Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care

Objectives To measure the effectiveness and cost effectiveness of providing care in a chest pain observation unit compared with routine care for patients with acute, undifferentiated chest pain. Design Cluster randomised controlled trial, with 442 days randomised to the chest pain observation unit or routine care, and cost effectiveness analysis from a health service costing perspective. Setting The emergency department at the Northern General Hospital, Sheffield, United Kingdom. Participants 972 patients with acute, undifferentiated chest pain (479 attending on days when care was delivered in the chest pain observation unit, 493 on days of routine care) followed up until six months after initial attendance. Main outcome measures The proportion of participants admitted to hospital, the proportion with acute coronary syndrome sent home inappropriately, major adverse cardiac events over six months, health utility, hospital reattendance and readmission, and costs per patient to the health service. Results Use of a chest pain observation unit reduced the proportion of patients admitted from 54% to 37% (difference 17%, odds ratio 0.50, 95% confidence interval 0.39 to 0.65, P < 0.001) and the proportion discharged with acute coronary syndrome from 14% to 6% (8%, –7% to 23%, P = 0.264). Rates of cardiac event were unchanged. Care in the chest pain observation unit was associated with improved health utility during follow up (0.0137 quality adjusted life years gained, 95% confidence interval 0.0030 to 0.0254, P = 0.022) and a saving of £78 per patient (–£56 to £210, P = 0.252). Conclusions Care in a chest pain observation unit can improve outcomes and may reduce costs to the health service. It seems to be more effective and more cost effective than routine care

Effectiveness and reach of a directed-population approach to improving dental health and reducing inequalities: a cross sectional study

Background Childsmile School adopts a directed-population approach to target fluoride varnish applications to 20% of the primary one (P1) population in priority schools selected on the basis of the proportion of enrolled children considered to be at increased-risk of developing dental caries. The study sought to compare the effectiveness of four different methods for identifying individuals most in need when a directed-population approach is taken. &lt;p&gt;&lt;/p&gt; Methods The 2008 Basic National Dental Inspection Programme (BNDIP) cross-sectional P1 Scottish epidemiological survey dataset was used to model four methods and test three definitions of increased-risk. Effectiveness was determined by the positive predictive value (PPV) and explored in relation to 1-sensitivity and 1-specificity. &lt;p&gt;&lt;/p&gt; Results Complete data was available on 43470 children (87% of the survey). At the Scotland level, at least half (50%) of the children targeted were at increased-risk irrespective of the method used to target or the definition of increased-risk. There was no one method across all definitions of &lt;i&gt;increased-risk&lt;/i&gt; that maximised PPV. Instead, PPV was highest when the targeting method complimented the definition of &lt;i&gt;increased-risk&lt;/i&gt;. There was a higher percentage of children at &lt;i&gt;increased-risk&lt;/i&gt; who were not targeted (1-sensitivity) when caries experience (rather than deprivation) was used to define &lt;i&gt;increased-risk&lt;/i&gt;, irrespective of the method used for targeting. Over all three definitions of &lt;i&gt;increased-risk&lt;/i&gt;, there was no one method that minimised (1-sensitivity) although this was lowest when the method and definition of &lt;i&gt;increased-risk&lt;/i&gt; were complimentary. The false positive rate (1-specificity) for all methods and all definitions of &lt;i&gt;increased-risk&lt;/i&gt; was consistently low (&#60;20%), again being lowest when the method and definition of &lt;i&gt;increased-risk&lt;/i&gt; were complimentary. &lt;p&gt;&lt;/p&gt; Conclusion Developing a method to reach all (or even the vast majority) of individuals at &lt;i&gt;increased-risk&lt;/i&gt; defined by either caries experience or deprivation is difficult using a directed-population approach at a group level. There is a need for a wider debate between politicians and public health experts to decide how best to reach those most at need of intervention to improve health and reduce inequalities. &lt;p&gt;&lt;/p&gt

The influence of oral health status on speech intelligibility, articulation and quality of life of older community-dwelling people

