Potential no man's land for the 4th year dental graduate.

The Royal College of Surgeons of England stipulates that to hold a substantive specialty or associate specialist (SAS) grade post a person must be a minimum of 4 years post-graduation and have at least 2 years' experience in their chosen speciality. We have noticed an increasing number of excellent applications for specialty doctor adverts posted by our trust without the necessary 4 years of post-graduate experience. Many of these applicants who do not comply with the RCS stipulations may be forced to take a job outside of their chosen career path. The reasons for this may be multifactorial, but it could have a worrying impact on their own future career and hospital service provision. We looked at the number of SAS grade adverts placed on NHS jobs in the year 2019 and the type of job advertised. We also considered the possible reasons for a rise in the number of applicants for SAS roles in oral surgery and oral and maxillofacial surgery, and what changes, if any, could be made to support this group of clinicians.

Conserving resources in the diagnosis of intraoral fibroepithelial polyps.

Fibroepithelial polyps (FEPs) are common, benign intraoral lesions that tend to develop slowly at predictable sites, often in response to local irritation or trauma. Historical precedent often results in referral to oral and maxillofacial surgery (OMFS) departments for biopsy, often irrespective of symptoms, and histological assessment. OMFS and pathology services are struggling to cope with an increasing workload that will potentially lead to widespread delays to diagnosis and treatment. Over the past 20 years, clinical pathways and guidance have been developed to ensure that healthcare interventions, such as the removal of third molars, tonsils, skin tags, and benign moles, are evidence-based, have a net patient benefit, and ensure the best use of finite NHS resources. However, no such guidance exists for intraoral lesions and we regard this as an oversight. We analysed the removal of 682 FEPs over a seven-year period and report sensitivities of 92.4% for a "confirmed clinical suspicion of an FEP" and 99.7% for a "confirmed clinical suspicion of a benign diagnosis". The incidence of non-benign disease was 0.3%. Primary care dentists should be able to diagnose and monitor FEPs and refer only if symptoms are serious or in high-risk patients or sites. Adopting this practice across the UK could free up to 1825 four-hour OMFS clinics, 405hours of consultant histopathologists' time, and recurring savings to the NHS estimated to be in the region of £620 000/annum. We believe that the removal of FEPs should be reclassified as an "intervention not normally funded", and the time and resources put to better use treating patients with lesions of questionable pathology.

Use of a dermal regeneration template and full-thickness skin grafts to reconstruct exposed bone in the head and neck.

Soft tissue defects over bone are difficult to reconstruct and this is compounded when there is no periosteum. We present what is to our knowledge the first reported use of a dermal regeneration template (Integra®, Integra Life Sciences Corp, Plainsboro, NJ, USA) to assist in reconstruction over an exposed mandible.

Malignant cutaneous adnexal tumours of the head and neck: an update on management.

Adnexal tumours form a heterogeneous group of relatively rare neoplasms. Many of them have a poor prognosis and treatment can sometimes be difficult and controversial. We summarise the latest publications relating to malignant cutaneous adnexal tumours of the head and neck, and give an update on their management. We discuss Merkel cell carcinoma and other rare malignant adnexal tumours including dermatofibrosarcoma protuberans and atypical fibroxanthoma.

The metastatic potential of head and neck cutaneous malignant melanoma: is sentinel node biopsy useful?

Results from a large multicentre trial suggest that sentinel lymph node biopsy examination may benefit disease-free survival in patients with cutaneous malignant melanoma of intermediate thickness, but this is controversial. We recorded the outcomes of patients with these lesions in the head and neck with specific reference to regional lymph node metastases, to find out whether routine sentinel lymph node biopsy examination would have been beneficial. We reviewed pathology databases, multidisciplinary outcomes, and notes for all patients managed by a regional melanoma service between 2004 and 2009, and recorded key characteristics of the tumours. Details on patients with malignant melanoma of intermediate thickness (1.2-3.5mm) were further analysed for the development of nodal metastases in the neck over a 3-year postoperative period. We compared our data with the rate of predicted nodal metastases generated from the trial. Of 132 patients with malignant melanoma of the head and neck, 33 (25%) had lesions of intermediate thickness, and nodal metastases developed in only one. The remaining 32 remained free of neck disease during the study period. Although trial data predicted that 16% (n=5 in this sample) would show signs of metastasis and require neck dissection, on the basis of our data, practice in our unit will not change. Sentinel node biopsy examination for melanoma remains controversial because the natural history of metastatic spread of disease is not fully understood.

Can telehealth deliver for rural Scotland? Lessons from the Argyll & Bute Telehealth Programme.

