Screening instruments for mental disorders need to be short, engaging, and valid. Current screening instruments are usually questionnaire-based and may be opaque to the user. A prototype approach where individuals identify with a description of an individual with typical symptoms of depression, anxiety, social phobia or panic may be a shorter, faster and more acceptable method for screening. The aim of the study was to evaluate the accuracy of four new prototype screeners for predicting depression and anxiety disorders and to compare their performance with existing scales.Short and ultra-short prototypes were developed for Major Depressive Disorder (MDD), Generalised Anxiety Disorder (GAD), Panic Disorder (PD) and Social Phobia (SP). Prototypes were compared to typical short and ultra-short self-report screening scales, such as the Centre for Epidemiology Scale, CES-D and the GAD-7, and their short forms. The Mini International Neuropsychiatric Interview (MINI) version 6  was usedThe study found that the rates of endorsement of the prototypes were commensurate with prevalence estimates. The short-form and ultra short scales outperformed the short and ultra short prototypes for every disorder except GAD, where the GAD prototype outperformed the GAD 7.The findings suggest that people may be able to self-identify generalised anxiety more accurately than depression based on a description of a prototypical case. However, levels of identification were lower than expected. Considerable benefits from this method of screening may ensue if our prototypes can be improved for Major Depressive Disorder, Social Phobia and Panic Disorder. Mental health screening tests identify individuals with a high probability of meeting clinical criteria for a current mental disorder or those who are at risk of developing such a disorder. At the population level, screening is important for targeting treatment and prevention , particuIn addition to being lengthy, screening instruments can be opaque to the user, boring or baffling, and, thus, be unacceptable to patients. The acceptability of screening tests to the public has rarely been examined, although completion rates of only 30-60% in general practice settings  suggest In this study, we sought to develop an alternative methodology in the hope that it might provide a superior approach to screening. We defined "superior" to connote a screening tool that retained high sensitivity, had fast administration time, greater transparency and that might be rated as more satisfactory by users (easier to complete and more enjoyable) in comparison to existing screening tools.A prototype is the most central or typical member of a category . PrototyVignettes (or extended prototypes)  have beeThe aim of the present project was to evaluate the use of a self-administered screening test in which users match their own thoughts and behaviours to prototypical descriptions of individuals who are experiencing a mental disorder. Prototypes were developed against DSM-IV criteria (see Method). In the interests of developing very brief screening, 'ultra short' prototypes were also developed by distilling the contents of the prototype down to one or two sentences. The short and ultra short prototypes were compared to established brief screening tools and to their short forms. The Center for Epidemiological Studies Depression scale  and a 1Fourteen thousand potential participants were selected randomly from the Electoral Roll, sampling from two federal electorates in the northern suburbs of Sydney, Australia. Registration on the Electoral Roll is compulsory in Australia. Males and females aged 18-65 were included in the sample. Surveys were mailed in May 2009, and by the July 2009 cutoff, 2,976 (21.3%) surveys had been returned. This study received ethics approval from the Human Research Ethics Committee at the Australian National University (Protocol 2009/425).Information was collected on age, gender, educational level, employment and literacy. Education level was based on four items assessing previous and current educational attainment. Employment status was rated as full-time, part-time and looking for full-time work, part-time, casual, unemployed - looking for work or not in the labour force. Literacy was assessed using three items: language spoken at home, confidence in filling out forms, and frequency of needing help to read printed materials.The measures of interest were short prototypes for Major Depressive Disorder, Generalised Anxiety Disorder (GAD), Panic Disorder and Social Phobia. These are common mental health disorders that often require clinical intervention and are targets of mental health prevention. The prototypes are presented in additional file Ultra short forms of the prototypes for each of the five disorders were also administered. These are presented in additional file For comparison, standardised scales were also included in the survey corresponding to each of the disorders assessed by the prototypes. These were the CES-D, the GAD-7, Panic Disorder Severity Scale -Self Report and Social Phobia Inventory (SPIN) and the short forms of these. The order of presentation of the scales was counterbalanced, so that half of the respondents received the prototype items followed by the standard scales, while the other half received the standard scales followed by the prototypes.The Mini International Neuropsychiatric Interview (MINI) version 6  was usedn = 64) were excluded from having a phone interview.Surveys included the short and the ultra short versions of the prototypes, the four standard scales and their short forms , questions on background characteristics, and a consent form for clinical interview. These surveys were mailed to the 14,000 potential participants, along with information about the study. A subsample of respondents was then selected for a clinical interview. An algorithm for clinical interview selection was designed prior to the study, aiming to administer clinical interviews with all of the respondents with high scores on the prototypes and some of the participants with low scores according to a weekly quota system. A random sample of respondents who did not identify with any of the prototypes was also selected for interview. Only participants who provided a telephone number and consented to be interviewed were contacted. Participants who identified at any level with the schizophrenia prototype  were conducted over the telephone by a team of four clinical psychology postgraduate students and one trainee clinical psychologist, all of whom received three hours of training in the administration of the clinical interview, including a videoconference with the authors of the MINI. From the 2,976 respondents, 1,257 consented and were eligible for a clinical interview. A total of 349 participants who endorsed a prototype and 129 who did not endorse a prototype were selected for clinical interviews. Of those selected, interviews were completed with 225 endorsers (64.5%) and 101 non-endorsers (78.3%). Up to seven call attempts were made in order to contact each of the selected participants, with a two-week window given to make contact after the survey was returned. Clinical interviewers were blinded to the survey responses of the interviewees. The sampling procedure is shown in Figure Prototype responses were examined across the five disorders, and compared to population rates of caseness. Receiver operating characteristic (ROC) curves were plotted for the prototypes, ultra short prototypes, scales and short-form scales, comparing criteria for caseness on each of these measures to clinical caseness based on the MINI. The critical test of the effectiveness each prototype as a screening tool was to assess whether the area under the short and ultra short prototype ROC curve was as large as the area under the versions of the standard scales and their short forms. Cutoffs for each prototype were established using Youden indices to maximise sensitivity and specificity. The sensitivity and specificity of these cutoffs were compared to the sensitivity and specificity of the scales and short-form scales using their established cutoff scores. Respondents with missing responses on a prototype or scale, or an incomplete module of the MINI were excluded from the comparison for that particular disorder only, resulting in analysis samples of 322 for depression, 324 for GAD, 324 for social phobia and the complete sample of 326 for panic disorder.