Objective: To investigate the impact of the oral health status on speech intelligibility, articulation and quality of life of older community-dwelling people. Background To our knowledge, there have been no studies on this topic in patients aged 75 years or older. Material and methods: Thirty outpatients of a university dental clinic (median [IQR] age of 77.00 [75-82] years) participated. The OHIP-14, a dental examination, a speech intelligibility study and an articulation examination were conducted. Results: Distortions of rhotacisms and sigmatisms were most common, followed by distortions of labiodentals and apicoalveolars. Seven participants (23%) required dental treatment. Distortions of rhotacisms were lowest in participants with loss of teeth in the posterior part of the maxilla and equal in participants with edentulous maxilla and loss of teeth in the anterior part of the maxilla (P = 0.014). Labiodental distortions were lowest in participants with loss of teeth in the posterior part of the maxilla, but were higher in participants with loss of teeth in the anterior part of the maxilla and highest in participants with an edentulous maxilla (P = 0.035). People with normal mouth opening had lower percentage of labiodental distortions than people with a reduced mouth opening (P = 0.05). The proportion of participants with inadequate denture hygiene and distortions of bilabials was 71.4% compared to 10.5% for participants with adequate denture hygiene (P = 0.005). Conclusion: Dentists must consider the impact of a denture on speech, but also should be aware of other oral health factors that influence the speech and quality of life of elders

Why is low waist-to-chest ratio attractive in males? The mediating roles of perceived dominance, fitness, and protection ability

Past research suggests that a lower waist-to-chest ratio (WCR) in men (i.e., narrower waist and broader chest) is viewed as attractive by women. However, little work has directly examined why low WCRs are preferred. The current work merged insights from theory and past research to develop a model examining perceived dominance, fitness, and protection ability as mediators of to WCR-attractiveness relationship. These mediators and their link to both short-term (sexual) and long-term (relational) attractiveness were simultaneously tested by having 151 women rate one of 15 avatars, created from 3D body scans. Men with lower WCR were perceived as more physically dominant, physically fit, and better able to protect loved ones; these characteristics differentially mediated the effect of WCR on short-term, long-term, and general attractiveness ratings. Greater understanding of the judgments women form regarding WCR may yield insights into motivations by men to manipulate their body image

Direct access:how is it working?

AimThe aim of this study was to identify and survey dental hygienists and therapists working in direct access practices in the UK, obtain their views on its benefits and disadvantages, establish which treatments they provided, and what barriers they had encountered.MethodThe study used a purposive sample of GDC-registered hygienists and therapists working in practices offering direct access, identified through a ‘Google’ search. An online survey was set up through the University of Edinburgh, and no-responses followed up by post.ResultsThe initial search identified 243 individuals working in direct access practices. Where a practice listed more than one hygienist/therapist, one was randomly selected. This gave a total of 179 potential respondents. Eighty six responses were received, representing a response rate of 48%. A large majority of respondents (58, 73%) were favourable in their view of the GDC decision to allow direct access, and most thought advantages outnumbered disadvantages for patients, hygienists, therapists and dentists. There were no statistically significant differences in views between hygienists and therapists. Although direct access patients formed a small minority of their caseload for most respondents, it is estimated that on average respondents saw approximately 13 per month. Treatment was mainly restricted to periodontal work, irrespective of whether the respondent was singly or dually qualified. One third of respondents reported encountering barriers to successful practice, including issues relating to teamwork and dentists’ unfavourable attitudes. However, almost two thirds(64%) felt that direct access had enhanced their job satisfaction, and 45% felt their clinical skills had increased.DiscussionComments were mainly positive, but sometimes raised worrying issues, for example in respect to training, lack of dental nurse support and the limited availability of periodontal treatment under NHS regulations

The development and psychometric properties of the Arabic version of the child oral health impact profile-short form (COHIP- SF 19)

BACKGROUND: This study aims to cross-culturally adapt the original English-language COHIP-SF 19 to Arabic culture and to test its psychometric properties in a community sample. METHODS: The Arabic COHIP-SF 19 was developed and its psychometric properties were examined in a population-based sample of 876 schoolchildren who were aged 12 years of age, in Benghazi, Libya. The Arabic COHIP-SF 19 was tested for its internal consistency, reproducibility, construct validity, factorial validity and floor as well as ceiling effects. A Mann-Whitney U test was used to compare the mean scores of COHIP-SF 19 by participants' caries status and self-reported oral health rating, satisfaction and treatment need. RESULTS: The Arabic COHIP-SF 19 was successfully and smoothly developed. It showed an acceptable level of equivalence to the original version. Overall, the internal consistency and reproducibility were acceptable to excellent, with a Cronbach's alpha of 0.84 and an intra-class correlation coefficient (ICC) of 0.76. All hypotheses predefined to test construct validity were confirmed. That is, children who had active dental caries, and who rated their oral health as poor, were not satisfied with their oral health or indicated the need of treatment had lower COHIP-SF 19 scores (P < 0.05). Floor or ceiling effects were not observed. The exploratory Factorial analysis suggested a 4-component solution and deletion of one item. CONCLUSION: The Arabic COHIP-SF 19 was successfully developed. The measure demonstrated satisfactory reliability and validity to estimate OHRQoL in a representative sample of 12-year-old schoolchildren

