Improvements in Survival and Clinical Benefit With Gemcitabine as First-Line Therapy for Patients With Advanced Pancreas Cancer: A Randomized Trial.

PURPOSE: Most patients with advanced pancreas cancer experience pain and must limit their daily activities because of tumor-related symptoms. To date, no treatment has had a significant impact on the disease. In early studies with gemcitabine, patients with pancreas cancer experienced an improvement in disease-related symptoms. Based on those findings, a definitive trial was performed to assess the effectiveness of gemcitabine in patients with newly diagnosed advanced pancreas cancer. PATIENTS AND METHODS: One hundred twenty-six patients with advanced symptomatic pancreas cancer completed a lead-in period to characterize and stabilize pain and were randomized to receive either gemcitabine 1,000 mg/m2 weekly x 7 followed by 1 week of rest, then weekly x 3 every 4 weeks thereafter (63 patients), or to fluorouracil (5-FU) 600 mg/m2 once weekly (63 patients). The primary efficacy measure was clinical benefit response, which was a composite of measurements of pain (analgesic consumption and pain intensity), Karnofsky performance status, and weight. Clinical benefit required a sustained (> or = 4 weeks) improvement in at least one parameter without worsening in any others. Other measures of efficacy included response rate, time to progressive disease, and survival. RESULTS: Clinical benefit response was experienced by 23.8% of gemcitabine-treated patients compared with 4.8% of 5-FU-treated patients (P = .0022). The median survival durations were 5.65 and 4.41 months for gemcitabine-treated and 5-FU-treated patients, respectively (P = .0025). The survival rate at 12 months was 18% for gemcitabine patients and 2% for 5-FU patients. Treatment was well tolerated. CONCLUSION: This study demonstrates that gemcitabine is more effective than 5-FU in alleviation of some disease-related symptoms in patients with advanced, symptomatic pancreas cancer. Gemcitabine also confers a modest survival advantage over treatment with 5-FU.

Improvements in survival and clinical benefit with gemcitabine as first-line therapy for patients with advanced pancreas cancer: a randomized trial.

PURPOSE: Most patients with advanced pancreas cancer experience pain and must limit their daily activities because of tumor-related symptoms. To date, no treatment has had a significant impact on the disease. In early studies with gemcitabine, patients with pancreas cancer experienced an improvement in disease-related symptoms. Based on those findings, a definitive trial was performed to assess the effectiveness of gemcitabine in patients with newly diagnosed advanced pancreas cancer. PATIENTS AND METHODS: One hundred twenty-six patients with advanced symptomatic pancreas cancer completed a lead-in period to characterize and stabilize pain and were randomized to receive either gemcitabine 1,000 mg/m2 weekly x 7 followed by 1 week of rest, then weekly x 3 every 4 weeks thereafter (63 patients), or to fluorouracil (5-FU) 600 mg/m2 once weekly (63 patients). The primary efficacy measure was clinical benefit response, which was a composite of measurements of pain (analgesic consumption and pain intensity), Karnofsky performance status, and weight. Clinical benefit required a sustained (> or = 4 weeks) improvement in at least one parameter without worsening in any others. Other measures of efficacy included response rate, time to progressive disease, and survival. RESULTS: Clinical benefit response was experienced by 23.8% of gemcitabine-treated patients compared with 4.8% of 5-FU-treated patients (P = .0022). The median survival durations were 5.65 and 4.41 months for gemcitabine-treated and 5-FU-treated patients, respectively (P = .0025). The survival rate at 12 months was 18% for gemcitabine patients and 2% for 5-FU patients. Treatment was well tolerated. CONCLUSION: This study demonstrates that gemcitabine is more effective than 5-FU in alleviation of some disease-related symptoms in patients with advanced, symptomatic pancreas cancer. Gemcitabine also confers a modest survival advantage over treatment with 5-FU.

Computer-assisted learning in dentistry. A view from the UK.