χ2 (2) = 2.2, p = .332]. The age distributions of respondents to the survey and respondents to the clinical interview were also not significantly different . While efforts were made to select a representative sample, representativeness is not critical for the purposes of comparing multiple measures. The participants who completed a clinical interview were well educated , with the majority in full-time  or part-time  employment. Almost all respondents to the clinical interview spoke exclusively English at home  and very few relied on assistance for completing forms  or for reading printed materials .The flow of participants in the trial is shown in Figure n = 2,976) are shown in Figure Rates of prototype endorsement across the survey sample n = ,976 are The prototypes, ultra short prototypes, scales and short-form scales were compared to MINI criteria using ROC curves, displayed in Figure Based on Youden indices to maximise sensitivity and specificity, cutoffs were established for each of the prototypes and ultra short prototypes. For depression and panic disorder, the cut-off that maximised the trade-off between sensitivity and specificity was 2, while for GAD and social phobia it was a score of 3. For the ultra short prototypes, a cut-off of 2 was selected. Sensitivity and specificity for each of these measures, along with the standard scales and short-form standard scales, is shown in Table The core finding of the present study is that in general, the prototypes did not perform better than the standard screening tools. Indeed, although the scales and prototypes had overlapping confidence intervals, it appeared that the scales and short-form scales outperformed the short and ultra short prototypes for every disorder except GAD. With respect to GAD, the findings suggest that people can self-identify generalised anxiety better than other disorders based on a description of a prototypical case. The reason the GAD prototypes performed as well or better than the screener is unclear. The superiority of the screening scales over the depression prototype may arise because depression symptoms are heterogeneous, or it may be due to the fact that depression modifies people's perceptions of symptoms. It may also be due to the relative positive compared to a negative symptom profile associated with anxiety compared to depression. For example, anxiety is associated with fast heartbeat and sweating. Depression is associated with reduced energy, lower mood, and slower activities. The fact that the GAD prototype was superior or at least as good as the GAD-7 scale suggests that self identification of mental health symptoms is possible. Nevertheless, based on the data collected to date, conventional screening tests are generally more useful than our prototypes for all disorders with the exception of GAD. Because of the small numbers in the social phobia and panic categories, replication of these findings in a larger sample is required.The study found that the rates of endorsement of the prototypes were commensurate with prevalence estimates, although the rates appeared to be lower for social phobia. Differences in rates between the prototypes and population estimates may be explained by the non-exclusion of other anxiety disorders from GAD caseness in our study, the predictive merits of the prototypes and differing response rates in the community across the disorders. For social phobia, for example, fewer individuals with social phobia may have agreed to the study, or the prototype might have been too strictly limited in symptoms. In addition, the rates of endorsement of the prototypes displayed reasonably good correspondence with existing scales.Although most prototypes were not superior to those of the brief screening scales, their performance as screening tools was generally respectable, with sensitivity > 75% at specific cutoffs for the GAD and depression prototypes. Data suggests that standardised questionnaires to detect depression have a median sensitivity of 75% . In geneThere were insufficient cases of Social Phobia or Panic Disorder to evaluate the protocols for this study - these will need to be further assessed in a future study. The time frame for symptom duration was different across the scales, and this may have affected differences in specificity and sensitivity. We did not measure acceptability of the prototypes or the standard scales. It may be that prototypical screening tools have the advantage that they provide a positive learning experience for the user, facilitate improved self recognition, lead to the intention to seek help, or are associated with higher acceptability. However these factors, along with additional measures of validity and reliability, were not measured in this study, and are the target of ongoing research. Although the response rate of 21% is consistent with other mail-based community surveys, the sample may have been prone to a number of selection biases. The sample was well educated and most were highly literate in English, and it is possible that different outcomes may have arisen if the sample was less well educated. Whether the prototypes might perform better in a less well educated sample requires further research. Nevertheless, the primary aim of the study was to compare the accuracy of responses on two scales , so representativeness does not diminish this within-person comparison. An additional limitation of the study is that the gold standard employed to detect "caseness" used non-exclusion based diagnosis, and did not attempt differential diagnosis. As such, the use of non-exclusion based diagnosis as the core gold standard will produce different prevalence rates than those based on differential diagnosis. For example, the National Comorbidity Survey reported prevalence estimates with exclusions for the DSM-III-R hierarchical rules . NeverthFurther research is needed to test the anxiety prototype and to investigate whether the depression prototype might be improved. It is not clear whether prototypes are accurate screening tools for particular individuals, and we are currently investigating predictors, such as previous depression history, to determine for whom the prototypes might be useful. We will also investigate symptoms that are most strongly associated with prototype endorsement and to refine prototype descriptions. We also plan to investigate satisfaction and ease of use  for the We were motivated to develop a new method of screening for a number of reasons, including ease of use and satisfaction for users. Without further refinement, the evidence suggests that, with the exception of GAD, screening for mental health problems at this stage is superior if short screening tools are used.The authors declare that they have no competing interests.HC designed the study and drafted the manuscript, and wrote the grant that supported the research; PJB contributed to the design of the study, managed the study, performed the analyses and drafted parts of the manuscript; JBG contributed to the design of the study, searched the literature and developed the prototypes, managed the study and drafted parts of the manuscript. KMG and AJM assisted in the design of the study and the prototypes, and commented on the manuscript. All authors read and approved of the final version of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2288/11/154/prepubPrototype Items. The prototype measures used in the present study.Click here for fileUltra short prototype items. The ultra short prototype measures used in the present study.Click here for file


This paper provides an overview and a synthesis of the findings of a large, multifaceted study investigating outcomes from paediatric cochlear implantation. The study included children implanted at several Australian implant clinics and attending a variety of early intervention and educational settings across a range of locations in eastern Australia. It investigated three major aspects of childhood cochlear implantation: (1) parental expectations of their children's implantation, (2) families' decision-making processes, and (3) the communication, social, and educational outcomes of cochlear implantation for deaf children. It employed a mixed-methods approach in which quantitative survey data were gathered from 247 parents and 151 teachers, and qualitative data from semistructured interviews with 27 parents, 15 teachers, and 11 children and adolescents with cochlear implants. The summarised findings highlight several areas where challenges remain for implant clinics, parents, and educators if children with cochlear implants are to reach their full potential personally, educationally, and socially. In most developed nations, the rate of paediatric cochlear implantation (CI) has increased to the point where it is now the predominant response to profound and, increasingly, severe childhood deafness. The majority of published studies investigating CI in children have focused on children's audition, speech production and perception, and spoken language development. As time goes on, it is becoming more possible to report on longer-term outcomes of children's functioning in their everyday lives at home, at school, and in the community , 2. It is important to assess how children are functioning, communicating, and achieving in their everyday lives from parent and teacher reports, which may more closely reflect the functional outcomes of children in everyday life situations than assessments made in clinical settings –5. The rThe current study explored these broader areas of functional communication, educational, and psychosocial outcomes, as well as parents' preimplant expectations and postimplant experiences and the degree of concordance between these anticipated and experienced outcomes. In addition, it investigated parents' experiences of making the decision to choose CI for their children, and their experiences of the rehabilitation demands involved after their children's implantation. It utilised a mixed-methods approach that allowed quantitative survey findings to be extended and elaborated by qualitative findings from in-depth interviews. It included children with varying lengths of time since implantation, enabling insights to be gained into the lived experience and functional outcomes for children over time. The various aspects of the study and its findings have been reported in detail in papers covering the following topics: parents' experiences of making the decision for CI for their children ; parentaA combination of quantitative and qualitative approaches was adopted in a sequential approach in which one method is used to further explore and expand the findings of another . QuantitSurvey participants were from two groups in three states of eastern Australia: (a) parents of children who had received cochlear implants before the age of 18, and (b) teachers working with deaf children in early intervention programs, primary schools, and secondary schools. Each teacher was asked to complete a survey based on one randomly selected