Policy-makers consider telehealth to be a potential solution to delivery of care in rural Scotland. Telehealth can support patients in the community and may reduce emergency admissions to hospital. The Argyll & Bute telehealth initiative, which commenced in 2007, trialled home telehealth monitoring of patients with chronic obstructive pulmonary disease (COPD), and community- and surgery-based monitoring of general wellbeing and hypertension. An evaluation in 2010 assessed staff and patient satisfaction by questionnaire, impact on hospital and general practice attendance by case record review and detailed opinions on the programme by qualitative interviews with key staff. Home monitoring for COPD was associated with high levels of patient satisfaction and a reduction in hospital admissions and other health service contacts. Delays in implementation and some technical challenges compromised evaluation of the surgery and community initiatives. Patients and staff were generally enthusiastic but also identified potential barriers to development. This paper describes the implementation and outcomes of the initiative and identifies issues that clinicians embarking on telehealth programmes must consider: technical factors; governance and security; staff profiling and training; clinical outcomes; and scalability.

More than health: the added value of health services in remote Scotland and Australia.

Health services are suggested to contribute to remote communities in the ways that extend beyond healthcare delivery. This international multiple case-study research provides qualitative evidence of the social, economic and human contributions (the 'added-value') that may be lost should remote communities lose in-situ health provision. We present a typology of added-value contributions that differentiates institutional aspects (residing in buildings, or embodied in the specific status, capabilities and skills of health professionals) and individual aspects (attributable to health professionals' unique personalities and choices). This typology has relevance for communities, policymakers and managers when considering the impacts of potential service changes.

The clinical effectiveness and cost-effectiveness of computed tomography screening for lung cancer: systematic reviews.

OBJECTIVES: The aim of this review is to examine the clinical and cost-effectiveness of screening for lung cancer using computed tomography (CT) to assist policy making and to clarify research needs. DATA SOURCES: Electronic databases and Internet resources. REVIEW METHODS: A systematic review was undertaken and selected studies were assessed using the checklists and methods described in NHS Centre for Reviews and Dissemination (CRD) Report 4. Separate narrative summaries were performed for clinical effectiveness and cost-effectiveness. Cost-effectiveness analysis resulting in a cost per quality-adjusted life-year was not feasible, therefore the main elements of such an appraisal were summarised and the key issues relating to the existing evidence base were discussed. RESULTS: Twelve studies of CT screening for lung cancer were identified, including two randomised controlled trials (RCTs) and ten studies of screening without comparator groups. The quality of reporting of these studies was variable, but the overall quality was adequate. The two RCTs were of short duration (1 year) and therefore there was currently no evidence that screening improves survival or reduces mortality. The proportion of people with abnormal CT findings varied widely between studies (5-51%). The prevalence of lung cancer detected was between 0.4% and 3.2% (number need to screen to detect one lung cancer = 31-249). Incidence rates of lung cancer were lower (0.1-1% per year). Detection of stage I and resectable tumours was high, 100% in some studies. Adverse events, as a result of investigation or surgery, or the screening process per se were poorly reported. Incidental findings of other abnormalities requiring medical follow-up were reported to be as high as 49%. Six full economic evaluations of population CT screening programmes for lung cancer were included in the review. The magnitude of cost-effectiveness ratios reported varied widely. None was set in the UK and generalisation was complicated by wide variation in the data used in different countries and a paucity of UK data for comparison. All six made the fundamental assumption that screening with CT for lung cancer reduced mortality. At the current time, there is no evidence to support that assumption. In the absence of evidence of health gains from screening for lung cancer, in terms of either quantity or quality of life, and faced with a range of uncertainties, from the frequency of abnormal screening findings within a population to the natural history of screening detected lung cancers, it is not feasible at the current time to develop accurately and meaningfully an economic argument for CT screening for lung cancer in the UK. For subgroups, in particular certain occupational groups, there is evidence of increased risk of lung cancer, but the role of screening has not been demonstrated by the current studies. CONCLUSIONS: The accepted National Screening Committee criteria are not currently met, with no RCTs, no evidence to support clinical effectiveness and no evidence of cost-effectiveness. RCTs are needed to examine the effect of CT screening on mortality, either with whole-population screening or for particular subgroups; to determine the rate of positive screening and detected lung cancers. Research is also needed to understand better the natural history and epidemiology of screening-detected lung cancers, particularly small, well-differentiated adenocarcinomas; as well as the impacts on quality of life. Increased collection is needed of UK health service data regarding resource use and safety data for lung cancer management and services. Research is also needed into the feasibility and logistics of tracing people who have in the past worked in industry where there was exposure to lung carcinogens.