OBJECTIVES: The objectives of this paper are to review the development and impact of computer assisted learning (CAL) in dentistry with emphasis on the UK. DATA SOURCES: This is a wide ranging review of dental, medical and technical literature. STUDY SELECTION: An attempt has been made to evaluate present knowledge in an objective manner and to make some prediction as to the future development and use of computer-based teaching methods in dentistry. CONCLUSIONS: The introduction of computers as an educational tool in dentistry and the provision of CAL is having an impact not only on how dentists are trained but also on the skills they will need to acquire in the future to keep pace with this new technology. It is suggested that there is a great potential for computer-based continuing professional education for dental practitioners, and that the Internet will provide access to such material.

Consultant opinion on orthodontic treatment plans used by dental practitioners: a pilot study.

Prior to 1987, dental practitioners in England and Wales intending to carry out all but the simplest orthodontic treatment within the National Health Service, were required to submit pretreatment study models, details of the orthodontic assessment and the proposed treatment plan to the Dental Estimates Board prior to starting treatment. Models taken at the end of treatment were required by the Board to enable payment to be made. In this pilot study, the acceptability of orthodontic treatment plans used by practitioners working in the General Dental Services was assessed by eight hospital consultants, using information about 40 cases submitted to the Dental Estimates Board in 1987/88. All consultants considered a high proportion of plans to be unacceptable, but agreement between the consultants was variable and some agreed with one another on very few plans. A single scorer used the weighted PAR (Peer Assessment Rating) index to assess the degree of departure from normal occlusion of both pre- and post-treatment models. Using accepted standards, only nine cases were greatly improved (PAR reduction > 70%) and the mean percentage reduction in PAR score was low. Consultant opinion on the appropriateness of treatment planning was not related to the outcome of orthodontic treatment.

Gemcitabine: a new approach to treating pancreatic cancer.

PURPOSE/OBJECTIVES: To review the clinical benefit and nursing considerations of the new anticancer agent gemcitabine hydrochloride in the treatment of patients with pancreatic cancer. DATA SOURCES: Peer-reviewed publications, books. DATA SYNTHESIS: Unsatisfactory tools for assessment of pancreatic cancer have led to the development of a novel end point, "clinical benefit," to assess improvements in disease-related symptoms and performance status. The first clinical studies to use this end point assessed gemcitabine, Results showed that 24% of patients on gemcitabine were clinical benefit responders compared to 5% of patients on 5-fluorouracil (5-FU). In patients refractory to 5-FU, 27% showed a clinical benefit response to gemcitabine. CONCLUSIONS: Gemcitabine provides significantly better clinical benefit than standard treatment for pancreatic cancer. IMPLICATIONS FOR NURSING PRACTICE: Clinical benefit assessments rely on oncology nurses to classify the response to treatment in addition to managing the side effects.

Report of a survey conducted by the Consultant Orthodontists Group. The nature and distribution of clinical assistant posts in orthodontics in the United Kingdom in 1987.

This paper describes and discusses the results of a survey, conducted by the Consultant Orthodontists Group in the United Kingdom in 1987, which examined the nature and distribution of clinical assistant posts, and consultants' attitudes to the concept of appointing orthodontic auxiliaries. This survey demonstrated a large regional variation in the number of clinical assistant posts and in the number of 'specialist practitioners' and community orthodontists. More than 90% of consultants teach their clinical assistants how to use removable appliances, headgear and simple fixed appliances. More than 70% of consultants also teach their clinical assistants how to use multi-bracketed techniques and functional appliances. Ninety-one per cent of consultants would give their support to developing regional training schemes for clinical assistants in orthodontics. Eighty-eight per cent of consultant orthodontists favoured the appointment of orthodontic auxiliaries to carry out intra-oral work, and 75% believed that they already had a member of staff capable of doing these duties with some further training.

Left-handedness in dental undergraduates and orthodontic specialists.

A questionnaire was devised involving a group of dental students (n = 70) and a group comprising all consultant orthodontists in the UK (n = 170) to investigate the prevalence and role of handedness in dental specialisation. Subjects were classified as being pure left-, mixed- or pure right-handed according to responses to a hand preference questionnaire and the results were compared with a very similar previous study of the general population. The prevalence of sinistrality (self-classified by writing) was recorded as 8.6% among dental students and 17.2% amongst orthodontists; this compares with 7.4% among the general population. More mixed-handers presented in both the dental groups compared to the general population. This agreed with the right shift theory of laterality. No significant correlation was noted between handedness and any other variable between the two dental groups.