child whom they supported.Completed surveys used in the analysis numbered 247 for parents and 151 for teachers. Copies of the paper surveys and invitations to participate in the study were disseminated by a large number of schools, cochlear implant clinics, early intervention centres, and parent organizations for deaf children, and we cannot know exactly how many parents or teachers received a copy of the survey or an invitation to complete the survey. Figures provided by the cochlear implant clinics indicated that 1260 children under the age of 18 had been implanted up to the data collection period in March 2008. However, there is no way of knowing what percentage of that number of families received the survey or invitation to participate.Of the parent survey respondents, almost 90% were mothers. Almost 97% were hearing, with 7 parents stating that they were hard of hearing and one parent identifying as Deaf . Most of the teachers worked as itinerant teachers of the deaf who visit students and collaborate with class teachers in regular school settings (40%), or as teachers of the deaf based on a support class or deaf facility in a regular school (40%); the remainder were largely early intervention specialists or general class teachers.Approximately 25% of the children in both the parent and teacher surveys had additional disabilities or difficulties. Respondents specified a wide range of conditions including learning difficulties, cerebral palsy, intellectual impairment, asthma, and needing to wear glasses. Tables Although parents and teachers were reporting on children drawn from the same population , these two groups of respondents were not necessarily reporting on the same children in each case.Approximately 10% of the survey respondents in these two groups were interviewed: 27 parents and 15 teachers. In addition, 11 CI users, aged between 10 and 17 years, were interviewed.The parent survey contained three sections. The first collected background information, including family demographics and child-related information such as age at hearing loss occurrence and identification, age at cochlear implantation, occurrence of bilateral implantation, use of hearing aids before the implant , educational setting, and communication approach in the educational setting. The second section asked about the process of making the decision about CI, and included questions about the sources of information parents used while making the decision to have their child implanted, the length of time parents considered CI before making their decision, and their satisfaction with the information, help, and support received from a range of professionals.The third section asked about parents' expectations and experiences of their children's CI and was adapted from a survey developed by Zaidman-Zait and Most  for use Two subscales (rehabilitation efforts and rehabilitation stress) asked parents about the demands on themselves and their families of the ongoing rehabilitation process and their perceptions of stress around making the decision to implant, the rehabilitation process, and generally encountered with their deaf children.strongly disagree, disagree, neither agree nor disagree, agree and strongly agree. At the end of the survey, parents were invited to write an open-ended response to the question “if there is one central message that you would like to convey to us about the experiences you have had with your deaf child and his or her cochlear implantation, what would that be?” For each item on all subscales, parents were asked about their expectations before their child received the CI and about their experiences currently, since their child had the CI. In addition, six items rated parents' overall satisfaction with their children's social, academic, and communication abilities; for example, “overall the expectations I had before my child was implanted are now being met” and “currently, I am satisfied with my child's communication abilities.” Respondents were asked to rate their level of agreement with each item on a 5-point scale with responses The teacher survey also contained 3 sections. The first section collected data on the role of the teacher , and details about the child, including gender, current age, age at implantation, occurrence of bilateral implantation, hearing aid use, type of educational setting, and the communication approach or program used with the child in that setting.Approval for the project was gained from the relevant university, state government education department, early intervention centre, and hospital Human Research Ethics Committees. Cochlear implant clinics, early intervention centres, and the education departments facilitated the distribution of copies of the survey to all families and teachers of implanted children on their data bases. Parents and teachers were informed of the option of completing and submitting the questionnaire online. All survey and interview data were collected in 2008.We aimed to conduct follow-up interviews with approximately 10% of parents and teachers who completed surveys. Because almost 80% of both the parent and teacher survey respondents agreed to be contacted for an interview, we needed to make a selection of participants to invite to be interviewed. In keeping with the aims and qualitative approach of this phase of the study, sampling was purposeful, that is, designed to select information-rich cases likely to best illuminate the questions being investigated and yield insights and in-depth understanding, rather than empirical generalizations . We seleThe semistructured interviews used an initial list of questions serving as a guideline only, allowing unanticipated information to emerge. The questions included in the interview guide covered the parents' decision making about CI for their children, their expectations before their children's implantation, and their experiences and perceptions of their children's communication, personal, social, and educational development since implantation. In the teacher interviews, the questions fell into two categories: first, questions that related to the specific child about whom the teacher had completed the survey and, second, questions relating more generally to the teachers' experiences of working with children with CI. Teachers were asked about their experiences of the outcomes of CI in terms of the child's development in language and communication, educational achievement, social participation, and identity. Children and adolescents were asked open-ended questions about their feelings about their cochlear implants, their communication modes, their use of telecommunications technology, and their friendships. Further details about the parent, teacher, and child interviews are presented in the individual reports emanating from the larger study –14, 16.A full account of the quantitative and qualitative findings in regard to parents' decision making is presented in Hyde et al. . The quaOverall, the decision-making period was quite short, with 60% of parents taking less than three months to make the decision. Almost half (48%) of the parents reported that making the decision to have their child implanted was extremely stressful. However, a sizeable group of parents (39%) reported otherwise. The qualitative findings showed that some parents decided quickly, usually because they felt that an implant was the only way their child would gain communication through speech and hearing, and so was the only option for their child. Other studies have reported that deciding about CI was easier for parents who believed their children would not develop speech without an implant  and who The study compared parents' reports of their preimplant expectations with their experiences of postimplant outcomes on a large number of items related to five outcome domains . The quaIn addition, the findings indicated that parents' experiences of their children's outcomes with CI were at relatively high levels. In most outcome domains, there was no statistically significant difference between parents' expectations and subsequent experiences of their children's outcomes with the CI. On some items in the subscales, there were high levels of uncertainty in expectations; for example, 35% were uncertain whether their child would easily make friends with hearing children, and 23% were unsure if their child would be able to use the telephone. Uncertainties were informed by subsequent experiences, usually in a positive direction. In response to questions about overall satisfaction with the CI, approximately four fifths of the parents indicated that their expectations had been met. These findings suggest that the majority of parents had high levels of satisfaction with their children's outcomes with their CI. However, a tenth of parents reported that their overall expectations had not been met. Further, a tenth of parents were not currently satisfied with their children's communication abilities, social skills, and academic abilities. These findings show consistency with those of other studies in which between 5% and 20% of parents have reported unmet expectations , 28. OurFrom the qualitative findings, it is clear that parental expectations were closely intertwined with parental hopes. The findings suggest that parents' levels of expectations, beliefs, and hopes about CI may reflect their determination to do the best for their child and their conviction that a CI is the only way for their child to most fully participate in a hearing world, rather than the explanations and cautions about potential outcomes that may be presented to them by professionals. The parents tended to interpret such explanations in the most positive context.The retrospective nature of parents' responses