Graduate medical education success coaching for residents and fellows: a single-institution real-world experience.

While coaching has been employed as a success strategy in many areas such as athletics and business for decades, its use is relatively new in the medical field despite evidence of its benefits. Implementation and engagement regarding coaching in graduate medical education (GME) for residents and fellows is particularly scarce. We report our three-year experience of a GME success coaching program that aims to help trainees reach their full potential by addressing various areas of medical knowledge, clinical skills, efficiency, interpersonal skills and communication, professionalism, and mental health and well-being. The majority of participants (87%) were identified by themselves, their program director, and/or the GME coaches to have more than one area of need. The majority (79%) of referrals were identified by the coaches to have additional needs to the reasons for referral. We provide a framework for implementation of a GME coaching program and propose that coaching in GME may provide an additional safe environment for learners to reveal areas of concerns or difficulty that otherwise would not be disclosed and/or addressed.

Added value of electrical impedance spectroscopy in adjunction of colposcopy: a prospective cohort study.

OBJECTIVE: To assess whether electrical impedance spectroscopy (EIS) as an adjunctive technology enhances the performance of colposcopy. DESIGN: Prospective cohort study. SETTING: University Hospital colposcopy clinic. PARTICIPANTS: Colposcopy with EIS for 647 women and conventional colposcopy for 962 women. INTERVENTIONS: Comparison of the performance of colposcopy by referral cervical cytology in two cohorts, with and without EIS as an adjunctive technology. OUTCOME MEASURES: Prevalence of cervical intraepithelial neoplasia grade 2 or worse (CIN2+), diagnostic testing accuracy to detect CIN2+ with and without EIS and their relative differences between cohorts. RESULTS: The prevalence of CIN2+ varied between the cohorts according to referral cytology: 17.0% after abnormal squamous cells of unknown significance referral cytology in EIS cohort and 9.1% in the reference cohort, 16.5% and 18.9% after low-grade squamous intraepithelial lesion (LSIL), 44.3% and 58.2% after atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (HSIL) (atypical squamous cells that cannot exclude HSIL), and 81.9% and 77.0% after HSIL cytology, respectively. Sensitivity to detect CIN2+ was higher in the EIS cohort, varying from 1.79 (95% CI 1.30 to 2.45) after LSIL referral cytology to 1.16 (95% CI 1.09 to 1.23) after HSIL referral cytology, with correspondingly lower specificity after any referral cytology. CONCLUSIONS: Colposcopy with EIS had overall higher sensitivity but lower specificity to detect CIN2+ than conventional colposcopy. CIN2+ prevalence rates were, however, not consistently higher in the EIS cohort, suggesting innate differences between the cohorts or truly lower detection rates of CIN2+ for EIS, highlighting the need for randomised controlled trials on the effectiveness of EIS.

HPV vaccination and cervical screening: the knowledge and attitudes of mothers of adolescent girls.

OBJECTIVE: Mothers play a significant role in decision making about human papillomavirus (HPV) vaccination for their daughters and about cervical screening attendance for themselves. This study had three objectives, to explore: (1) mothers' knowledge and attitudes about HPV and HPV vaccination, (2) their knowledge and attitudes about cervical cancer and screening, and (3) whether their daughter's HPV vaccination invitation was an opportunity to nudge mothers to attend screening. DESIGN: 138 women from North Staffordshire completed a cross-sectional survey and 15 took part in follow-up focus groups. RESULTS: Despite high self-reported engagement with both the cervical screening and HPV vaccination programmes, relatively low levels of knowledge and some uncertainty were evident. There was mixed opinion about the potential of using the vaccination invite as an opportunity to nudge mothers to attend cervical screening. CONCLUSION: Even amongst women who do engage positively with the programmes, knowledge is not as complete and certain as it could be. Further research is needed with women who are less likely to accept the vaccination for their daughters. Women need to be better informed, which may go some way to reversing the decline in screening and maintaining high levels of vaccination.

The Impact of COVID-19 Pandemic on Screening Programs for Cervical Cancer Prevention Across Europe.