Modal Analysis and Coupling in Metal-Insulator-Metal Waveguides

This paper shows how to analyze plasmonic metal-insulator-metal waveguides using the full modal structure of these guides. The analysis applies to all frequencies, particularly including the near infrared and visible spectrum, and to a wide range of sizes, including nanometallic structures. We use the approach here specifically to analyze waveguide junctions. We show that the full modal structure of the metal-insulator-metal (MIM) waveguides--which consists of real and complex discrete eigenvalue spectra, as well as the continuous spectrum--forms a complete basis set. We provide the derivation of these modes using the techniques developed for Sturm-Liouville and generalized eigenvalue equations. We demonstrate the need to include all parts of the spectrum to have a complete set of basis vectors to describe scattering within MIM waveguides with the mode-matching technique. We numerically compare the mode-matching formulation with finite-difference frequency-domain analysis and find very good agreement between the two for modal scattering at symmetric MIM waveguide junctions. We touch upon the similarities between the underlying mathematical structure of the MIM waveguide and the PT symmetric quantum mechanical pseudo-Hermitian Hamiltonians. The rich set of modes that the MIM waveguide supports forms a canonical example against which other more complicated geometries can be compared. Our work here encompasses the microwave results, but extends also to waveguides with real metals even at infrared and optical frequencies.Comment: 17 pages, 13 figures, 2 tables, references expanded, typos fixed, figures slightly modifie

HCV IRES manipulates the ribosome to promote the switch from translation initiation to elongation.

The internal ribosome entry site (IRES) of the hepatitis C virus (HCV) drives noncanonical initiation of protein synthesis necessary for viral replication. Functional studies of the HCV IRES have focused on 80S ribosome formation but have not explored its role after the 80S ribosome is poised at the start codon. Here, we report that mutations of an IRES domain that docks in the 40S subunit's decoding groove cause only a local perturbation in IRES structure and result in conformational changes in the IRES-rabbit 40S subunit complex. Functionally, the mutations decrease IRES activity by inhibiting the first ribosomal translocation event, and modeling results suggest that this effect occurs through an interaction with a single ribosomal protein. The ability of the HCV IRES to manipulate the ribosome provides insight into how the ribosome's structure and function can be altered by bound RNAs, including those derived from cellular invaders

Stable isotope evidence for late medieval (14th-15th C) origins of the eastern Baltic cod (Gadus morhua) fishery

Although recent historical ecology studies have extended quantitative knowledge of eastern Baltic cod (Gadus morhua) exploitation back as far as the 16th century, the historical origin of the modern fishery remains obscure. Widespread archaeological evidence for cod consumption around the eastern Baltic littoral emerges around the 13th century, three centuries before systematic documentation, but it is not clear whether this represents (1) development of a substantial eastern Baltic cod fishery, or (2) large-scale importation of preserved cod from elsewhere. To distinguish between these hypotheses we use stable carbon and nitrogen isotope analysis to determine likely catch regions of 74 cod vertebrae and cleithra from 19 Baltic archaeological sites dated from the 8th to the 16th centuries. δ¹³C and δ¹⁵N signatures for six possible catch regions were established using a larger sample of archaeological cod cranial bones (n = 249). The data strongly support the second hypothesis, revealing widespread importation of cod during the 13th to 14th centuries, most of it probably from Arctic Norway. By the 15th century, however, eastern Baltic cod dominate within our sample, indicating the development of a substantial late medieval fishery. Potential human impact on cod stocks in the eastern Baltic must thus be taken into account for at least the last 600 years.The research was funded by the Leverhulme Trust (grant no. F/00 224/S), the History of Marine Animal Populations project (supported by the Alfred P. Sloan Foundation) and the McDonald Institute for Archaeological Research