about their expectations prior to their children's implantation may have the potential to be affected by recall bias. However, in other studies, researchers have found that most parents had detailed and accurate recall of significant events such as the diagnosis of their children's deafness even many years later , 30. We This section provides a summary of the quantitative findings of children's outcomes from each of the communication, social, academic, wellbeing, and future life domains in the study, as well as the qualitative findings pertaining to these outcome areas. Full details are presented in the relevant individual papers –13.Spoken language communication abilities were reported to be relatively high by parents and somewhat lower by teachers. Some children were developing, or had developed over a period of years, near normal speech and language outcomes, but these tended to be in specific situations involving familiar communication partners, such as family members, and in familiar contexts and optimal listening environments. In broader contexts, such as in regular classrooms and in social groups and gatherings, the picture was not as positive, with parents and teachers reporting difficulties for children in these environments. For instance, 20% of parents and 48% of teachers reported that the child could not follow a spoken conversation with a group of people. These findings were confirmed in the qualitative findings in which interviewees described difficulties in groups of hearing peers.In the survey subscale social skills and participation, parents indicated relatively positive outcomes for their children. However, the qualitative findings revealed that the area of their children's social skills and participation remained a concern for most parents, who were aware of their children's difficulties in groups and how those difficulties affected their social inclusion. In addition, findings from both the quantitative and qualitative teacher data indicate less than optimal social outcomes. For example, teachers reported that a third of the children did not easily make friends with hearing children and did not have age-appropriate social skills, and 10% were not accepted by their hearing peers. The findings from the interviews with parents, teachers, and adolescents indicated that situations involving hearing peers were often difficult, and the development of some social skills, such as understanding subtleties and nuances in social interactions, were delayed in these children with CI. Social participation and emotional wellbeing became more problematic for some children as they reached adolescence and appeared to struggle with issues around being deaf, feeling self-conscious about the CI external equipment they needed to wear, and fitting in with hearing peers. These findings are similar to others reported in studies on social participation and quality of life for adolescents who use hearing aids , 32 and More than two thirds of parents reported that their children were able to participate easily in a regular class, and slightly more than one third of teachers reported this. Between 50% and 60% of teachers disagreed that children were achieving high standards in reading, writing, and maths or were achieving at the expected level for their age, whereas between 18% and 23% of parents indicated disagreement on these items. Almost 70% of children in the teacher reports fell below the class median in academic performance.Although the teachers interviewed were generally positive about the outcomes and educational experiences of students with cochlear implants, they identified a number of problems and challenges. A major concern was that some students were at risk of missing out on learning in certain pedagogical environments such as group discussion activities, and that often students would not admit their difficulties and seek help in those situations. This is a challenge for educators, particularly in secondary schools, where children who have done well in primary school may need more specialist support to access a more challenging curriculum . HoweverParents and teachers often used the term “still deaf” to describe their children and asserted that many people, including regular class teachers and school authorities, had misconceptions about the nature of CI. These parent and teacher interviewees believed that there was a lack of understanding that CI does not “fix” deafness and that children with CI still experience difficulties in many auditory environments and delays in aspects of their development that necessitate ongoing support and accommodations in the school setting. It appeared that this lack of understanding was particularly the case for those children whose spoken language was good. Other studies have reported a similar lack of understanding on the part of teachers (and other students) about students with hearing loss in regular classes , 38.Some of the teachers interviewed reported a lack of liaison with CI clinics and of professional development about CI for themselves as well as for regular class teachers. Teachers pointed out the complexity of the technology involved, especially when cochlear implants are used with FM systems and hearing aids, and the challenges for teachers and parents attempting to identify and rectify problems with the equipment. Other researchers have emphasized the importance of close liaison between CI centres and local educational services in order to ensure the best management and continuing use of the CI technology , 39.In areas of children's general functioning, independence and identity as deaf or hearing persons, the large majority of parents believed their children were happier, less frustrated, and safer than they would have been without the implant. Almost 60% of parents believed their child functioned like a child with normal hearing, whereas only 30% of teachers reported this. In terms of identity, close to 30% of parents and teachers believed the child had developed an identity as a deaf person, while two thirds of parents, and slightly more than one third of teachers, reported that the child comfortably shared both deaf and hearing identities. These findings are consistent with those of implanted adolescents' self-reported sense of identity in other studies. For example, a UK study found that young people displayed a flexible attitude towards their identity as deaf or hearing people , and a Ut = −2.41 (df = 246), P < 0.05), with parents experiencing more stress than they had expected before their children's CI. A major theme in the qualitative findings concerned the amount of work and time parents dedicated to their deaf children in the areas of early intervention and speech training as well as in terms of frequent appointments for mapping and other ongoing requirements related to the use of the CI. They reported feeling stressed by the time needed to travel to and attend appointments, and by the difficulties this imposed on their other children and on the family's financial situation. Parents described frequent problems with implant equipment breaking and parts needing replacing. When these could not be replaced quickly, it was worrying for parents and difficult and frustrating for the children to be unable to use their implant and thus be without their means of hearing until replacements arrived. Similar concerns have been reported in studies of parental experiences of their children's CI [The findings related to rehabilitation demands and parental stress are reported in detail in Punch and Hyde . A statiren's CI , 42, 43.A recurring theme throughout the qualitative data was of the difficulties and stress experienced by parents living some distance from implant, rehabilitation, and early intervention services. In Australia, CI is undertaken in hospitals in major cities only, and most of the providers of early intervention services for deaf children are based in the major cities although some have centres or therapists in regional areas and some provide an outreach service for remote families. However, some families live large distances from many of the services they need for their deaf children. Spencer  reportedParents whose children did not do well with the implant and whose speech and language development was poor went through particularly stressful periods. In cases where auditory-oral approaches were not proving effective and parents moved towards using sign, they often lost a valuable support base if they were unable to continue attending their auditory-oral early intervention centre. One aim of the study was to ascertain the extent of use of various forms and modes of communication, including oral-aural, sign-supported spoken English, and Australian sign language (Auslan), by children with CI, both in their educational settings and with their families. The findings in regard to children's communication patterns and use of signed communication are reported in full in Hyde and Punch . The quaThe qualitative findings elaborated on these findings, providing details of ways in which children were using signed communication. The interview findings showed that many parents had become convinced of the benefits of signing for their children. Of the 27 parents interviewed, 19 were using signed communication to some extent with their children. Some parents found that early use of signing aided their children's spoken language development after CI. In addition, parents saw the value of developing communication with their children through signing so that they could communicate whenever the children were not wearing their implants' external device, whether because of equipment breakdown or when the children were in situations where it could not be worn, such as