Screening for abdominal aortic aneurysm in a geographically isolated area.

BACKGROUND: Screening for abdominal aortic aneurysm has been shown to reduce aneurysm-related mortality, but the applicability of the results to the whole of the UK has been questioned. This study examined screening in a remote and rural area. METHODS: Over 3 years, men aged 65-74 years were offered screening in the community by ultrasonography, usually in general practitioner surgeries. Men with an aneurysm were rescanned at intervals or assessed for surgery. The screening and hospital costs of the programme were calculated. RESULTS: Some 9323 men were offered screening of whom 8355 (89.6 per cent) attended. Uptake was high in all areas. A total of 430 scans (5.1 per cent) were abnormal; 40 men had an aneurysm greater than 55 mm in diameter. Twenty further men had an aorta that enlarged to greater than 55 mm during follow-up. A total of 54 men had elective repair with one death (mortality rate 2 per cent). The cost of screening alone was 16 pound per invitation and the overall cost of the programme, including surgery, was 58 pound per invitation. CONCLUSION: Screening for abdominal aortic aneurysm can be carried out in a remote and rural area with high uptake, acceptable clinical results and at no greater cost than in more densely populated areas.

Rural health care in the U.K.: a rapidly changing scene.

Delivery of medical, nursing, and other health-related services in remote and rural areas is challenging. Historically, in the U.K., rural health care delivery has focused on medically qualified general practitioners or family physicians providing primary care services, together with isolated small hospitals providing limited specialist services such as surgery, obstetrics, and internal medicine. However, three recent developments in Europe and the U.K. will change these traditional practices. These are implementation of the European Working Time Directive, constraints related to "clinical governance", and a new contract for general medical practitioners. Delivery of services in rural areas currently faces potential conflict between national standard setters and local practicalities, and re-design of services is required. Public engagement with redesign is essential, but the outcome may be dependent on the methods used. Evaluation of new services is essential. This article gives brief examples of: two public engagement processes (a survey and a discrete choice experiment), two redesign experiments related to screening for aortic aneurysm and consultant-supported care in an island hospital, and some issues concerning the use of new technologies (telemedicine and telephone triage) in remote communities. Future implications are discussed.

Deprivation, smoking, and quality of life in asthma.

AIMS: To explore associations of deprivation and smoking, with prevalence of asthma, wheeze, and quality of life. METHODS: Survey, using International Study of Asthma and Allergies in Childhood (ISAAC) methodology, of children aged 13-14 years attending Scottish schools previously surveyed in 1995. RESULTS: 4665/5247 (89%) pupils completed questionnaires. 3656/4665 (78.4%) had missed school for any reason in the last 12 months, 587 (12.6%) because of asthma or wheeze. Compared to children with 1-3 wheeze attacks per year, those with >12 attacks in the last year were more likely to have missed school, twice as likely to have missed physical education in the last month, to report interference with home activities, or to have visited accident and emergency departments, and three times more likely to have been hospitalised. Deprivation was not independently associated with self-reported asthma or wheeze, but was associated with school absence, either for any reason or specifically for asthma or wheeze, but not with use of services such as accident and emergency visits, doctor visits, or hospital admissions. Active smoking was associated with wheezy symptoms, and active and passive smoking with use of medical services. These associations were independent of wheeze severity, treatment taken, and other associated atopic conditions. Smoking also had an impact on school absence and home and school activities. CONCLUSIONS: Deprivation does not affect the prevalence of asthma or wheeze. Exposure to cigarette smoke was associated with the increased use of services. Deprivation and smoking have independent adverse effects on the quality of life in subjects with asthma or wheeze.

Consultant supported intermediate care--a model for remote and island hospitals.