OBJECTIVE: The aim of the study was to estimate the impact of COVID-19 pandemic on the practice of cervical cancer screening in European countries. MATERIALS AND METHODS: A 3 rounds e-survey was conducted among the 31 European Federation for Colposcopy member countries during 2020. Each representative was asked to answer to each questionnaire for their own country. Questionnaires were not anonymous. The first questionnaire was sent in April 2020 and second and third in June and December 2020, respectively. RESULTS: Twenty five of the 31 European countries solicited responded. A total of 19 countries (70.4%) reported that screening for cervical cancer was suspended at least once during the 3 rounds of questionnaires. In addition, 11 countries reported stopping colposcopy and treatments for cervical precancerous lesions at least once during the 3 rounds of questionnaires. These situations evolved with time, with the highest rate of countries recommending suspension of screening, colposcopy, and treatments during the second round of the survey. At round 3, no country recommended screening, colposcopy, and treatment, and 12 countries (57.5%) reported normal screening was fully implemented. CONCLUSIONS: Our results suggest massive disruption in cervical cancer screening programs across Europe resulting from COVID-19 pandemic. Increase in the incidence of cervical cancer is to be expected.

Public transit infrastructure and heat perceptions in hot and dry climates.

Many cities aim to progress toward their sustainability and public health goals by increasing use of their public transit systems. However, without adequate protective infrastructure that provides thermally comfortable conditions for public transit riders, it can be challenging to reach these goals in hot climates. We took micrometeorological measurements and surveyed riders about their perceptions of heat and heat-coping behaviors at bus stops with a variety of design attributes in Phoenix, AZ, USA, during the summer of 2018. We identified the design attributes and coping behaviors that made riders feel cooler. We observed that current infrastructure standards and material choices for bus stops in Phoenix are insufficient to provide thermal comfort, and can even expose riders to health risks. Almost half of the study participants felt hot or very hot at the time they were surveyed, and more than half reported feeling thermally uncomfortable. On average, shade reduced the physiological equivalent temperature (PET) by 19 °C. Moreover, we found significant diurnal differences in PET reductions from the shade provided by various design attributes. For instance, all design attributes were effective in reducing PET in the morning; however, a vegetated awning did not provide statistically significant shade reductions in the afternoon. Temperatures of sun-exposed surfaces of man-made materials exceeded skin burn thresholds in the afternoon, but shade was effective in bringing the same surfaces to safe levels. Aesthetically pleasing stops were rated as cooler than stops rated as less beautiful. We conclude that cities striving to increase public transit use should prioritize thermal comfort when designing public transit stops in hot climates.

National guidelines for management of cervical squamous intraepithelial lesion: A survey of European Federation for colposcopy members.

OBJECTIVES: The management of women with cervical squamous intraepithelial lesions (SIL) is fundamental to prevention of cervical cancer in an organized cervical screening programme. Clinical guidance should improve quality of care and clinical effectiveness if developed and implemented appropriately. This survey provides an update on the current situation of national guidelines for management of cervical SIL amongst member countries of European Federation for Colposcopy (EFC). STUDY DESIGN: A questionnaire was sent to representatives of each member country of EFC. The questionnaire contained questions on: guidelines for management of cervical SIL of the National Societies/Associations of Colposcopy or others national societies/associations including the development and the consultation processes, guidelines for management of lower genital tract diseases and the regulations in each country for colposcopy practice. RESULTS: We received responses from all 34 member countries. Thirty countries reported a national guideline for management of cervical SIL that were developed by, or in conjunction with, their national societies or associations of colposcopy. In most cases there was adherence to the recommended steps for guideline development: they were developed by a multi-disciplinary group of specialists (29 countries) and society members were consulted before publication (21 countries). A small number of countries (8) reported to have guidelines for the management of lower genital tract dysplasia (e.g. vulval disease) developed by other national societies. In most countries (26) the colposcopists are obliged to follow the guidelines but this is regulated in only 6 and in 12 countries the colposcopists need to be certified by the national society of colposcopy in order to practice. CONCLUSION: There are advances in the development and provision of country specific guidance on the management of cervical SIL. Most EFC member countries have appropriate national guidelines that were developed using a clear methodology, are updated according to progresses in the field and are accessible online to current practitioners. These guidelines support colposcopists to follow evidence-based practice and provides understanding of best practice in guideline development and access.