swimming. Several of the parents also valued Auslan as a way for their children to establish a connection to other deaf people and a sense of Deaf identity. Overall, these findings show consistency with studies from several countries reporting that signed communication is used by many implanted children, usually as a support to their spoken language acquisition, and is not incompatible with the main aim of the development of oral communication –48.Associations among the four outcome variables communication abilities, social skills and participation, academic achievements, and future life  and a select array of variables were examined via a series of step-wise regression analyses of the parent survey data. These findings are presented in full in Hyde et al. . In addiSeveral variables related to oral communication and mainstream placement were shown to predict positive outcomes in many of the outcome domains. The outcomes of children who were more “oral” were rated more highly by their parents on the everyday functioning areas of hearing and spoken language communication, social skills and participation, and general functioning and independence, but not in the area of academic achievements. The child being in regular, mainstream educational settings was predictive of positive communication and academic outcomes. In the area of communication abilities, these findings are consistent with other reports –53. HoweConsistent with other studies –56, a yoThe child having additional disabilities was strongly predictive of less positive outcomes in all domains. We cannot know from the data whether additional disabilities limited the benefits of the children's CI or whether they affected the children's ability to achieve positive outcomes, regardless of CI.The regression findings indicated that families' location in major city areas was associated with positive communication outcomes, and that living in regional or remote areas predicted greater rehabilitation stress for parents. This large, multifaceted mixed-method study's findings have highlighted challenges that remain for cochlear implant programs, support services, early intervention providers, education authorities, teachers, and families and have implications for professionals working with families and children who have CI. The major challenges, implications, and recommendations that the study's findings have suggested are as follows.Implant programs should continue to advise with caution about the range of likely outcomes but also be aware that families are likely to be influenced by their hopes and aspirations for their children as much, if not more, than by the information they have received. Consequently, information-giving processes should be regularly repeated, extended, and evaluated through ongoing discussion and counselling. There should be greater use of the experiences of deaf and hard of hearing people in support of the decision-making process, and of associated media materials available for those parents not able to attend day or evening sessions. Increased opportunity should be provided for parents to consider situations where their child may use signed communication or develop more than the identity of a “hearing” child. It is important for information about sign language and the Deaf community to be more accessible to families both before and after their children's implantation. Parents should be made aware that choice of a communication mode need not be an either/or option, and that sign language exposure or bilingualism is not solely something to be resorted to if children fail to develop oral-aural communication proficiency but can be used to provide fuller access to cognitive development and communication competence across a range of situations and social settings, thus maximising the child's life experience and potential. It is important for service providers to respond with flexibility when children's and parents' needs change over time, particularly when expected outcomes are not achieved, and it becomes apparent that alternative strategies and approaches are necessary.Perhaps one of the most concerning aspects of the study's findings is that 70% of the children were judged by their teachers to be below the median level of their class in academic achievement, particularly in literacy and numeracy. While the parent data suggest that they were not as aware of this outcome as the teachers, there would seem to be an urgent need to address this situation if these children are to have school achievements commensurate with their communication potential and language acquisition. This remains a significant challenge, as Marschark et al.  indicateFrom the perspective of their functional communication, children with cochlear implants should be supported by teachers and school authorities essentially as if they were hard of hearing; that is, the children are likely to need supports similar to those provided to children without CI with moderate or severe levels of hearing loss. Even those children whose spoken language capacity and proficiency is high are likely to have listening difficulties in particular social and educational contexts and will not have full access to school curricula or to many activities promoting social inclusion. It is necessary for educators involved with children with CI, both teachers of the deaf and general classroom teachers, to have access to professional development and training about CI device equipment and the needs of children with CI. In addition, the maintenance of the CI device equipment necessitates strong communication links among teachers, parents, and implant professionals. The clear links found between families' localities and parental stress and children's communication outcomes suggest that, for children to receive optimal benefits from their implants and for the demands and stress on parents to be reduced, it is necessary that continuing efforts are made to improve access to audiological, rehabilitation, and ongoing device maintenance services for families who live away from major urban centres. In conclusion, the results of the study are largely positive and essentially reflective of parents' high hopes and expectations of CI for their children. Proponents of implantation, both professional and nonprofessional, are generally quick to accept and project these largely positive findings. However, they are often more reticent about supporting equally consistent findings, such as are reported in this and other studies, indicating that signed communication and sign languages will also be part of the lives of many of these children, with the potential to benefit their spoken language development as well as their social development and participation within their various communities. In some ways, the very success that these children seem to be demonstrating in early spoken language acquisition and use within their families has the potential to mask some of the difficulties that were found in this study within schools, the curriculum, and in some social settings. While making clear the benefits of CI and its important role in extending opportunities for profoundly deaf children, this mixed-method study's findings indicate that challenges remain for children with CI and families, implant clinics, early intervention centres, and educators. Systems that support children with CI and their parents face challenges most notably in the areas of children's academic achievement and social development and participation with hearing peers. Ongoing attempts to address these challenges are essential if children with CI are to be fully supported to reach their potential personally, educationally, and socially.


Digitised monogenean images are usually stored in file system directories in an unstructured manner. In this paper we propose a semantic representation of these images in the form of a Monogenean Haptoral Bar Image (MHBI) ontology, which are annotated with taxonomic classification, diagnostic hard part and image properties. The data we used are basically of the monogenean species found in fish, thus we built a simple Fish ontology to demonstrate how the host (fish) ontology can be linked to the MHBI ontology. This will enable linking of information from the monogenean ontology to the host species found in the fish ontology without changing the underlying schema for either of the ontologies.In this paper, we utilized the Taxonomic Data Working Group Life Sciences Identifier (TDWG LSID) vocabulary to represent our data and defined a new vocabulary which is specific for annotating monogenean haptoral bar images to develop the MHBI ontology and a merged MHBI-Fish ontologies. These ontologies are successfully evaluated using five criteria which are clarity, coherence, extendibility, ontology commitment and encoding bias.In this paper, we show that unstructured data can be represented in a structured form using semantics. In the process, we have come up with a new vocabulary for annotating the monogenean images with textual information. The proposed monogenean image ontology will form the basis of a monogenean knowledge base to assist researchers in retrieving information for their analysis. Over the years, we have been collating information on monogeneans found in Malaysian waters, digitized these images and stored them as unstructured data. These images which were extracted from journal publications are meaningless without their textual annotations. Contemporary approaches to organizing image data and its corresponding textual descriptions are by using either the relational database technologies or the XML technologies. For example, the Biota , InsideWSemantics is needed to organize data by focusing on the meaning of objects by expressing