Exploring experiences of living with removable dentures-A scoping review of qualitative literature

OBJECTIVE

Examine the literature on the experiences of living with removable dentures (complete or partial) to identify any gaps and provide a map for future research.

BACKGROUND

Increasing proportions of society are living partially dentate with some form of restoration, including removable dentures. Previous studies have reported on the location, materials and usage of these prostheses, along with effects on oral-health-related quality of life (OHRQoL). However, less is known about experiences with removable dentures from a patient-centred perspective.

METHODS

A scoping review of the qualitative literature was undertaken using the framework of Arksey and O'Malley, updated by Levac et al. Literature searches were carried out using Medline and Web of Science. Papers were screened by title and abstract using inclusion and exclusion criteria. Remaining papers were read in full and excluded if they did not meet the required criteria. Nine papers were included in the final review.

FINDINGS

Key themes from these papers were: impact of tooth loss and living without teeth, and its impacts in relation to social position, appearance, confidence and function (chewing and speaking); social norms and tooth loss, including attitudes to tooth retention and treatment costs, and changes in intergenerational norms towards dentures; expectations of treatment, including patients being more involved in decision making, viewing the denture as a "gift" and dentures helping to achieve "an ideal"; living with a removable denture (complete or partial), including patient preparedness for a denture, adaptation and impacts on activities and participation; and the dentist-patient relationship, including issues with information and communication, and differing priorities between patients and dentists.

CONCLUSION

Little qualitative research exists on experiences of living with a removable denture. Existing literature demonstrates the importance of dispersed activities in differing social, spatial and temporal contexts when wearing removable dentures. Focusing on processes of positive adaptation to dentures and OHRQoL, rather than deficits, is also required to fully understand patients' experiences. Additionally, more complex technological advances may not always be in the best interest of every patient.

Association between oral health status and future dietary intake and diet quality in older men: The PRIME study

OBJECTIVES

This study investigated whether oral health status, defined as number of natural teeth and subsequent prosthodontic rehabilitation, was associated with future dietary intake and diet quality in older adults in The Prospective Epidemiological Study of Myocardial Infarction (PRIME).

METHODS

PRIME was originally established to explore cardiovascular risk factors in 50-59 year old men in Northern Ireland (1991-1994). A rescreening phase assessed oral health (2001-2004), while diet was assessed in 2015. Diet quality was characterised by the Dietary Diversity Score and Mediterranean Diet Score. In the current analysis, associations between oral health status, dietary intake and quality were assessed using regression models in 1096 participants.

RESULTS

Amongst study participants, the overall mean number of teeth was 18.5, 51.5 % had ≥21 natural teeth and 49.6 % wore dentures. Oral health status was categorised into five groups: 21-28 teeth with (n = 111) and without (n = 453) dentures, 1-20 teeth with (n = 354) and without (n = 99) dentures and edentate with dentures (n = 79). After full adjustment, men with ≥21 teeth and dentures had a higher future intake of fruit, vegetables, and nuts, and diet quality scores, compared to those with <21 teeth with dentures. Edentate men with dentures were less likely to achieve the future fruit dietary recommendation.

CONCLUSIONS

Having ≥21 natural remaining teeth positively affected the future intake of fruit, vegetables, and nuts, as well as diet quality. Dentures may be beneficial in men with ≥21 natural remaining teeth, as they were associated with an increased future intake of fruit, vegetables, and nuts and better diet quality.

CLINICAL SIGNIFICANCE

Oral health status is associated with dietary intake, after an average time period of 13 years, with those with a larger number of natural teeth having a better diet quality. Further research is required to investigate this relationship in larger, diverse populations with more detailed dietary assessment.

An RCT of atraumatic restorative treatment for older adults: 5 year results

OBJECTIVES

to compare the survival of ART and a conventional restorative technique (CT) for restoring carious lesions in older adults after 5 years.

METHODS

In this parallel randomised controlled clinical trial, 219 independently-living adults were recruited from a dental hospital/community and a geriatric day hospital. Ninety-nine patients who met the inclusion criteria and presented with carious lesions were randomly allocated to receive either ART or conventional restorations (anaesthesia, rotary instruments and resin-modified glass ionomer). The status of restorations was assessed 6 months, 1, 2 and 5 years after restoration placement. Estimates of cumulative survival were calculated for each interval between assessments and a Cox Proportional Hazards (PH) model was fitted to the interval-censored survival time.

