The CEA Second-Look Trial: a randomised controlled trial of carcinoembryonic antigen prompted reoperation for recurrent colorectal cancer

Objective In patients who have undergone a potentially curative resection of colorectal cancer, does a ‘second-look’ operation to resect recurrence, prompted by monthly monitoring of carcinoembryonic antigen, confer a survival benefit?Design A randomised controlled trial recruiting patients from 1982 to 1993 was recovered under the Restoring Invisible and Abandoned Trials (RIAT) initiative.Setting 58 hospitals in the UK.Participants From 1982 to 1993, 1447 patients were enrolled. Of these 216 met the criteria for carcinoembryonic antigen (CEA) elevation and were randomised to ‘Aggressive’ or ‘Conventional’ arms.Interventions ‘Second-look’ surgery with intention to remove any recurrence discovered.Primary outcome measure Survival.Results By February 1993, 91/108 patients had died in the ‘Aggressive arm’ and 88/108 in the ‘Conventional’ arm (relative risk=1.16, 95% CI 0.87 to 1.37). By 2011 a further 25 randomised patients had died. Kaplan-Meier analysis showed no difference in long-term survival.Conclusions The trial was closed in 1993 following a recommendation from the Data Monitoring Committee that it was highly unlikely that any survival advantage would be demonstrated for CEA prompted second-look surgery. This conclusion was confirmed by repeat analysis of survival times after 20 years.Trial registration number ISRCTN76694943

Dental practitioners' views on the need to treat developmental defects of enamel

Objectives: To assess dental practitioners' views on the need to treat developmental defects of enamel (DDE). In addition, to identify factors associated with practitioners' treatment decision (tooth factors and dentist-related). Methods: A random sample of 300 Hong Kong dentists were sent a booklet containing computer-generated images of various forms of DDE and asked to rate the treatment need. In addition, some dentist-related information was collected. Results: The response rate was 79% (237/300). The majority of the dental practitioners considered that aesthetic treatment was indicated for people with DDE subtypes of brown demarcated opacities (51.0%), confluent/patchy plus staining and/or loss of enamel (80.2%), missing enamel (67.1%) and the combination of discolouration and diffuse opacities (83.1%); their decisions were in relation to the type (P < 0.001), size (P = 0.001) and colour (P < 0.001) of the enamel defects. Dental professionals who were older, self-employed, graduated from institutions overseas, or had postgraduate qualifications, tended to consider aesthetic treatment for the teeth that exhibited the milder forms of enamel defects (P < 0.05). Conclusions: Dentists frequently perceive that DDE constitutes a 'great need' for dental treatment. Dentists' perceptions of the need to treat DDE is influenced by type, size and colour of DDE and associated with dentist-related factors, principally the age of the dentist. © 2007 The Authors. Journal compilation 2007 Blackwell Munksgaard.link_to_subscribed_fulltex

Implementation of oral health recommendations into two residential aged care facilities in a regional Australian city

Background: Residents of aged care facilities usually have a large number of oral health problems. Residents who suffer from dementia are at particular risk. A systematic review of the best available evidence with regard to maintaining the oral health of older people with dementia in residential aged care facilities provided a number of recommendations. Objectives: The aim of the implementation project was to introduce evidence-based oral hygiene practices for patients with dementia in two publicly funded residential aged care facilities and monitor for changes in nursing awareness, knowledge, documentation and practice to improve patient outcomes and ensure appropriate accreditation standards were met. An additional aim was to identify barriers and strategies to overcome barriers to implementation of evidence-based recommendations. Methods: Two facilities, a 40-bed facility and a 71-bed facility in the health service district of the regional Australian city of Toowoomba, provided the setting. A quality improvement approach was taken, using a number of strategies from the National Health and Medical Research Council guidelines for implementation studies. The implementation involved a number of stages, including project development, interactive oral health education, oral audits of residents, changes to oral hygiene practice via care plans and critical reflection. Results The multidisciplinary approach to improving oral healthcare appeared to improve knowledge and awareness and move oral health practices in facilities closer to best practice. Specialised training in oral health was provided to a Clinical Nurse Consultant. Regular oral audits were introduced and facility staff were trained in the use of the oral audit tool. Care plans at one facility were of better quality and more comprehensive than before the intervention. Comments made during critical reflection suggested improvements in the oral health of residents, increased use of oral swabs and saliva substitutes, improved care of dentures and mention of the use of mouth props in resident care plans. There was also some evidence that changes brought about by the implementation are sustainable. Conclusion: The majority of recommendations provided in the systematic review of oral healthcare for dementia patients were applicable to the applied context. The importance of day-to-day leaders was highlighted by the apparently varied outcomes across target facilities. The quality improvement approach would appear to have considerable advantages when applied to improving practice in residential aged care