relationships. It provides necessary vocabularies to link different data entities to their properties .In this paper, we intend to semantically annotate the haptoral bars of the monogenean species in a structured manner with their textual information or descriptions  taxonomic classification and (2) description of properties of an image found in publications  are needed as Monogeneans are parasitic platyhelminths and are distinguished based on both soft reproductive anatomical features as well as shapes and sizes of sclerotised hard parts such as the haptoral bar, anchor, hook and male and female copulatory organ [The Taxonomic Data Working Group (TDWG)  stronglyry organ .Specimen, TaxonName, PublicationCitation, KindofSpecimenTerm, TaxonRankTerms, PublicationTypeTerms are defined using the TDWG LSID controlled vocabulary, whereas the DiagnosticPartTerm is a new concept. Specimen concept represents the illustrated images of the haptoral bars of the monogeneans. TaxonName represents a single scientific name. PublicationCitation represents a reference to the publication of the monogenean species. KindofSpecimenTerm represents the specimen terms such as illustration, digital object and still image. TaxonRankTerms represents the taxon rank terms for taxonomic classification. PublicationTypeTerms represents type of publication for example an article in journal or book. DiagnosticPartTerms represents the name of the monogenean hard parts.Seven concepts are described from the monogenean data used in this paper - There are two types of properties for the semantics representation which are object properties and datatype properties. Object properties are relationships between two individuals , whereas datatype properties describe relationships between an individual and data values. The properties defined for the seven concepts are mentioned here and descriptions are available in Additional file kindOfSpecimen, isHaptorBar, isCitedIn , typeForName and three datatype properties; specimenId, imgDir and imgDescription.Four object properties are defined under the Specimen concept; rank, isBelong,part,hasSpecies,hasGenus,hasFamily,hasOrder,isHostedIn and four datatype properties; nameComplete, authorship, year and locality.Eight object properties are defined under the TaxonName concept; pubType and lists and five datatype properties; author, year, title, parentPublicationString, number.Two object properties are defined under PublicationCitation concept; DiagnosticPartTerms, KindofSpecimenTerms, TaxonRankTerms, PublicationTypeTerms concepts, which is called definedTerm. This property is given a generic name as it will be used to bind multiple concepts together.One datatype property is defined for 7 concepts, 27 properties, and the relationships between them represent conceptualization of the data used in this paper. This conceptual framework needs to be converted in a machine readable formal specification to reason about the identified concepts and eventually describe the data. This formal specification of shared conceptualization is called ontology .OWL  is an oninstances. While there are no fixed rules to name the instances nevertheless the names should be reflective of the data they represent. For example, for the Specimen concept the record of each image of the haptoral bar or instance is given a unique label that will include its taxon name, diagnostic part depicted by the image and its sequence number in the directory  in the TaxonName concept in the MHBI ontology as an object property to merge with the TaxonName concept in the Fish ontology as shown in the graph model , or from the practical view (usability of the designed ontology). For the purpose of evaluation of quality of the designed ontologies, we adopted five criteria suggested by Gruber  against We introduce some level of formality into this discussion by adopting criteria suggested by Gruber  against Definitions within an ontology need to be stated in such a way that the number of possible interpretations of a concept would be restricted. This will contribute to the effectiveness of communication between agents. In the design of our MHBI Ontology, we stated that for each concept c with property p; the pair  exactly specifies a unique pair. During the design of MHBI Ontology this rule is enforced, and the uniqueness of the definition of concepts is guaranteed  . We have used this ontology to improve the efficiency of CBIR for Biodiversity ,21. As aThe authors declare that they have no competing interest.SKD headed the study and structured the whole research. AA developed the system as part of her PhD. AS assisted in ontology evaluation. AA, LLHS and AS assisted in manuscript writing. All authors contributed in this study. All authors read and approved the final manuscript.LSID TDWG and new vocabularies. LSID TDWG and new vocabularies (highlighted with gray background). The range of the vocabulary refers to the type of values for the object and datatype properties [operties .Click here for file


The masticatory musculature of rodents has evolved to enable both gnawing at the incisors and chewing at the molars. In particular, the masseter muscle is highly specialised, having extended anteriorly to originate from the rostrum. All living rodents have achieved this masseteric expansion in one of three ways, known as the sciuromorph, hystricomorph and myomorph conditions. Here, we used finite element analysis (FEA) to investigate the biomechanical implications of these three morphologies, in a squirrel, guinea pig and rat. In particular, we wished to determine whether each of the three morphologies is better adapted for either gnawing or chewing. Results show that squirrels are more efficient at muscle-bite force transmission during incisor gnawing than guinea pigs, and that guinea pigs are more efficient at molar chewing than squirrels. This matches the known diet of nuts and seeds that squirrels gnaw, and of grasses that guinea pigs grind down with their molars. Surprisingly, results also indicate that rats are more efficient as well as more versatile feeders than both the squirrel and guinea pig. There seems to be no compromise in biting efficiency to accommodate the wider range of foodstuffs and the more general feeding behaviour adopted by rats. Our results show that the morphology of the skull and masticatory muscles have allowed squirrels to specialise as gnawers and guinea pigs as chewers, but that rats are high-performance generalists, which helps explain their overwhelming success as a group. The rodents are some of the most highly specialised mammals with regard to their feeding apparatus. The defining characteristic of the order is the grossly enlarged pair of incisors, seen in both the upper and lower jaws, which are open-rooted and continue to grow through life Aplodontia rufa), the masseteric origin is restricted to the zygomatic arch e.g. Aplodontia, have modified the jaw-closing musculature so that the masseter extends its origin on to the rostrum. This can be done in one of three ways, referred to as sciuromorphy, hystricomorphy and myomorphy To cope with the demands imposed by such an unusual dentition and propaliny, the masticatory musculature of rodents has become highly specialised. The masseter is the dominant jaw-closing muscle, forming between 60% and 80% of the masticatory musculature The three morphotypes described above were originally designated as suborders of the Rodentia Previous biomechanical analyses of rodent mastication have tended to focus on one or two species. Electromyography has been used extensively to study the muscle activation patterns and movements of the lower jaw in rats This study seeks to investigate the biomechanics of feeding in three rodent species representing the sciuromorph, hystricomorph and myomorph conditions. Specifically, it is hypothesised that the three different arrangements of masticatory muscles will lead to different patterns of stress and strain across the three skull geometries during biting, and that the stress distributions generated by gnawing will be different to those arising from chewing. It is further predicted that differences of muscle and skull morphology between the three rodents will confer benefits or costs to biomechanical performance (e.g. biting efficiency) that reflect an adaptation to a particular habitual or facultative mode of feeding. It has been noted, for instance, that the diet of squirrels contains a high proportion of hard foods, such as seeds and nuts, whereas guinea pigs principally feed on vegetation in vivo experiments. FEA also enables us to study the effect of non-realistic loading conditions, such as using the muscle proportions of one rodent on the skull of another, which can be used to test whether the muscle morphology is optimised for certain outcomes, such as minimising stress or maximising biting efficiency.Biomechanical performance in terms of the stresses and strains generated across the skull by gnawing and chewing will be studied in these rodents using the technique of finite element analysis (FEA). Although originally developed as an engineering tool, FEA has been widely used in recent years to model stress and strain in complex biological objects, frequently vertebrate skulls The results of this study will help to further our understanding of how the arrangement of masticatory muscles can affect the biomechanical performance of the skull. If, as hypothesised, it can be shown that the three muscle morphologies are adapted for different feeding strategies, then this may provide an explanation of why each of the three morphotypes appears to have evolved multiple times independently within the Rodentia, and why certain groups within the Rodentia are particularly successful.The