RESULTS

Three hundred restorations (ART n=142; CT n=158) were placed on 99 patients, 46 males and 53 females, with a mean age of 73.2, SD: 6.8 (65-90 yrs). After 5 years, ART and CT presented cumulative probability of survival of 85% and 79% (p=0.8095), respectively.

CONCLUSIONS

ART presents survival rates comparable to a conventional technique, when treating older adults after 5 years. The ART approach could be a useful tool to provide dental care for older adults particularly in the nonclinical setting. (Trial Registration number: ISRCTN 76299321).

CLINICAL RELEVANCE

This study shows that ART presents survival rates comparable to conventional techniques to treat carious lesions in older patients after 5 years. It is well accepted by this age cohort, and therefore could be an alternative to treat the elderly, especially those who are homebound or cannot attend the dentist.

Evaluation of the Cariogram for root caries prediction

OBJECTIVES

The aim of this study was to evaluate complete and reduced Cariogram models in predicting root caries risk in independently living older adults by comparing the caries risk assessment of the programme to observed root caries increment over a two-year period.

METHODS

A prospective study recording root caries incidence was conducted on 334 dentate older adults. Data were collected on participant's medical history, fluoride exposure, and diet. Saliva samples were collected to measure salivary flow rate, buffer capacity and bacterial counts. Clinical examination was completed to record decayed, missing and filled teeth (DMFT) and also exposed, filled and decayed root surfaces (RDFS). This was repeated after 12 and 24 months. Scores were entered into the Cariogram and baseline risk category was recorded. Reduced Cariogram models were generated by omitting individual salivary variables and all salivary variables. The performance of the complete and reduced Cariogram models in predicting root caries incidence were evaluated by receiver operating characteristic (ROC) analysis.

RESULTS

280 participants were examined at two year follow up. 55.6% of those in the highest risk group developed new caries compared to 3.8% in the lowest risk group. The mean root caries increment in the highest risk group was 2.00 (SD 3.20) compared to 0.04 (SD 0.20) in the lowest risk group. The area under the ROC curve for the complete Cariogram model was 0.77 (95% CI 0.70-0.83) indicating a fair performance in predicting root caries. Omitting individual or all salivary variables did not significantly alter the predictive ability of the Cariogram.

CONCLUSION

Within the limitations of this study, the Cariogram was clinically useful in identifying individuals with a high risk of developing root caries.

CLINICAL SIGNIFICANCE

Identification of a caries risk assessment tool which could reliably select high-risk individuals for root caries prevention strategies would maximise the cost effectiveness of professionally delivered prevention measures.

Tooth replacement for partially dentate elders: A willingness-to-pay analysis

OBJECTIVES

The primary aim of this study was to investigate partially dentate elders' willingness-to-pay (WTP) for two different tooth replacement strategies: Removable Partial Dentures (RPDs) and, functionally orientated treatment according to the principles of the Shortened Dental Arch (SDA). The secondary aim was to measure the same patient groups' WTP for dental implant treatment.

METHODS

55 patients who had completed a previous RCT comparing two tooth replacement strategies (RPDs (n=27) and SDA (n=28)) were recruited (Trial Registration no. ISRCTN26302774). Patients were asked to indicate their WTP for treatment to replace missing teeth in a number of hypothetical scenarios using the payment card method of contingency evaluation coupled to different costs. Data were collected on patients' social class, income levels and other social circumstances. A Mann-Whitney U Test was used to compare differences in WTP between the two treatment groups. To investigate predictive factors for WTP, multiple linear regression analyses were conducted.

RESULTS

The median age for the patient sample was 72.0 years (IQR: 71-75 years). Patients who had been provided with RPDs indicated that their WTP for this treatment strategy was significantly higher (€550; IQR: 500-650) than those patients who had received SDA treatment (€500; IQR: 450-550) (p=0.003). However patients provided with RPDs indicated that their WTP for SDA treatment (€650; IQR: 600-650) was also significantly higher than those patients who had actually received functionally orientated treatment (€550; IQR: 500-600) (p<0.001). The results indicated that both current income levels and previous treatment allocation were significantly correlated to WTP for both the RPD and the SDA groups. Patients in both treatment groups exhibited little WTP for dental implant treatment with a median value recorded which was half the market value for this treatment (€1000; IQR: 500-1000).