Orthodontics in the General Dental Services of England and Wales: the provision of treatment.

A survey has been undertaken on a representative sample of 1210 patients collected from a 5% sampling procedure employed by the Dental Practice Board. Discontinued cases were excluded from the study. It was revealed that the majority of orthodontic treatment was undertaken by practitioners who had in general been qualified for at least 10 years and, in the main, did not possess an orthodontic qualification. The greater proportion of treatment was undertaken using removable appliances, although fixed appliances were used in 43% of prior approval cases and treatments attracted an average fee of 171 pounds (1988 prices). There was a marked variation in the proportion and type of treatment carried out in the various regions within the General Dental Services.

The evaluation of three computer-assisted learning packages for general dental practitioners.

Two studies were undertaken to determine the acceptability of computer-assisted learning (CAL) to general dental practitioners. The first was a single programme in two parts designed to give experience in orthodontic cases assessment and treatment planning, developed at the Bristol Dental School. The second contained two modules, one on the planning and management of dental biopsy and the other on surgical endodontics, developed within the Leeds Dental Institute. An identical self-administered questionnaire was completed by participants in the evaluation study. Knowledge and skill gains were indicated following study of the modules. The modules were also found to be easy to use and useful. The CAL approach was rated positively compared to audio tapes, books and journals, but a less consistent pictures when CAL was compared with videotapes. The study provides evidence for the acceptability and potential of the CAL approach to general dental practitioners.

Orthodontic teaching practice and undergraduate knowledge in British dental schools.

AIM: The aim was to survey current orthodontic teaching practice in the undergraduate syllabus at British dental schools and to test the abilities of undergraduate students according to the requirements of the GDC regulations. MATERIALS AND METHODS: Information collected by means of a questionnaire sent to each dental school in 1998 was compared with similar data from 1994. The orthodontic knowledge and treatment planning ability of students was assessed by a multiple-choice examination paper completed by a random 10% sample of students from each dental school. RESULTS: In 1998 on average 195 curriculum hours were devoted to orthodontics and each student treated five patients. The teaching of fixed appliances had increased considerably between 1994 and 1998. The average MCQ score was 58% (range 39-72%). Students scored well on questions that tested basic knowledge but much less well when they were required to apply that knowledge. Only three schools felt that it was realistic to expect undergraduates to formulate orthodontic treatment plans, as they are required to do by the GDC. CONCLUSION: Results support the view that undergraduate orthodontic training should concentrate on diagnosis and recognition of problems rather than on providing limited exposure to treatment techniques.

Orthodontics in the general dental service of England and Wales: a critical assessment of standards.

Out of a sample of 1210 orthodontic patients treated within the General Dental Services in England and Wales, a high proportion showed no improvement. Upper and lower fixed appliances had the greatest influence on the outcome of treatment in terms of aesthetics, dental health need and standards. When treatment was analysed according to the appliance used, there were no statistically significant differences in the standard of treatment undertaken by specialist orthodontists and general dental practitioners. Methods for improving British orthodontic standards are considered.

Quality control in orthodontics: indices of treatment need and treatment standards.

Two reliable and valid occlusal indices have been developed to assess treatment need (Index of Treatment Need, IOTN) and the standard of treatment (The PAR Index, Peer Assessment Rating). The IOTN assesses both dental aesthetics and dental health need. The PAR index provides a single summary score for the overall alignment and occlusion. The difference between the pre- and post-treatment scores reflects the degree of improvement and the success of orthodontic intervention and active treatment. Several practical uses of the indices are described: the estimation of treatment need in an unselected and a referred population and the assessment of the standard of treatment in the Hospital and General Dental Services. It has been suggested that the use of the occlusal indices would offer several advantages: (1) uniformity in prescribing patterns, (2) safeguards for the patient, (3) patient counselling and (4) monitoring and promoting standards.

An investigation into the standard of orthodontic treatment carried out by GDPs after completion of a clinical assistant training.