Using technology to harmonise treatment approaches in colposcopy in the face of a changing environment.

The overall numbers of precancerous lesions are expected to fall as human papillomavirus (HPV) vaccinated women enter the cervical screening programme. Juxtaposed against an increase in referrals from the introduction of primary high-risk HPV screening, colposcopists expect to see a decreasing incidence of high-grade cervical intraepithelial neoplasia (CIN). Correct identification of lesions will become more challenging, as the prevalence of high-grade lesions becomes minimal and conventional colposcopy is subject to a lower sensitivity. In this review, we explore the scenarios where adjunct technologies could support colposcopists to manage referrals and diagnose treatable lesions with more confidence.

Identification of European-wide clinical priorities for guideline development in the management of pre-invasive cervical disease.

OBJECTIVE: Addressing management controversies in the treatment of pre-invasive cervical disease is a key priority for the European Federation for Colposcopy/European Society of Gynaecologic Oncology who aim to develop a practical handbook of European centred guidelines to address areas where there is a lack of high-quality evidence or identifiable practice variation. Clinical opinion across the EFC network was sought to identify topics likely to have the most impact on clinical practice for systematic review and development of practice recommendations. STUDY DESIGN: A scoping exercise comprising of a three-iteration modified Delphi with representation from each member society of the EFC was conducted in 2018. Round one identified 19 potential topics which were scored for importance using a five-point Likert scale by EFC members in round two and ranked. Results from round two were discussed at an open EFC satellite meeting resulting in exclusion of five topics. A third round of the 14 remaining topics was conducted to allow members to modify scores after viewing the second-round rankings. Responses were analysed and topics were allocated a weighted score. RESULTS: Strategies for management of persistent HPV infection in the context of normal colposcopy and negative cytology was the highest overall weighted topic (4.40) followed by identification of appropriate length of follow up for ASCUS or LSIL prior to excisional treatment (3.95) and the impact of length of excision on patient outcomes (3.95). Topics to identify best practice for management of challenging topics scored highly including optimising follow up strategies for cervical stenosis (3.91) and management of HSIL in the under 25 year olds (3.64) or pregnancy (3.64). CONCLUSION: A European wide systematic modified-Delphi has prioritised six topics for systematic review and generation of clinical practice recommendations aiming to assist management in areas of controversy in pre-invasive cervical disease.

EBCOG position statement: Gender neutral HPV vaccination for young adults.

Human Papilloma Virus (HPV) has been implicated in the initiation of several types of cancers in both females and males. Therefore, it is imperative that national immunization programs should ensure that both young women and young men receive full immunization for herd immunity in their teenage years. A recent review confirmed that vaccination of boys and girls would be most cost-effective under the circumstances that both individual costs and coverage are low. By doing so, it would be possible to reduce the incidence of HPV-related malignancies to a large extent at later age in both sexes.

Barriers and motivators for uptake of cervical cancer prevention strategies in Eastern Europe: the perspective from Latvia.

INTRODUCTION: The incidence of cervical cancer (CC) in eastern European countries is high; however, uptake of available prevention strategies is suboptimal. We explored knowledge, behaviors, and attitudes toward CC prevention strategies in Latvian women. METHODS: A mixed-methods study of Latvian women, consisting of surveys and semi-structured interviews, was conducted in Riga, Latvia in September and October 2015. RESULTS: Altogether, 158 surveys were completed and 10 interviews were conducted. In total, 87% (n = 135) had previously had a smear test, and 67% (n = 105) correctly identified that cervical cytology was performed to identify precancerous changes. The practice of annual gynecological checkups was prevalent, and many believed it to be synonymous with cervical screening. Detailed knowledge of human papillomavirus (HPV) infection and the HPV vaccine was deficient, although 73% (n = 115) and 70% (n = 90), respectively, claimed to have heard of them. Negative attitudes existed regarding the HPV vaccine due to fear of potential side effects. On learning that HPV was transmitted through sexual contact, the notion of testing positive for HPV was met with shame and embarrassment. CONCLUSIONS: A small proportion of Latvian women are over-screened, whereas many women remain unscreened. The main contributing factor for this was their poor understanding of the roles that cervical screening and HPV vaccination play in preventing CC.