CONCLUSIONS

Amongst this patient cohort previous treatment experience had a strong influence on WTP as did current income levels. Both treatment groups indicated a very strong WTP for simpler, functionally orientated care using adhesive fixed prostheses (SDA) over conventional RPDs.

CLINICAL SIGNIFICANCE

Partially dentate older patients expressed a strong preference for functionally orientated tooth replacement as an alternative to conventional RPDs.

Evaluation of Biodentine in the Restoration of Root Caries

There is no “gold-standard” material for the operative management of root caries. The aim of this study was to determine if the clinical performance of Biodentine would be acceptable for the restoration of root caries in older adults. A randomized controlled clinical trial was conducted comparing a calcium silicate cement (Biodentine), a high-viscosity glass ionomer cement (Fuji IX GP Extra), and a resin-modified glass ionomer cement (Fuji II LC). Of the 334 volunteers assessed for eligibility, 249 were excluded. A total of 303 lesions in 85 participants were randomized, with 151 lesions allocated to receive Biodentine, 77 to Fuji IX GP Extra, and 77 to Fuji II LC. Patients were reviewed by a calibrated dentist who was not involved in restoration placement and who was blinded to material allocation. Restorations were assessed according to a modified US Public Health Service criteria. The cumulative survival percentages after 6 mo and 1 y were 58.6% and 47.2% in the Biodentine group, 89.6% and 83.8% in the Fuji IX GP Extra group, and 89.5% and 84.9% in the Fuji II LC group, respectively. There were statistically significant differences ( χ2 test, P < 0.001) in restoration failure rates between restoration groups. There was no difference between Fuji IX GP Extra and Fuji II LC, but differences ( P < 0.001) were shown between the Fuji II GP Extra group and the Biodentine group and also between the Fuji II LC group and the Biodentine group at both time points. Based on the results of this study, Biodentine cannot be recommended for the operative management of root caries. Fuji IX GP Extra and Fuji II LC displayed similar success rates, and high-viscosity glass ionomer cement and resin-modified glass ionomer cement continue to be the best available option for the restoration of root caries ( ClinicalTrials.gov NCT01866059).

Knowledge Transfer Statement: The results of this study can assist dental practitioners when selecting a restorative material for the operative management of root caries. This randomized controlled trial compared the 1-y clinical performance of a calcium silicate–based material to that of a high-viscosity glass ionomer cement and a resin-modified glass ionomer cement in the operative management of root caries. The study concluded that high-viscosity glass ionomer cement and resin-modified glass ionomer cement continue to be the best available option to dental practitioners when restoring the root surface.

Prosthodontic rehabilitation for a patient with acromegaly

Acromegaly is a condition which results from an excess of growth hormone produced by the pituitary gland after epiphyseal plate closure at puberty. The most common cause of acromegaly is a benign pituitary adenoma. Acromegaly is characterised by enlargement of the hands, feet, nose and ears; expansion of the skull and pronounced brow protrusion. From an oral standpoint, the most relevant symptoms are mandibular protrusion, spacing of the lower teeth and macroglossia. A 46 year-old patient was referred to University Dental School and Hospital by her General Dental Practitioner. The patient had been diagnosed with acromegaly and was receiving medical care from a consultant endocrinologist. The patient was partially dentate with only her lower anterior dentition remaining. She was wearing a complete upper denture but was unable to function effectively due to a lack of occlusal support. Treatment comprised non-surgical periodontal management, construction of upper and lower removable prostheses in a class III relationship and composite restorations on the remaining lower teeth.

Prosthodontic rehabilitation of a patient using a swing-lock lower denture after segmental mandibulectomy

A swing-lock denture is useful in partially dentate patients where the configuration of the remaining teeth means that either the retention or stability available for a conventional removable partial denture is compromised. Such removable prostheses can also prove to be extremely useful when providing prosthodontic rehabilitation following surgical resection of oral cancer. A 20 year-old patient was referred to the Restorative Department of Cork University Dental Hospital following segmental mandibulectomy to treat a calicifying epithelial odontogenic tumour (Pindborg Tumour). Initial treatment using a conventional lower partial denture failed. This paper outlines the successfully rehabilitation using a lower Cobalt-Chromium swing-lock partial denture.

