Benefits of simulation using standardized patients for training dermatology residents in breaking bad news.

INTRODUCTION: Simulation in healthcare is a rapidly developing teaching method in the training of technical procedures. It is also used to enable caregivers to learn how to inform patients of serious illness and complex health status. However, its use is not widespread in the field of dermatology. This study investigated the utility of simulation as regards disclosing melanoma diagnosis, taking resident physician satisfaction as a primary endpoint. MATERIALS AND METHODS: Fifteen dermatology residents were recruited as trainees. Four scenarios were allocated based on length of residency. An introductory briefing was held prior to the training sessions. Debriefing took place on completion of the diagnosis disclosure consultation. The participants completed questionnaires after the simulation session, after debriefing, and 3 months after the simulation session. The primary endpoint was usefulness of the session felt by trainees several months after the simulation. RESULTS: The majority of participants (93.3%) thought the session helped with stress management, improved their attitude and control over their reaction (86.6%), and improved their communication skills (100%). They rated the usefulness of the simulation at 7.79/10 on average (range: 5-10). DISCUSSION: According to our findings the resident physicians involved, particularly those with the least experience, were satisfied with this type of learning technique. Any difficulties encountered by these residents were brought to light and addressed during debriefing. CONCLUSION: There would appear to be real benefits to be reaped from simulation, whatever the stage of medical training at which it takes place. Simulation should become an increasingly important part of contemporary pregraduate specialty programs.

Interobserver variability of cervical cytology in HIV-infected women.

OBJECTIVES: Our objectives were to determine the reproducibility of cytological specimen interpretation between two pathologists in human immunodeficiency virus (HIV)-infected women (from the VIHGY, ANRS CO17 study of human papillomavirus genital pathology among HIV-positive women) and to analyse the improvement, if any, between conventional and liquid-based cytology (LBC) interpretations. MATERIALS AND METHODS: A sample of all abnormal and 40% of randomly selected normal Papanicolaou (Pap) tests was randomly ordered and read blindly by a second pathologist using the revised Bethesda terminology 2001. For both conventional and liquid-based preparations, unweighted and Cicchetti-Allison-weighted kappa and their 95% confidence intervals (CIs) were calculated. Kappa values were then compared using the Altman rule to classify the reproducibility of cytological specimen interpretation. RESULTS: Two hundred and seventy-seven conventional Pap tests were reviewed, including 79 abnormal and 10 unsatisfactory results. Overall agreement between the two observers was 78%, with an estimated Cicchetti-Allison-weighted kappa of 0.69 (95%CI, 0.61-0.77). The corresponding values for the 268 LBCs, including 123 abnormal and two unsatisfactory results, were 84% and 0.82 (95%CI, 0.76-0.87), respectively. The reproducibility of LBC interpretations was significantly higher than that of conventional preparations (P = 0.009) and, for both laboratories, the percentages of unsatisfactory results were significantly lower for LBC. CONCLUSION: In HIV-infected women in the combination antiretroviral therapy era, the strength of agreement was better for LBCs than for conventional preparations, with a lower percentage of unsatisfactory results. When available, LBC should be preferred because of its higher reproducibility.

[Risk factors for incident cervical intraepithelial neoplasia (CIN) among HIV-infected women: a prospective study]. / Facteurs de risque d'acquisition de lésions du col utérin dans une population de femmes infectées par le VIH: étude prospective.

OBJECTIVES: To study risk factors for incident cervical intraepithelial neoplasia (CIN) among HIV-infected women. PATIENTS AND METHODS: Prospective study of a population of 97 HIV-infected women with normal Pap smear at inclusion. RESULTS: Fourteen CIN (diagnosed by colposcopy and confirmed with biopsy) were observed within a median follow-up of 38 months (13 CIN 1, one CIN 2). The incidence of cervical lesions was estimated to be 2%, 7% and 10% respectively at one year, two and three years after inclusion, The time to occurrence was very variable (ranging from 7 months to 6 years) among our patients. No known risk factors, in particular neither the CD4 cell count nor antiretroviral treatment, were identified to be associated with occurrence of CIN in our study population. CONCLUSION: Regardless of their immune status and HIV treatments, extensive and prolonged gynaecological follow up of HIV-infected women remains necessary.

Human papillomavirus infection and anogenital condyloma in bone marrow transplant recipients.

BACKGROUND: Secondary malignant diseases are late complications after allogeneic bone marrow transplantation (BMT). Anogenital lesions associated with human papillomavirus (HPV) infection have been described in renal transplant recipients but not after BMT. HPV types 16 and 18 are strongly linked to the malignant transformation. METHODS: In a series of 238 patients with allogeneic BMT, three had anogenital lesions. We looked for HPV in DNA extracted from embedded tissue to study HPV genotypes, p53 expression, and ploidy. RESULTS: In two patients, HPV sequences were detected. One of them, with giant condyloma, had HPV type 18 and two aneuploid clones, but p53 expression was not found. CONCLUSION: As in solid organ transplant recipients, anogenital condyloma may develop after BMT. Because the oncoprotein of HPV is able to bind and to degrade p53, it may lead to genetic instability, and subsequently to malignant transformation.

[Intraepithelial carcinoma and invasive carcinoma of the vulva, vagina and penis in Ile-de-france. Enquete PETRI on 423 cases]. / Carcinomes intraépithéliaux et carcinomes invasifs de la vulve, du vagin et du pénis en Ile-de-France. Enquête PETRI portant sur 423 cas.