Human papillomavirus vaccination: The ESGO-EFC position paper of the European society of Gynaecologic Oncology and the European Federation for colposcopy.

Vaccines against human papillomavirus (HPV) are available in Europe since 2006. They have been highly effective in preventing infection and disease caused by the vaccine types. Clinical efficacy data are available for cervical, vulvovaginal and anal precancer and invasive cervical cancer. Disease reduction is best with early vaccination and a coverage of more than 70%. Gender-neutral vaccination provides direct protection for all men and improves the coverage. A good coverage is followed by herd protection of the unvaccinated men and women. School-based programs appear to be most effective; under the age of 15 years, two doses with an interval of 6-12 months are sufficient. From the age of 15 years, the standard regimen with three doses is recommended. A broad catch-up program for young adult women and men improves the effectiveness. The vaccines are also effective in sexually active women and men with previous but cleared infections. Vaccination in addition to local treatment of HPV-related disease appears to reduce recurrent or subsequent HPV-related disease. Combination of HPV vaccination and screening with HPV testing is the most effective approach to prevention of cervical cancer. The screening intervals may increase in the vaccinated cohorts. The upper age limit for vaccination remains to be evaluated, is country specific and depends on cost-effectiveness. The European Society of Gynaecologic Oncology and the European Federation for Colposcopy strongly support gender-neutral vaccination programs for children and young adolescents, with a catch-up program for young adults.

2017 update of the European Federation for Colposcopy (EFC) performance standards for the practice of colposcopy.

A refinement of quality indicators (QIs) is described whereby the quality of care can be measured across colposcopy services in different countries and healthcare settings. A five-round Delphi process was conducted at successive satellite meetings from 2011 to 2015 of leading European colposcopists to refine the most high-scoring QIs relevant to colposcopic practice. A review and refinement of the wording of the standards and their criteria was undertaken by national society representatives. Six quality indicators were identified and refined. "Documentation of whether the squamocolumnar junction (SCJ) has been visible or not" was changed into "for cervical colposcopy transformation zone (TZ) type (1, 2 or 3) should be documented". The standard "percentage of cases having a colposcopic examination prior to treatment for abnormal cytology" was changed to "percentage of cases having a colposcopic examination prior to treatment for abnormal cervical screening test". The standard "percentage of all excisional treatments/conizations containing CIN2+ (cervical intra-epithelial neoplasia grade two or worse)" was changed into "percentage of excisional treatments/conizations having a definitive histology of CIN2+. Definitive histology is highest grade from any diagnostic or therapeutic biopsies". The standard "percentage of excised lesions/conizations with clear margins" was unchanged. The remaining two QIs define the minimum caseloads required for colposcopists. However, "cytology" was replaced by "screening results" to acknowledge the introduction of human papillomavirus testing to European screening programmes. Six QIs were identified to define good practice in colposcopy.

Incomplete excision of cervical precancer as a predictor of treatment failure: a systematic review and meta-analysis.