Provision of resin bonded bridgework for a patient with microstomia secondary to scleroderma

Scleroderma is a connective tissue disorder that can present with orofacial involvement. A 48 year-old patient presented to Cork University Dental Hospital with concerns about the appearance of her upper central incisor teeth, which had become progressively mobile in recent years. A diagnosis of localised scleroderma had been made a number of years previously by her medical practitioner and the patient reported that her scleroderma-associated microstomia had progressed significantly in recent years. Most reports of this condition advocate the use of sectional impression trays and sectional dentures to replace missing teeth. This report describes the use of resin-bonded bridgework (RBB) and discusses the possible advantages of this treatment option over those already presented in the literature.

Dilemmas concerning dose distribution and the influence of relative biological effect in proton beam therapy of medulloblastoma

OBJECTIVE

To improve medulloblastoma proton therapy. Although considered ideal for proton therapy, there are potential disadvantages. Expected benefits include reduced radiation-induced cancer and circulatory complications, while avoiding small brain volumes of dose in-homogeneity when compared with conventional X-rays. Several aspects of proton therapy might contribute to reduced tumour control due to (a) the use of more homogenous dose levels which can result in under-dosage, (b) differences in relative biological effectiveness (RBE) between that prescription RBE of 1.1 and the RBE of brain and spinal cord (likely to exceed 1.1) and in medulloblastoma cells (where RBE is likely to be below 1.1). Such changes, although speculative for RBE, might result in potential underdosage of tumour cells and a higher bio-effect in brain tissue.

METHODS

Dose distributions for X-ray and proton treatment are compared, with allocation of likely RBE values for fast growing medullolastoma cells and stable central nervous system tissue.

RESULTS

These physical and radiobiological factors are shown to combine to give a higher risk of tumour recurrence with further risks on tumour control when dose reduction schedules used for X-ray therapy are replicated for proton therapy for "low-risk" patients.

CONCLUSION

The dose distributions and prescribed doses of proton therapy, taking into account RBE, in children and adults with medulloblastoma, need to be reconsidered.

Supporting career choices in dentistry

The Cork University Dental School & Hospital, University College Cork, introduced an innovative programme in April 2011, which provided prospective dental students with an opportunity to participate in a one-day experiential workshop. The aim of the workshop was to provide students with an overview of the dental undergraduate programmes. Feedback on the workshop was exceptionally positive, and prospective students would recommend the workshop to a fellow student, as it helped to inform their decision about choosing dentistry as a first option.

Is the shortened dental arch an underused treatment strategy in the Republic of Ireland?

OBJECTIVES

To determine the proportion of Republic of Ireland 35-44 and 65+ year-olds currently satisfying the criteria for a classic shortened dental arch (SDA) of 20 anterior teeth.

RESEARCH DESIGN

Secondary analysis of data collected in the 2000/02 epidemiological survey of the oral health of Irish adults.

CLINICAL SETTING

Participants underwent a clinical oral examination in health board dental clinics and completed a detailed interview pertaining to dental and general health.

PARTICIPANTS

The analysis is based on a random sample of adults, aged 35 to 44 years (n = 978), and 65 years and older (n = 714).

MAIN OUTCOME MEASURES

The SDA was measured as 20 teeth in the mouth in the positions normally described as from the left second premolar to the right second premolar in each arch.

RESULTS

Only one of the 35-44 year-olds and none of the 65+ year-olds had teeth in their mouths in positions normally described as a classic SDA. However, of the 35-44 year old age group only five patients who had at least a premolar dentition of 20 contiguous teeth had been provided with a removable denture compared to one patient from the 65+ years group.

CONCLUSIONS

Very few older patients in the Republic of Ireland have a SDA based on the measure used. However, very few have been provided with removable dentures where they already possess at least a premolar dentition of 20 contiguous teeth. Suggested reasons for this may include limitations of the data recorded, patient preferences and economic factors.

Abstract 5501: Evaluation of the first potent and highly selective inhibitor of ATR kinase: An approach to selectively sensitize cancer cells to ionizing radiation and hypoxia

DNA damaging agents, such as ionizing radiation (IR), have provided a basis for the treatment of solid tumors for decades, yet they provide only modest benefit for most patients. This reflects, in part, the efficient repair of DNA damage via a complex signaling and repair network known as the DNA damage response (DDR). The ATR, ATM and DNA-PK phosphoinositol 3-kinase-like serine/threonine protein kinases (PIKKs) are the key regulators of the DDR to IR-induced double-strand DNA breaks. This acts to detect the DNA lesions, enforce checkpoints to arrest cell cycle progression, and stimulate repair. Various components of the DDR have been shown to be commonly defective in cancer cells. These cells are widely hypothesized to become dependent on their remaining DDR pathways for survival from DNA damage. The tumor microenvironment has been reported to induce a DDR and in particular, ATR-mediated signaling in response to severe hypoxia.