A sample of 172 orthodontic patients treated by 10 general dental practitioners in their practices was assessed in terms of treatment need and standard of treatment provided. The practitioners had been clinical assistants, for a minimum of 2 years, at a District General Hospital before starting any of the cases. Prior to treatment 70% of the cases had a 'clear need' for treatment on dental health grounds and 73% of the cases had a 'moderate' or 'great need' for treatment on aesthetic grounds. Using the Peer Assessment Rating nomogram to assess the treatment standard, 83% of patients could be classed as 'improved' or 'greatly improved' with treatment but 17% were 'worse or no different'. The standard of treatment produced by fixed appliances was found to be superior to that produced by removable appliances alone. When removable appliances were used the best results were obtained when consultant advice was given. The results for the clinical assistant sample are compared with the results for the GDS sample published in 1993. Ways of further improving the treatment standards produced by the general dental practitioners are considered.

Orthodontic auxiliaries--a pilot project.

AIM: To undertake a pilot study to determine a possible training programme for orthodontic auxiliaries. DESIGN AND SETTING: Trainee hygienists who had been accepted onto a 2-year programme were asked to attend the Bristol Dental School well before their course was due to begin in order to participate in a pilot orthodontic assistant auxiliary training programme. METHODS: A modular course of one month's duration was constructed based on the programme at the University of British Columbia. This aimed to teach skills such as impression taking, bond placement, debracketing, band cementation as well as core knowledge relevant to these procedures. RESULTS: At the end of the course all participants were judged to be performing the tasks they had been taught competently and safely. CONCLUSION: UK dental nurses can be trained to fill the role of an orthodontic auxiliary. It would appear that an introductory clinical skills course of one week followed by an orthodontic skills training of three weeks is sufficient for a qualified dental nurse of above average abilities such as typifies those who are currently applying for places on UK dental hygiene courses. It is estimated that a further period of nine months supervised training will be necessary for those who have successfully completed such a training to develop clinically useful speeds when delivering these skills.

The relationship between the index of orthodontic treatment need and consensus opinion of a panel of 74 dentists.

This study looked at the aesthetic and dental health components of the index of orthodontic treatment need in relation to peer assessment of dental health and aesthetic need (panel of 74 dentists). The dental health component had a Spearmans correlation coefficient of +0.64 and the aesthetic component +0.86 when compared with the mean subjective opinion of 74 dentists. It has been proposed to have three categories for both the dental health and aesthetic components in accordance with consensus opinion. The panel of 74 examiners were more likely to regard aesthetics as a greater need for treatment than dental health.

Three-dimensional measurement: the accuracy and precision of the reflex metrograph.

The Reflex Metrograph is an optical plotter which is linked directly to a microcomputer and allows direct three-dimensional measurements of irregular shaped objects up to 300 mm maximum dimension without contacting the object. This study shows that it is possible to generate reproducible results with an operator measurement error of less than 0.2 mm for linear distances on objects up to 200 mm maximum dimension. The Reflex Metrograph tends to undermeasure by 0.67% or by up to 2.00 mm per 300 mm and is very slightly less accurate in the vertical plane. The potential use of this measuring instrument is discussed.

Three-dimensional measurement: the accuracy and precision of the Reflex Microscope.

The Reflex Microscope is an optical plotter which is linked directly to a microcomputer and allows direct three-dimensional measurements of irregular shaped objects up to 100 mm maximum dimension. This study shows that it is possible to generate reproducible results with an operator measurement error of less than 0.15 mm for linear distances. The Reflex Microscope tends to undermeasure by 0.28% or by up to 0.14 mm per 50 mm. There was no detectable difference in accuracy between the three planes X, Y and Z. In planes X and Y the two-dimensional accuracy at high magnification of a 1.000 mm scale was 1.004 mm in X and 1.008 mm in Y planes.

Optical disguising of orbital deformity with prism and cylinder lenses.

This paper describes the way in which prism and cylinder lenses may be used to disguise orbital dystopia when the affected eye is blind. The lenses used can correct the height of the eye, the opening of the eyelids or the rotation or slant of the eye. Four cases are presented to illustrated this technique, which may be used either instead of, or as an adjunct to orbital surgery. An investigation of these effects is described using a mannikin head fitted with an optician's trial frame, with measuring by the reflex metrograph. This revealed that an inferiorly displaced eye may be elevated by 4 to 5 mm, that the vertical eyelid opening may be widened (or narrowed) by just under 20% and that an adverse slant of the eye may be rotated in either direction by about 4 degrees.