A central review of histopathology reports after breast cancer neoadjuvant chemotherapy in the neo-tango trial.

BACKGROUND: Neo-tAnGo, a National Cancer Research Network (NCRN) multicentre randomised neoadjuvant chemotherapy trial in early breast cancer, enroled 831 patients in the United Kingdom. We report a central review of post-chemotherapy histopathology reports on the surgical specimens, to assess the presence and degree of response. METHODS: A central independent two-reader review (EP and HME) of histopathology reports from post-treatment surgical specimens was performed. The quality and completeness of pathology reporting across all centres was assessed. The reviews included pathological response to chemotherapy (pathological complete response (pCR); minimal residual disease (MRD); and lesser degrees of response), laterality, the number of axillary metastases and axillary nodes, and the type of surgery. A consensus was reached after discussion. RESULTS: In all, 825 surgical reports from 816 patients were available for review. Out of 4125 data items there were 347 discrepant results (8.4% of classifications), which involved 281 patients. These involved grading of breast response (169 but only 9 involving pCR vs MRD); laterality (6); presence of axillary metastasis (35); lymph node counts (108); and type of axillary surgery (29). Excluding cases with pCR, only 45% of reports included any comment regarding response in the breast and 30% in the axillary lymph nodes. CONCLUSION: We found considerable variability in the completeness of reporting of surgical specimens within this national neoadjuvant breast cancer trial. This highlights the need for consensus guidelines among trial groups on histopathology reporting, and the participation of histopathologists throughout the development and analysis of neoadjuvant trials.

General practitioners' attitudes to the development of midwifery group practices.

BACKGROUND: The report Changing childbirth (1993) has led to the development of midwifery-led schemes that aim to increase the continuity of maternity care. AIM: To determine the impact of midwifery group practices on the work of general practitioners (GPs) and their perceptions of midwifery group practice care. METHOD: Postal questionnaires were sent to 58 GPs referring women to the care of midwifery group practices (group-practice GPs), and a shorter questionnaire was sent to the remaining 67 GPs (non-group-practice GPs) within the same postcode area as a comparison group. In-depth interviews were conducted with 12 GPs. RESULTS: Questionnaires were returned by 71% of group-practice GPs and 81% of non-group practice GPs. One third of the group practice GPs felt that they were seeing group practice women too few times, and 50% thought midwives discouraged women from visiting their GP for antenatal checks. Over 80% of group practice GPs believed that midwives had the skills to detect deviation from the normal, and 66% would confidently refer women to their care. However, only 14% of group practice GPs believed that their own role was clear, while 64% agreed that communication with group practice midwives was poor, and concerns were expressed about the level of consultation before establishing schemes. Of the non-group practice GPs, 87% said they would consider referring women to the care of a midwifery group practice in the future. CONCLUSIONS: General practitioners were generally positive about the quality of care provided by midwifery group practices but identified issues that require addressing in developing this model of care.

Quality of midwifery led care: assessing the effects of different models of continuity for women's satisfaction.

BACKGROUND: Changing Childbirth (1993), a report on the future of maternity services in the United Kingdom, endorsed the development of a primarily community based midwifery led service for normal pregnancy, with priority given to the provision of "woman centred care". This has led to the development of local schemes emphasising continuity of midwifery care and increased choice and control for women. AIMS: To compare two models of midwifery group practices (shared caseload and personal caseload) in terms of: (a) the extent to which women see the same midwife antenatally and know the delivery midwife, and (b) women's preference for continuity and satisfaction with their care. METHODS: A review of maternity case notes and survey of a cohort of women at 36 weeks of gestation and 2 weeks postpartum who attended the two midwifery group practices. Questionnaires were completed by 247 women antenatally (72% response) and 222 (68%) postnatally. Outcome measures were the level of continuity experienced during antenatal, intrapartum, and postnatal care, women's preferences for continuity of carer, and ratings of satisfaction with care. RESULTS: The higher level of antenatal continuity of carer with personal caseload midwifery was associated with a lower percentage having previously met their main delivery midwife (60% v 74%). Women's preferences for antenatal continuity were significantly associated with their experiences. Postnatal rating of knowing the delivery midwife as "very important indeed" was associated with both previous antenatal ratings of its importance, and women's actual experiences. Personal continuity of carer was not a clear predictor of women's satisfaction with care. Of greater importance were women's expectations, their relations with midwives, communication, and involvement in decision making. CONCLUSIONS: Midwifery led schemes based on both shared and personal caseloads are acceptable to women. More important determinants of quality and women's satisfaction are the ethos of care consistency of care, good communication, and participation in decisions.