von Mises stress patterns resulting from bilateral gnawing at the incisors and unilaterally chewing at the first and last right cheek tooth in the squirrel, guinea pig and rat are shown in The bottom row of images in in vivo measurements of 19.45±2.53 N for the guinea pig and 31.12±10.75 N for the rat. Furthermore, the value predicted for the rat incisor bite is also very similar to the mean value of 24.3 N measured by Robins In order to compare simulated bite performance in the three rodents without the confounding variable of size, the predicted bite force was divided by the total applied muscle force to calculate the mechanical efficiency of biting . This mein vivo muscle proportions, or for the squirrel skull, in which the rat muscle arrangement lowers median stress compared to the squirrel muscles across all bites. Indeed, it can be seen that no matter what the skull geometry, the rat muscle configuration will always result in lower stress than the squirrel muscle arrangement.The effect of changing the masticatory muscle arrangement on the median von Mises stress across the skull is shown in in vivo has a negative impact on biting efficiency. Precisely the opposite is true for the guinea pig - applying the rat and squirrel muscle arrangements to the guinea pig skull produces an increase in efficiency in both cases. Changing muscle proportions on the rat model to those of squirrels or guinea pigs has very little effect, with the only noticeable change being a slight increase in the mechanical efficiency of bites on the second molarWhilst there is a great deal of information in Sciurus carolinensis, Cavia porcellus and Rattus norvegicus, were successfully constructed, loaded and solved. The bite force values predicted by the models were very close to the values measured by the authors and previous researchers Finite element models of three rodent species, in vivo biting fairly closely.As hypothesised, incisor gnawing and molar chewing gave rise to very different patterns of stress across the skull. Incisor bites gave rise to large stresses in the rostrum and the posterior orbit, whereas molar bites tended to stress the whole orbital region, with particularly high stresses in the ventral orbit, but not the rostrum (as might be expected from the position of the molar teeth). In all bites, the zygomatic arch experienced the largest stresses, almost certainly as a result of the large muscle mass attaching directly to this part of the skull. In all mammals, a large amount of muscle attaches to this, often slender, rod of bone Despite the substantial differences in skull geometry and muscle morphology, the general pattern of stress across the skull was similar in all three rodents . HoweverThe analysis of bite efficiency  demonstrIn comparison to squirrels, guinea pigs show an increased efficiency of biting at the molars , which sRattus norvegicus and the myomorph rodents as a whole, particularly the subfamily Murinae, which contains well over 500 species distributed widely across Europe, Asia, Africa and Australia and contains some of the most detrimental wide-spread invasive species among vertebrates Of the three rodents studied here, the rat has the most efficient bite at all teeth . Thus, tin vivo. Previous research has indicated that gape angle can affect maximum bite force The models presented in this analysis were necessarily simplified representations of the highly complex interactions of muscle, teeth, bone and food that occur The results of this analysis have given insights into how the skull and muscle morphology of the squirrel, guinea pig and rat are adapted to particular dietary niches. Further analysis of other rodent species is needed to understand if biting efficiency at different parts of the tooth row is specific to these three rodent species or an inherent property of the sciuromorph, hystricomorph and myomorph muscle arrangements. If the latter is the case, this may shed a great deal of light on why the three different muscle arrangement evolved from the primitive morphology, and why each has evolved multiple times, independently within the Rodentia.Sciurus carolinensis), domesticated guinea pig (Cavia porcellus) and brown rat (Rattus norvegicus) were selected to represent the sciuromorph, hystricomorph and myomorph morphologies respectively. All specimens were from formalin-fixed collections maintained at the University of Liverpool, which had been obtained for earlier studies The grey squirrel . The skull, teeth and periodontal ligament were all rendered separately so that they could be assigned separate elastic properties. For the same reasons, the enamel, dentine and pulp layers of the incisors were separated; however, these components were not so easily distinguishable in the molars . Hence, the molars were modelled as a single volume in all three models. The completed models were converted to three-dimensional meshes in Hypermesh 10.0 . Each model was composed of between 800,000 and 1.2 million tetrahedral linear elements with an average size of 0.25 mm. This is well below the element size of 0.92 mm at which the results of an FEA of a pig skull were found to converge The six separate volumes in each model  were modelled as linearly elastic and were each assigned different values of Young's modulus to reflect the variation in stiffness of each of these tissues. Owing to the small size of the specimens in this analysis, it was assumed that the skulls were composed entirely of cortical bone. This assumption was felt to be justified by recent research on felids Three or four nodes  in each model were constrained to prevent translation and rotation in space when the muscle loads were applied. A node on the ventral surface of the zygomatic process of the squamosal bone was constrained on both sides of the model to simulate the temporo-mandibular joint (TMJ). The node on the left TMJ was constrained in all three dimensions, but the node on the right TMJ was only constrained in the antero-posterior and dorso-ventral axes, so as to allow medio-lateral expansion and contraction of the skull. In addition, a node was constrained at the bite point(s) in the axis of the bite. At the molars this was deemed to be perpendicular to the occlusal plane, but at the incisors it was modelled at 75° to the occlusal plane, based on previous sensitivity studies ex vivo data in most cases. Pennation angle was not taken into account in calculations of PCSA as it was sufficiently small to be negligible. The physiological cross-sectional areas were converted to muscle forces by multiplying by a muscle stress value of 0.3 Nmm−2The jaw-closing muscles of the squirrel, guinea pig and rat were studied in great detail using both traditional dissection and contrast-enhanced microCT In order to assess the effect of the relative proportions of the masticatory muscles on stress and strain across the skull, further analyses were conducted in which the muscle forces were adjusted on each model to resemble those of the other two rodents. Firstly, the percentage of the total force contributed by each muscle was calculated . These pwww.r-project.org), and plotted as contour maps of stress and strain across the skulls. Using an especially written script in the Abaqus Python scripting interface, the results from a number of analyses representing bites on all possible teeth were combined, and contour maps were plotted of the maximum stress experienced by each element across all models. The mechanical efficiency of biting in each model was assessed by calculating the ratio of predicted bite force to the applied muscle force The rodent finite element models were solved using Abaqus 6.10.2 . Von Mises stresses for each element were extracted from Abaqus, analysed using R 2.13.1 statistical software , 48.2 mm (squirrel) and 57.5 mm (guinea pig). In contrast to some recent FEA studies, it was decided not to scale the models, either to a uniform surface area in vivo measurements of incisor bite forces were obtained from two adult rats (321±8.5 g) and two adult guinea pigs (355±22.6 g) using a Kistler (type 9203) bite force transducer attached to a Kistler charge amplifier (type 5995) and mounted in a custom-built set-up Results of the FEA were validated from


Objective: The use of local anesthetics associated to vasoconstrictor agents in dentistry is thoroughly justified and is widely extended, but we cannot ignore the fact that anesthetic infiltration poses risk of complications throughout the dental treatment period. The objective of the present review is to document the reported effects the use of the local anesthetics most widely employed in dentistry, with or without association to vasoconstrictor agents may have in patients with any sort of cardiopathy. Study Design: We have searched for randomized clinical trials on the assessment of the cardiovascular effects of local anesthetics used in dentistry, without limits as regards age or sex, conducted in patients with any type of cardiopathy which were published during the last decade and were index-linked in Cochrane, Embase and Medline.Results: We have found six randomized clinical trials index-linked in Medline and Cochrane in the past ten years. These trials compare different types of anesthetics: lidocaine 2%, mepivacaine 2%, prilocaine 2% , associated or not to different vasoconstrictor concentrations such as adrenaline or felypressin. The cardiopathies affecting the patients included in the different trials range from hypertension, ischemic heart disease, arrythmias, chronic coronary disease to heart transplantation. Conclusions: The use of anesthetics associated to vasoconstrictor agents is justified in the case of patients with cardiopathies  and in controlled hypertensive