BACKGROUND: Incomplete excision of cervical precancer is associated with therapeutic failure and is therefore considered as a quality indicator of clinical practice. Conversely, the risk of preterm birth is reported to correlate with size of cervical excision and therefore balancing the risk of adequate treatment with iatrogenic harm is challenging. We reviewed the literature with an aim to reveal whether incomplete excision, reflected by presence of precancerous tissue at the section margins, or post-treatment HPV testing are accurate predictors of treatment failure. METHODS: We did a systematic review and meta-analysis to assess the risk of therapeutic failure associated with the histological status of the margins of the tissue excised to treat cervical precancer. We estimated the accuracy of the margin status to predict occurrence of residual or recurrent high-grade cervical intraepithelial neoplasia of grade two or worse (CIN2+) and compared it with post-treatment high-risk human papillomavirus (HPV) testing. We searched for published systematic reviews and new references from PubMed-MEDLINE, Embase, and CENTRAL and did also a new search spanning the period Jan 1, 1975, until Feb 1, 2016. Studies were eligible if women underwent treatment by excision of a histologically confirmed CIN2+ lesion, with verification of presence or absence of CIN at the resection margins; were tested by cytology or HPV assay between 3 months and 9 months after treatment; and had subsequent follow-up of at least 18 months post-treatment including histological confirmation of the occurrence of CIN2+. Primary endpoints were the proportion of positive section margins and the occurrence of treatment failure associated with the marginal status, in which treatment failure was defined as occurrence of residual or recurrent CIN2+. Information about positive resection margins and subsequent treatment failure was pooled using procedures for meta-analysis of binomial data and analysed using random-effects models. FINDINGS: 97 studies were eligible for inclusion in the meta-analysis and included 44 446 women treated for cervical precancer. The proportion of positive margins was 23·1% (95% CI 20·4-25·9) overall and varied by treatment procedure (ranging from 17·8% [12·9-23·2] for laser conisation to 25·9% [22·3-29·6] for large loop excision of the transformation zone) and increased by the severity of the treated lesion. The overall risk of residual or recurrent CIN2+ was 6·6% (95% CI 4·9-8·4) and was increased with positive compared with negative resection margins (relative risk 4·8, 95% CI 3·2-7·2). The pooled sensitivity and specificity to predict residual or recurrent CIN2+ was 55·8% (95% CI 45·8-65·5) and 84·4% (79·5-88·4), respectively, for the margin status, and 91·0% (82·3-95·5) and 83·8% (77·7-88·7), respectively, for high-risk HPV testing. A negative high-risk HPV test post treatment was associated with a risk of CIN2+ of 0·8%, whereas this risk was 3·7% when margins were free. INTERPRETATION: The risk of residual or recurrent CIN2+ is significantly greater with involved margins on excisional treatment; however, high-risk HPV post-treatment predicts treatment failure more accurately than margin status. FUNDING: European Federation for Colposcopy and Institut national du Cancer (INCA).

Defining the Cervical Transformation Zone and Squamocolumnar Junction: Can We Reach a Common Colposcopic and Histologic Definition?

Quality assurance and research in colposcopy and cervical pathology require standardized terminologies and reporting. However, clinical and histologic definitions of the cervical transformation zone (TZ) and squamocolumnar junction (SCJ) vary considerably. We aimed to identify areas of agreement and areas where work is required to standardize the definitions of the TZ and the SCJ. We conducted a survey among the board members of the European Federation of Colposcopy member societies and members of the International Society of Gynecological Pathologists. Overall, 22 expert colposcopists and 34 gynecologic pathologists responded. There was broad agreement that the TZ is the area where squamous metaplasia has occurred. There was consensus that the original SCJ can appear colposcopically indistinct in cases of maturation of the metaplastic squamous epithelium but can be identified histologically by the presence of the so-called last cervical gland. It was agreed that the border between the metaplastic squamous epithelium and the columnar epithelium on the surface of the cervix is called the new SCJ. Areas where work is required include the questions as to whether the cervical crypts lined by columnar epithelium in the field of squamous metaplasia are an integral part of the TZ or not and whether the individual microscopic borders between the metaplastic squamous epithelium of glandular crypts and the residual columnar epithelium of glandular crypts should be considered as part of the new SCJ or not. This paper is a step in an attempt to standardize colposcopic and histologic definitions among colposcopists and pathologists.

Psycho-social influences upon older women's decision to attend cervical screening: A review of current evidence.