OBJECTIVE: Precancerous and invasive carcinoma of the external genitalia and of the vagina are rare tumors and their incidence is not very well known in the Paris region. The objective of this study was to evaluate the frequency of precancerous and invasive lesions of the vulva, the vagina and the penis as well as their variation according to age. METHODS: A prospective study was conducted implicating private and public pathology laboratories in Paris and the seven departments around. Four hundred and twenty three genital biopsies have been analyzed: 160 from the vulva, 151 from the vagina and 112 from the penis. RESULTS: The mean age of the patients was 45 years. The highest frequency of genital biopsies was similar for the three anatomical sites and concerned patients of 25-34 years old. intraepithelial neoplasias represented 77p. 100 of the biopsies (32p. 100 of low grade and 45p. 100 of high grade), invasive squamous carcinoma and adenocarcinoma represented 21p. 100 and 2p. 100 of cases, respectively. The mean age of the patients with low grade vulvar intraepithelial neoplasia, low grade vaginal intraepithelial neoplasia and low grade penile intraepithelial were 34, 40 and 33 years old, respectively. An interval of three to seven years separates the mean age of low grade intraepithelial neoplasia from the mean age of high grade. High grade intraepithelial neoplasia present a peak of frequency in the same class of age for the three localizations (25-34 years) and the risk of developing a high grade intraepithelial neoplasia of the external genital was higher between 25 and 35 years and between 35-45 years of the vagina. The mean age of invasive vulvar carcinoma, vagina carcinoma and penile carcinoma was 62, 59 and 68 years old, respectively. CONCLUSIONS: The correlation between the development of intraepithelial neoplasia of the vulva and the penis supposes a common aetiologic factor in the majority of the cases. The diagnosis of a intraepithelial neoplasia implies a clinical, colposcopic and follow-up of the entire genital area.

[Guidelines for the evaluation of internal quality control of smears for screening of uterine cancer in France in the structures of Pathologic Anatomy and Cytology. French Association for Quality Assurance in Pathologic Anatomy and Cytology (AFAQAP)--Commission for cervical smears]. / Recommandations pour l'évaluation de qualité interne des frottis de dépistage du cancer du col utérin en France dans les structures d'Anatomie et Cytologie Pathologiques. Association Française pour l'Assurance de Qualité en Anatomie et Cytologie Pathologiques (AFAQAP)-Commission Frottis du col utérin.

A national organized mass-screening effective programme is the only way to reduce the risk of cervical cancer, if properly organized and correlated with a system of Quality Assurance. Since 1900, an Association for Quality Assurance was created by the French pathologists, named "AFAQAP". These pathologists thus demonstrated their interest in this kind of action that should be effective if women and clinicians are also implied. The pathologists have concluded the first part of their programme with these French guidelines for internal quality control of pap smears.

[Precancerous and cancerous involvement of the uterine cervix. Results of a survey conducted by the "Genital Cancers" group of Ile-de-France, May 1990-May 1992, based on 8,805 biopsies]. / Pathologie précancéreuse et cancéreuse du col de l'utérus. Résultats d'une enquête conduite par le groupe "cancers génitaux" de PETRI, dans la région Ile-de-France, de mai 1990 à mai 1992, et portant sur 8,805 biopsies.

Results of a study conducted by the "cervix cancer group" of PETRI, in Ile-de-France, from May 1990 to May 1992, and based on 8,805 biopsy specimens. In the absence of Cancer Registry in the Ile de France, no reliable data on invasive and preinvasive neoplasia of the cervix are available concerning this area. The aim of this survey, performed between May 15th, 1990 and May 15th, 1992 in 62 laboratories of pathology under the aegis of the Petri Association (Prévention et épidémiologie des tumeurs en Ile-de-France), was to obtain a better knowledge of this pathology, in which one of the major risk factors is the infection of the cervical epithelium by specific types of human papillomavirus. Over the course of these two years, 8,805 biopsy specimens, taken from neoplastic lesions of the cervix, were analyzed. Intra epithelial neoplasia represented more than 90% of the registered lesions. The average age at the time of the diagnosis was 32.4 years for the cases of condyloma, 32.7 years for CIN I, 33.8 years for CIN II, 36.3 years for CIN III, 45.7 years for micro-infiltrative carcinoma and 50.8 years for infiltrative squamous cell carcinoma. The breakdown of the different histological types of lesions is presented for three characteristic age groups (20-25, 30-35, and 60-70 years old). Differences observed in the eight departments belonging to the Ile-de-France are discussed.

[Ulcerative colitis caused by Histoplasma capsulatum in a patient with the acquired immunodeficiency syndrome]. / Colite ulcéreuse à "Histoplasma capsulatum" chez un patient atteint d'un syndrome d'immunodépression acquise (SIDA).

The authors report a case of ulcerative colitis due to Histoplasma capsulatum in a previously healthy 35 year-old french geologist with acquired immune deficiency syndrome (AIDS). Gomori-Grocott and PAS stains and indirect immunofluorescence revealed Histoplasma capsulatum in colonic biopsies. The search for LAV antibody was positive. T-lymphocyte analysis revealed 10/mm3 OKT4 with OKT4/OKT8 ratio of 0.16. Histoplasmosis should be considered in subjects with ulcerative colitis according to the epidemiological context. In patients with AIDS relapses after discontinuation of treatment are to be expected and suppressive therapy with an imidazole derivative should probably be continued indefinitely.