Modelled impacts of badger culling on cattle TB in a real area with geographic boundaries.

As a part of bovine tuberculosis eradication strategy, the Welsh Government has proposed a badger cull in a defined area in and around North Pembrokeshire, and has published information on herd densities and incidence levels within and close to the area. In the present study, three sets of previously published data relating the impact of badger culling inside and around previous culling areas to distances from culling area boundaries have been used to model possible impacts of the proposed cull, taking account of three possible scenarios in which geographic boundaries reduce, to varying extents, adverse effects caused by increased badger movements. For the scenarios considered, the results predict average changes in confirmed herd incidences (CHIs) in the range -15.7 (-29.1 to 1.6 per cent) to -25.3 per cent (-52.2 to 46.1 per cent) over a period of 10 years, comprising average changes in the culling area in the range -26.1 (-34.8 to -14.8 per cent) to -32.6 per cent (-59.6 to 47.6 per cent), and average changes on adjoining land in the range 4.5 (-21.8 to 39.8 per cent) to 7.8 per cent (-16.1 to 38.5 per cent). The overall impacts equate to average reductions in the number of CHIs of between 122 (37 to 187) and 158 (-254 to 304).

Day care after operations for hernia or varicose veins: a controlled trial.

Alternative systems of care after operations for varicose veins or hernia were compared in a total of 360 selected patients, of whom 121 were allocated to be managed in an acute ward for 48 h, 122 in a convalescent hospital for 48 h and 117 to be discharged directly home to the care of the district nursing sister and general practitioner. There were no deaths or major complications. Anaesthetic or surgical problems caused 5 patients (3 convalescent and 2 day care) to be retained in hospital on the day of operation. Minor complications were recorded in approximately one-third of the patients. The majority of these were effectively dealt with by the district nursing sister and only one-third of the complications needed the attention of the general practitioner. Two of the ward patients and 1 of the convalescent patients required readmission to hospital (1 per cent in all). No significant difference was demonstrated in the medical outcome between the three groups after operation. Day care was the most economical of the three systems of care. Inquiry into the patients' opinions elicited the highest proportion of favourable responses in the day care group.

Consumer acceptability of day care after operations for hernia or varicose veins.

The opinions of patients and of caring persons (usually relatives) were sought in this trial of different methods of providing care for 360 patients after operations for hernia or varicose veins. Analysis of patients' opinions suggested that day care was the most acceptable of the three types of care examined. The reactions of caring persons did not reveal any major criticisms or disadvantages.

Economic aspects of day care after operations for hernia or varicose veins.

In a trial of 360 patients with hernia or varicose veins, day care surgery provided an economic alternative to the provision of surgical aftercare either in the surgical wards of a district hospital or in a convalescent hospital. There was only slightly more work for general practitioners. Most of the additional work for the community services was carried out by district nurses, with an average contact time in the postoperative period of 325 minutes for day care patients, compared with 186 minutes and 204 minutes respectively for patients admitted for 48 hours to the surgical or convalescent wards. Day care produced estimated savings of 30 pounds compared with the costs of a 48-hour stay in the surgical wards, and savings of 22 pounds compared with a 48-hour stay in the convalescent wards.