Cervical cancer is the fourth most common cancer in women worldwide (WHO, 2016). In many developed countries the incidence of cervical cancer has been significantly reduced by the introduction of organised screening programmes however, in the UK, a fall in screening coverage is becoming a cause for concern. Much research attention has been afforded to younger women but age stratified mortality and incidence data suggest that older women's screening attendance is also worthy of study. This paper provides a review of current evidence concerning the psycho-social influences that older women experience when deciding whether to attend cervical screening. Few studies have focussed on older women and there are significant methodological issues with those that have included them in their samples. Findings from these studies indicate several barriers which may deter older women from screening, such as embarrassment and logistical issues. Drivers to screening include reassurance and a sense of obligation. Physical, social and emotional changes that occur as women age may also have an impact on attendance. This review concludes that there is a clear need for better understanding of the perceptions of older women specifically with regard to cervical cancer and screening. Future research should inform the design of targeted interventions and provision of information to enable informed decision-making regarding cervical screening among older women.

Awareness of HPV infection and attitudes toward HPV vaccination among Latvian adolescents.

OBJECTIVE: To evaluate awareness of HPV and its vaccine among Latvian adolescents. METHODS: A cross-sectional survey was conducted in a 2-week period in September 2015 among 270 adolescents attending a secondary school in Riga, Latvia. All students present during sexual-health classes (grades 10-12 [aged 16-21 years]) were included. A self-administered paper-based survey assessed sociodemographic factors, sexual behaviours, smear history and knowledge of sexually transmitted infections, HPV and HPV vaccine knowledge, and sources of information. RESULTS: Overall, 121 surveys were completed (62 by male students and 59 by female students). Latvian adolescents lacked awareness of HPV: only 26 (21.5%) had heard of HPV (21 [35.6%] female students vs 5 [8.1%] male students; P<0.001) and 12 (9.9%) of the HPV vaccine. Eighty (66.1%) participants felt inadequately informed about HPV. However, the adolescents partook in high-risk behaviours: 70 (57.9%) students were sexually active, 26 (37.1%) of whom had already had three or more sexual partners. CONCLUSION: Despite the high prevalence of HPV in Latvia, poor knowledge about HPV infection among adolescents could explain low uptake of the HPV vaccine by this high-risk population. Therefore, educational strategies that highlight the consequences of HPV could promote acceptance of vaccination.

The Use of the Colposcopically Directed Punch Biopsy in Clinical Practice: A Survey of British Society of Colposcopy and Cervical Pathology (BSCCP)-Accredited Colposcopists.

OBJECTIVES: The colposcopically directed punch biopsy has been an integral component of colposcopic practice. In light of the changing landscape of the cervical screening programme, a study was conducted to investigate the current practice of British Society of Colposcopy and Cervical Pathology-accredited colposcopists on technique and rationale for performing a punch biopsy. MATERIALS AND METHODS: A web-based questionnaire survey was e-mailed to all British Society of Colposcopy and Cervical Pathology-accredited colposcopists. Questions included selection criteria for performing a punch biopsy, number of biopsies, and technique. Results were analyzed by specialty, experience, and workload. RESULTS: A total of 749 colposcopists responded, 50.2% of the 1,493 total. The respondents were obstetrician and gynecologists (42.9%), gynecologists/oncologists (33.6%), and nurse colposcopists (19.8%). Most colposcopists (78.3%) had more than 5-year colposcopy experience and saw in excess of 11 new cases (73.4%) of abnormal cervical cytology/month. Most colposcopists (56%) aimed to take 2 biopsies to diagnose cervical intraepithelial neoplasia, and very few (16.2%) reported routinely taking random biopsies from normal areas of cervix. Looking at the trends in management in the case scenarios, there was a lower threshold for performing punch biopsy before large loop excision of the transformation zone in younger (age, <25 years) or nulliparous women versus older women (age, >40 years; p < .05). Colposcopists were more likely to take biopsies in women with low-grade cytology/colposcopic findings (71.2%, always or most of the times) as compared with high-grade cytology/colposcopic findings (40.3%, never or rarely). CONCLUSIONS: Colposcopically directed punch biopsy is routinely used by colposcopists; however, techniques, number of biopsies taken, and rationale for performing a biopsy vary greatly between colposcopists.