While inhibitors of a number of DDR enzymes, including ATM, DNA-PK, Chk1 and PARP, have been reported, there have been no reports of drug-like ATR inhibitors. Using the first potent and selective ATR inhibitor (VE-821), we now characterize the effects of ATR inhibition on the cellular response to IR and hypoxia. VE-821 sensitizes many cancer cell lines to IR in both clonogenic and short-term (MTS) assays. For example, VE-821 reduced the surviving fraction of MiaPaca-2 cells treated with 6 Gy IR by 3-fold. Consistent with this, ATR inhibition ablated both RAD51 focus formation and phosphorylation of Chk1 (but not Chk2) after IR treatment, delayed the IR-induced G2/M arrest analyzed by flow cytometry and slowed down DNA replication rates measured using DNA fiber technology. Furthermore, we provide evidence that a basis for the sensitization of cancer cell lines to IR with VE-821 is a synthetic lethal interaction between loss of ATM signaling (a frequent event in cancer resulting from loss of function of proteins such as ATM or p53) and ATR inhibition when cells are treated with IR. In keeping with these results, normal cells (with functional ATM) do not appear sensitized to IR by ATR inhibition. In this case a compensatory DDR is activated, which in turn leads to checkpoint arrest and a strong survival response. Importantly, ATR inhibition also sensitized cancer cells to IR under hypoxic conditions, and to anoxia alone.

These studies show for the first time that a selective ATR inhibitor can preferentially sensitize cancer cells to ionizing radiation under both normoxic and hypoxic conditions and exploit a synthetic lethal interaction between ATM and ATR signaling. This underpins the broad potential of ATR inhibition as a highly promising new strategy to improve the efficacy of DNA damaging therapy.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 5501. doi:10.1158/1538-7445.AM2011-5501

Attitudes of Irish dental graduates to vocational training

INTRODUCTION

Vocational training (VT) is a mandatory 12 month period for UK dental graduates after graduation. Graduates of Irish Dental Schools are eligible to enter the general dental service in Ireland or obtain an NHS performers list number in the UK immediately after qualification. Reports would suggest that some graduates of Irish Dental Schools are choosing to take part in VT in the UK and find the experience beneficial. This study aimed to record the uptake of VT amongst recent graduates from University College Cork and to document their experiences. It was designed to compare the attitudes and experiences of graduates of Irish Dental Schools who undertook VT compared with those who entered the general dental service.

METHOD

A self-completion questionnaire was distributed by e-mail to dental graduates from University College Cork who had graduated 2001-2007. Responses were returned by e-mail or post.

RESULTS

The response rate was 68.9%. There has been an increase in the numbers of graduates taking part in VT each year since 2004. 92.5% of Vocational Dental Practitioners (VDPs) found their experience beneficial as they received a guaranteed source of income, had a supportive peer network and worked in a positive learning environment. However, some felt that they earned a lower income than their associate colleagues, others found the pace of practice slow and that the duration of the training period was excessive. Eighty-five per cent of VDPs would choose the same position again after graduation as compared with 61.8% of associates (P < 0.001). Ninety per cent of VDPs would advise current undergraduates to take part in VT as compared with 51% of associates (P < 0.001). A larger proportion of VDPs had taken part in postgraduate studies but there was no significant difference between the two groups.

CONCLUSIONS

Larger proportions of recent graduates are undertaking vocational training.--The majority of VDPs and associates find their initial employment position beneficial.--VDPs benefit from a guaranteed source of income, a supportive peer network and a positive learning environment.--Some associates suffered from a lack of support, feeling isolated and overwhelmed with patients.--The majority of previous VDPs and associates would recommend VT to current undergraduates.--Almost 40% of associates would now choose to take part in VT if given the opportunity.

