double) by spectral values of the matrix of right invariant vector fields. We consider two applications for the spectral extension. First, we describe the extended Heisenberg double in terms of a new set of generators -- the Weyl partners of the spectral variables. Calculating defining relations in terms of these generators allows us to derive SLq(n) type dynamical R-matrices in a surprisingly simple way. Second, we calculate an evolution operator for the model of q-deformed isotropic top introduced by A.Alekseev and L.Faddeev. The evolution operator is not uniquely defined and we present two possible expressions for it. The first one is a Riemann theta function in the spectral variables. The second one is an almost free motion evolution operator in terms of logarithms of the spectral variables. Relation between the two operators is given by a modular functional equation for Riemann theta function.Comment: 38 pages, no figure

SARS-CoV-2 positivity in asymptomatic-screened dental patients

Enhanced community surveillance is a key pillar of the public health response to COVID-19. Asymptomatic carriage of SARS-CoV-2 is a potentially significant source of transmission, yet remains relatively poorly understood. Disruption of dental services continues with significantly reduced capacity. Ongoing precautions include pre- and/or at appointment COVID-19 symptom screening and use of enhanced personal protective equipment (PPE). This study aimed to investigate SARS-CoV-2 infection in dental patients to inform community surveillance and improve understanding of risks in the dental setting. Thirty-one dental care centres across Scotland invited asymptomatic screened patients over 5-years-old to participate. Following verbal consent and completion of sociodemographic and symptom history questionnaire, trained dental teams took a combined oropharyngeal and nasal swab sample using standardised VTM-containing testkits. Samples were processed by the Lighthouse Lab and patients informed of their results by SMS/e-mail with appropriate self-isolation guidance in the event of a positive test. All positive cases were successfully followed up by the national contact tracing program. Over a 13-week period (from 3August to 31October2020) n=4,032 patients, largely representative of the population, were tested. Of these n=22 (0.5%; 95%CI 0.5%, 0.8%) tested positive for SARS-CoV-2. The positivity rate increased over the period, commensurate with uptick in community prevalence identified across all national testing monitoring data streams. To the best of our knowledge this is the first report of a COVID-19 testing survey in asymptomatic-screened patients presenting in a dental setting. The positivity rate in this patient group reflects the underlying prevalence in community at the time. These data are a salient reminder, particularly when community infection levels are rising, of the importance of appropriate ongoing Infection Prevention Control and PPE vigilance, which is relevant as healthcare team fatigue increases as the pandemic continues. Dental settings are a valuable location for public health surveillance

The structure of blocks with a Klein four defect group

We prove Erdmann’s conjecture [16] stating that every block with a Klein four defect group has a simple module with trivial source, and deduce from this that Puig’s finiteness conjecture holds for source algebras of blocks with a Klein four defect group. The proof uses the classification of finite simple groups