patients. In any case, we must be very careful with the choice and execution of the anesthetic technique, being it possible to use a dose between 1.8 and 3.6 ml, on a general basis. Further studies are necessary to establish the effects of these drugs on severe hypertensive patients or in patients with other more advanced cardiopathies. Key words:Vasoconstrictor agents, epinephrine/adverse effects, local anesthetics, dental restoration, oral surgery, cardiovascular diseases, coronary arteriosclerosis, heart disease, hypertension, arrhythmias, coronariopathy. The use of anesthetics associated to vasoconstrictor agents is justified in the clinical practice of dentistry: it delays the absorption of local anesthetics and increases safety as lower doses of anesthetic are required . The use of Catecholamine type vasoconstrictors in certain patients is a controversial issue, especially in the case of patients with cardiopathies and/or diabetes and more precisely in those with coronariopathies and severe hypertension .In order to avoid these risks associated with the use of catecholamines, researchers have focused their efforts in searching for vasoconstrictor agents with a different chemical structure. Nowadays, only felypressin is marketed in Spain . It could be an adequate alternative to catecholamine type vasoconstrictors in the following circumstances: cardiopathies and especially ischemic cardiopathies, patients with high plasma concentrations of endogenous catecholamines (feochromocytoma) or thyroid hormones (primary or secondary hyperthyroidism), patients under treatment with substances susceptible of causing dangerous interactions with catecholamines  or allergy to vasoconstrictor agents themselves .One of the most delicate and risky actions throughout any type of dental treatment is anesthetic infiltration. If we consider as well the great number of pharmacologic effects infiltrated substances have (anesthetics themselves and the adrenergic vasoconstrictors used to increase biodisponibility and to reduce anesthetic toxicity), it is obvious that the specialist confronts a situation he must know and control thoroughly. This situation becomes even more delicate when the patient suffers from any cardiopathy.Within the category of patients with cardiovascular pathologies we include.- Hypertensive heart disease, which in turn comprises two varieties, namely, hypertensive urgency and hypertensive emergency. The latter may pose a vital risk for the patient and it requires urgent parenteral hypotension treatment . Stage A- Ischemic heart disease: first of all, we must bear in mind the fact that patients who have suffered acute myocardial infarction have a high risk of suffering a new infarction, and very often severe arrhythmias. Also, the risk of a second infarction during non cardiac surgery is known to reach 27% during the first months after infarction, 11% between months 3 and 6 and it drops to 5% from month 6 onwards. As a result, dental treatment is not indicated up to 6 months after the episode of acute myocardial infarction  and tachyarrhythmia (heart rate more than 100 beats per minute). In these patients preoperative evaluation must be detailed in order to assess the origin of the arrhythmia, the need of prior stabilization of the patient before the treatment, the risk of arrhythmia during treatment and the possibility of avoiding the use of local anesthetics associated to vasoconstrictor agents .- Patients who have undergone heart transplantation: survival rate of these patients has increased remarkably with the introduction of immunosuppressive drugs such as cyclosporine. The side effects of such drugs include a high incidence of gingival hyperplasia. We must determine the correct dose of local anesthetic to be administered to this type of patients .In line with different authors, we can state that in the case of healthy subjects the number of anesthetic carpules that can be administered is extrictly limited . TherefoNevertheless, the number of patients with cardiopathies who visit our clinics in increasing and the use of anesthetics associated to vasoconstrictor agents in this type of patients poses an interesting dichotomy. On the one hand, they imply greater safety and on the other hand their use may provoke cardiovascular complications.The aim of the present study is to search for and conduct a critical evaluation of recent reports on the effect and safety for the cardiovascular system of local anesthetics associated with vasoconstrictor agents used for dentistry in patients with cardiopathies.We have searched for studies published in the last decade (January 2000 through December 2010) which have been index-linked in Cochrane, Embase and Medline, in the latter using the Pubmed search tool.We established the following search paremeters: randomized controlled clinical trials conducted in humans without limit as regards age of male/female sex with any type of cardiopathy or cardiovascular disease written in English and Spanish and published in the last decade. The search words used were: vasoconstrictor agents, epinephrine/adverse effects, local anesthetics, dental restoration, oral surgery, cardiovascular diseases, coronary arteriosclerosis, heart disease, hypertension, arrhythmias, coronariopathy, using the Boolean operator OR to combine search words.Finally, the results obtained were manually filtered reading the abstracts published in the above mentioned sources in order to subsequently obtain the original version of the selected articles.We have found six randomized clinical trials: Ezmek and colls. (2010), Elad and colls. (2008), Fernán-dez-Cáceres and colls. (2008), Neves and colls. (2007), Conrado and colls. (2007), Meechan and colls. (2002) -14. ThesThe cardiopathies studied in the different trials range from hypertension to ischemic heart disease  including arrhythmias, chronic coronary disease and heart transplantation.Epinephrine or adrenaline is one of the most widely used vasoconstrictor agents in association with local anesthetics in dentistry. This substance provokes the constriction of the blood vessels in the mucosa and skin, which favours latency period and reduces the dissemination of the local anesthetic due to the action of alpha-adrenergic receptors. But the β1-adrenergic receptors of epinephrine will provoke an increase in heart rate and the β2-adrenergic receptors will cause vasodilation in muscles and internal organs. However, only a few reports exist which relate the use of non-selective beta-adrenergic blocking agents and severe hypertensive side effects in dentistry .A good number of publications assess the effects of different anesthetics on certain cardiovascular parameters. Most of these reports have been carried out in healthy subjects and in general the alterations observed in parameters such as arterial tension (mainly), heart rate and others are not significant when comparing the use of anesthetics with and without vasoconstrictor agents. In these studies we observe a slight increase in the value of the above mentioned parameters which the authors usually attribute to the stress of the patients and to the rise in the levels of endogenous epinephrine or adrenaline .The last systemic review of this subject, carried out by Bader and colls. in 2002 dealing with the cardiovascular effects of the use of epinephrine in dentistry in hypertensive patients showed that neither systolic nor diastolic blood pressure increased, even in the case of non-controlled patients .Since then, 6 other studies have been published which contribute level 1 evidence  in this field of study. These studies have expanded their field of research to include patients with ischemic cardiopathies  as well as patients with heart transplantation or chronic coronary artery disease. As a result of these recent studies we are nowadays aware of the effect local anesthetics with or without association to vasoconstrictor agents have on a wider range of pathologies related to the cardiovascular system.The first conclusion we must mention is that in most of these studies we did not observe significant differences between patients with cardiopathies treated with anesthetics with or without association to vasoconstrictor agents, and when such differences were statistically detected, the authors did not consider them critical from a clinical point of view  in association or not with vasoconstrictor agents such as adrenaline or felypressin. This indicates that no new drugs have been introduced which could increase safety in their use with patients with cardiopathies. The doses under study are similar to those administered to healthy subjects, so we must assume that in these studies local anesthetics are administered under normal conditions.Although some studies report the use of invasive techniques to control hemodynamic and cardiovascular variables, the variables measured in the studies we have selected were arterial tension, heart rate, oxygen saturation and the use of electrocardiogram . Only onGenerally, authors start to control these variables before the onset of treatment and finish once it has ended establishing three well differentiated periods : before The exclusion criteria ban from the studies those patients with temporary conditions which contraindicate the use of the treatment  and in controlled hypertensive patients, the use of local anesthetics associated to vasoconstrictor agents is justified. In any case, we must be very careful with the choice and execution of the anesthetic technique, being it possible to use a dose between 1.8 and 3.6 ml, on a general basis. Further studies are necessary to establish the effects of these drugs on severe hypertensive patients or in patients with other more advanced cardiopathies.