C-Raf-1 protein kinase is not essential for Ras transformation of mouse embryo fibroblasts

Transfection of primary cells with mutated oncogenic ras plus a cooperating oncogene such as myc results in the acquisition of the transformed cell phenotype. The pathways downstream of Ras that are required for transformation are an active topic of research. The Raf-MEKK-MAP kinase pathway is triggered by activation of Ras and thought to be important in Ras transformation of rodent fibroblasts. To further explore the involvement of this pathway, fibroblasts from homozygous knock out c-Raf-1 mouse embryos (20 KO) and wild-type c-Raf-1 mouse embryos (16 WT) were transfected with H-ras and myc(v). The resulting cell line derived from the knock out cells grew slower both in tissue culture and had a longer latency period as tumors than the transformed cell line from the wild-type cells. Both cell lines were however able to form tumors in nude mice. These results suggest that c-Raf-1 is not required for Ras transformation in this system.

Effect of oncogene transformation of rat embryo cells on cellular oxygen consumption and glycolysis

We found an unique effect of oncogene transfections on rat embryo cell (REF) respiration, glycolysis and radiation response. Radioresistance, defined as an increase in Do, increases for REF cells transfected with v-myc or H-ras oncogenes. The combination of both oncogenes confers the maximal radioresistance. Our work shows inhibition of oxygen uptake when cells are transfected with v-myc or H-ras alone. However, oxygen uptake increases when cells are transfected simultaneously with v-myc + H-ras (3.7,2.1,2.8). A higher oxygen consumption results from increased utilization of pyruvate via the Kreb's cycle. Succinate stimulates cellular oxygen consumption. The maximum stimulation of oxygen consumption by succinate occurred with v-myc + H-ras transfected cells. The glycolysis of the transfected cells is also altered by the oncogenes. Our glycolytic measurements indicate the H-ras oncogene causes the largest stimulation of glycolysis. Our data shows that transfection with oncogenes has a major effect on cellular glycolysis, oxidative metabolism as well as the subsequent radiation response.

Learning theories made easy: humanism

This is the last of three articles explaining theories of learning with particular relevance to clinical areas. In the story so far, the Director of Nursing Education at the St Elsewhere Academy of Nursing is trying to create the ultimate programme of nursing education. In order to ensure that the very highest standards of teaching and learning are achieved, the DNE has decided to employ a theorist of learning. She first interviewed the candidate representing the school of behaviourism, and last week the cognitivist candidate made his presentation. The series now concludes with the humanist candidate--and the final decision.

Learning theories made easy: cognitivism

This is the second of three articles explaining theories of learning with particular relevance to clinical areas. In the story so far, the Director of Nurse Education at the St Elsewhere Academy of Nursing is trying to create the ultimate programme of nursing education. In order to ensure that the very highest standards of teaching and learning are achieved, the DNE has decided to employ a theorist of learning. Last week she interviewed the candidate representing the school of behaviourism. This week, the candidate from the school of congnitivism makes his presentation.

Learning theories made easy: behaviourism

The last few years have witnessed many developments in nurse education, particularly as links with higher education are strengthened. The clinical environment, however, remains a key area for learning, and practitioners continue to make a huge contribution to the education of both pre- and post-registration students. In order to maximise opportunities, a knowledge of learning theories is useful. This is the first of three articles explaining the different theories of learning. This week the behaviourist theories are described. The following weeks will discuss cognitive and humanist perspectives. The series of three articles uses a creative approach to explain the theories, and to highlight their relevance for teaching in clinical practice.

Assessment of MYCN amplification in neuroblastoma biopsies by differential polymerase chain reaction

Amplification of the oncogene MYCN is a genetic change frequently observed in neuroblastoma and is an indicator of poor prognosis. MYCN copy number is currently determined by Southern blot hybridization. This technique takes 2 to 3 weeks, is labor-intensive, is sensitive to DNA degradation, and requires large quantities of DNA. We have evaluated a new, semiquantitative method of estimating gene copy number that uses differential polymerase chain reaction (PCR). The procedure can be performed in 1 day, is highly reproducible, and requires only nanogram quantities of DNA. It employs a semiquantitative, nonisotopic PCR technique based on differential competition for PCR substrates. MYCN gene primers are amplified together with primers from a single-copy internal control gene. Following electrophoretic separation, the ratio of the two PCR products is determined visually and by densitometric analysis of ethidium bromide-stained agarose gels. This differential ratio is then compared to a series of ratios generated from standards of known MYCN gene copy number. We compared the results obtained by this differential PCR method with those obtained by conventional Southern blotting in 16 cases of primary neuroblastoma. All amplified tumors were detected by differential PCR, and no false positives were observed. We confirmed that differential PCR is a rapid and reliable alternative to Southern blotting for MYCN copy number assessment and is highly suited to the analysis of DNA derived from needle biopsies.