INTRODUCTION: Providing local consultant-delivered hospital services in remote and island communities in the United Kingdom is increasingly problematic due to difficulties with recruitment and retention of staff, statutory restrictions to hours worked by health professionals and the expectation each clinician must manage an externally defined volume of cases to maintain clinical standards. This article describes a before-and-after evaluation of a novel method of providing consultant support for acute internal medicine to an island grouping off the Scottish coast. Under the scheme, local GPs provided acute medical care of inpatients. A consultant general physician was appointed in a district general hospital on the mainland, approximately 100 miles from the island group, to provide a lead clinician role for inpatient services at the island hospital, visiting the island on a twice-monthly basis, undertaking educational sessions and developing local guidelines and care pathways for the management of individual medical conditions. In addition, two junior doctors were appointed to the island hospital to support inpatient care. METHODS: A prospective recording system for case mix was established with agreed evidence-based protocols, developed as integrated care pathways (ICP), for indicator conditions. General case mix was determined during two 6-month periods, June-November 2001 and June-November 2002, before and after implementation of the new arrangements. Performance against an ICP for management of suspected cardiac chest pain was evaluated in detail, examining the process of management, clinical outcome and economics. Data from the clinical literature were used to estimate the potential health gains from observed changes in clinical practice. RESULTS: Total admissions rose by 25% in the second time period, with particular increases noted for cardiovascular, cerebrovascular disease, and cancer. Total air ambulance transfers between the islands and the mainland within these time periods increased by 31%, from 88 to 115 transfers. Recording specific details from the history and frequency of appropriate blood investigations increased and initial steps in management changed considerably after introduction of the ICP. The number of transfers to the mainland teaching hospital increased from 3/37 (8%) in 2001 to 15/56 (27%) in 2002. Based on an estimated 100 patients per year, of whom 15 would receive thrombolysis, total additional patient costs would be 64,000 pounds sterling. The annual cost of the additional resource input into the medical service was 148,000 pounds sterling. Approximately 16 adverse events would be avoided at a combined cost of 212,000 pounds sterling (148,000 pounds sterling direct costs of intervention + 64,000 pounds sterling additional treatment costs) or 13,250 pounds sterling per event avoided. This is a conservative estimate of benefit as all the direct costs of the intervention have been included. CONCLUSIONS: This study shows that appropriate standards of care can be delivered in the setting described. Costs of care increased, but the level of service provided increased concomitantly, and the health benefits were achieved at costs that compare favourably with other interventions recommended by health technology assessment groups. An estimate of notional costs involved in alternative models for the delivery of hospital medical services in a remote area suggests that costs would be similar for a three-consultant service, the present model, and a triage and transfer system. In the future, the models chosen by remote and island communities and healthcare providers are therefore likely to be determined by viability, sustainability and public acceptability rather than cost. Our study indicates that consultant supported intermediate care is a viable model.

Relationship between birth weight and adult lung function: controlling for maternal factors.

BACKGROUND: There is conflicting evidence on the "fetal origins hypothesis" of association between birth weight and adult lung function. This may be due to failure to control for confounding maternal factors influencing birth weight. In the present study access to birth details for adults aged 45-50 years who were documented as children to have asthma, wheezy bronchitis, or no respiratory symptoms provided an opportunity to investigate this association, controlling for maternal factors. METHODS: In 2001 the cohort was assessed for current lung function, smoking status, and respiratory symptoms. Birth details obtained from the Aberdeen Maternity and Neonatal Databank recorded birth weight, gestation, parity, and mother's age and height. RESULTS: 381 subjects aged 45-50 years were traced and tested for lung function; 323 (85%) had birth details available. A significant linear trend (p<0.01) was observed between birth weight and current forced expiratory volume in 1 second (FEV(1)) and forced vital capacity (FVC) values (adjusted for height, age, sex, weight, deprivation category (Depcat), childhood group, and smoking status). This trend remained significant after adjusting birth weight for gestation, parity, sex, mother's height and weight (p = 0.01). The relationship between birth weight and FEV(1) and FVC remained significant when adjusted for smoking history. There was no association between birth weight and current wheezing symptoms. CONCLUSION: There is a positive linear trend between birth weight, adjusted for maternal factors, and lung function in adulthood. The strength of this association supports the "fetal origins hypothesis" that impairment of fetal growth is a significant influence on adult lung function.

Characteristics associated with reported CAM use in patients attending six GP practices in the Tayside and Grampian regions of Scotland: a survey.

OBJECTIVES: To study the nature of CAM use in primary care attenders, the involvement of their NHS healthcare professionals in their CAM care and differences in characteristics between CAM users and non-users. DESIGN: Postal questionnaire for primary care attenders and analysis of practice leaflets. SETTING: Six Scottish GP practices with a range of practice size, CAM provision within practice, deprivation and rurality. RESULTS: Five hundred and fourteen primary care attenders described 1194 incidences of CAM use and gave details about their main therapy. 37% had contact with a practitioner, the rest mainly self-prescribed. The perceived effectiveness of CAM was high. Patients used CAM for a variety of health problems, mainly as an adjuvant to orthodox medicine rather than an alternative. The involvement of the NHS in CAM delivery was small but there is a significant role to ensure patient safety, especially regarding herb-drug interactions. Disclosure rate of CAM use was low. CAM offered options in areas where the provision in the NHS is difficult, including musculo-skeletal and mental health problems. Provision of CAM by the GP is associated with higher CAM use in primary care attenders. CONCLUSIONS: It is recommended that healthcare professionals include patients' use of CAM in history taking and clinical decision making.