The scope for health education in the accident and emergency department

This paper addresses the relevance and implementation of health education in the Accident & Emergency (A & E) department. The functions of an A & E department and the changing role of A & E nursing are introduced and the scope for health education in A & E is critically discussed. Factors which influence effective and realistic health education, such as inequalities of health, locus of control and the environment within a busy A & E department, are briefly explored. Finally, some recommendations for the implementation of realistic, meaningful health education are offered.

A clinical audit of glottic cancer in Nova Scotia: a paradigm for effectiveness research

We conducted a clinical audit of the recurrence-free rates and absolute survival of 146 patients who presented with T1-T3 glottic cancer and received primary radiotherapy treatment at the Nova Scotia Cancer Centre between 1984 and 1990. The outcomes are compared with a review of published results from other centres. We used stage T3 glottic cancer as an example to illustrate concepts of effectiveness research which are used to determine at what level interventions operate in the day to day practice of medicine. The actuarial recurrence-free rates at 5 years are: T1 91%, T2 73%, and T3 44%. The actuarial absolute survival rates are: T1 84%, T2 68%, and T3 52%. Effectiveness research may utilize efficacy research, clinical audit, quality of life assessment and decision making theory. Its objective is to aid the implementation of appropriate clinical management for specific individuals and defined communities. Expert computer systems may be necessary to synthesize the data and to enhance communication and decision making.

Voluntarism: is it a useful concept for health education in the accident and emergency department?

As the year 2000 looms closer, the emphasis on health education as a means of attaining the 38 targets for 'Health for All' increases. Despite various initiatives, little, if any, progress has been made in narrowing the health divide. Currently, terms such as 'self-care', 'individual responsibility' and 'community empowerment' are often used with emphasis on individual freedom to choose. The author contends that to assume all individuals have that freedom and act voluntarily, is to deny the impact of social structure on health. Health education and the concept of voluntarism will be critically examined from the perspective of nursing in an accident and emergency department.

Caring is the essence of nursing practice

Few would doubt that caring is an integral part of the art and science of nursing. However, unless nurses recognize and promote the value of caring as a basis for rational, scientific practice, their future in healthcare provision may be limited.

Neurologic, neuropsychologic, and computed cranial tomography scan abnormalities in 2- to 10-year survivors of small-cell lung cancer

In order to evaluate the relationship between neurologic function and cranial irradiation, 20 patients treated on National Cancer Institute (NCI) small-cell lung cancer (SCLC) trials who were alive and free of cancer 2.4 to 10.6 years (median, 6.2) from the start of therapy were studied. All were tested with a neurologic history and examination, mental status examination, neuropsychologic testing, and review of serial computed cranial tomography (CCT) scans. Fifteen patients had been treated with prophylactic cranial irradiation (PCI), two patients with therapeutic cranial irradiation, and three received no cranial irradiation. All patients but one were ambulatory and none were institutionalized. Fifteen patients (75%) had neurologic complaints, 13 (65%) had abnormal neurologic examinations, 12 (60%) had abnormal mental status examinations, 13 (65%) had abnormal neuropsychologic testing, and 15 (75%) had abnormal CCT scans. Compared with those given low-dose maintenance chemotherapy during PCI using 200 to 300 rad per fraction, patients who were given high-dose induction chemotherapy during the time of cranial irradiation or large radiotherapy fractions (400 rad) were more likely to have abnormal mental status examinations (6/6 v 4/9) and abnormal neuropsychologic tests (6/6 v 4/9), but no major difference in CCT findings was present. CCT scans in the majority of cases (11/18) showed progressive ventricular dilatation or cerebral atrophy up to 8 years after stopping therapy. We conclude neurologic abnormalities are common in long-term survivors of SCLC, and may be more prominent in patients given high-dose chemotherapy during cranial irradiation or treated with large radiotherapy fractions. The CCT scan abnormalities are common and progressive years after prophylactic cranial irradiation and chemotherapy are stopped.