Unilateral inguinofemoral lymphadenectomy in patients with early-stage vulvar squamous cell carcinoma and a unilateral metastatic sentinel lymph node is safe.

OBJECTIVE: Optimal management of the contralateral groin in patients with early-stage vulvar squamous cell carcinoma (VSCC) and a metastatic unilateral inguinal sentinel lymph node (SN) is unclear. We analyzed patients who participated in GROINSS-V I or II to determine whether treatment of the contralateral groin can safely be omitted in patients with a unilateral metastatic SN. METHODS: We selected the patients with a unilateral metastatic SN from the GROINSS-V I and II databases. We determined the incidence of contralateral additional non-SN metastases in patients with unilateral SN-metastasis who underwent bilateral inguinofemoral lymphadenectomy (IFL). In those who underwent only ipsilateral groin treatment or no further treatment, we determined the incidence of contralateral groin recurrences during follow-up. RESULTS: Of 1912 patients with early-stage VSCC, 366 had a unilateral metastatic SN. Subsequently, 244 had an IFL or no treatment of the contralateral groin. In seven patients (7/244; 2.9% [95% CI: 1.4%-5.8%]) disease was diagnosed in the contralateral groin: five had contralateral non-SN metastasis at IFL and two developed an isolated contralateral groin recurrence after no further treatment. Five of them had a primary tumor ≥30 mm. Bilateral radiotherapy was administered in 122 patients, of whom one (1/122; 0.8% [95% CI: 0.1%-4.5%]) had a contralateral groin recurrence. CONCLUSION: The risk of contralateral lymph node metastases in patients with early-stage VSCC and a unilateral metastatic SN is low. It appears safe to limit groin treatment to unilateral IFL or inguinofemoral radiotherapy in these cases.

Sentinel nodes in vulvar cancer: Long-term follow-up of the GROningen INternational Study on Sentinel nodes in Vulvar cancer (GROINSS-V) I.

OBJECTIVE: In 2008 GROINSS-V-I, the largest validation trial on the sentinel node (SN) procedure in vulvar cancer, showed that application of the SN-procedure in patients with early-stage vulvar cancer is safe. The current study aimed to evaluate long-term follow-up of these patients regarding recurrences and survival. METHODS: From 2000 until 2006 GROINSS-V-I included 377 patients with unifocal squamous cell carcinoma of the vulva (T1, <4 cm), who underwent the SN-procedure. Only in case of SN metastases an inguinofemoral lymphadenectomy was performed. For the present study follow-up was completed until March 2015. RESULTS: Themedian follow-up was 105 months (range 0­179). The overall local recurrence ratewas 27.2% at 5 years and 39.5% at 10 years after primary treatment, while for SN-negative patients 24.6% and 36.4%, and for SN-positive patients 33.2% and 46.4% respectively (p = 0.03). In 39/253 SN-negative patients (15.4%) an inguinofemoral lymphadenectomy was performed, because of a local recurrence. Isolated groin recurrence rate was 2.5% for SN-negative patients and 8.0% for SN-positive patients at 5 years. Disease-specific 10-year survival was 91% for SN-negative patients compared to 65% for SN-positive patients (p b .0001). For all patients, 10-year disease-specific survival decreased from 90% for patients without to 69% for patients with a local recurrence (p b .0001).

Young doctors' health--I. How do working conditions affect attitudes, health and performance?

Long hours and other difficult working conditions are thought to affect the health of young doctors, but there has been little evidence to support these assertions. Data are presented from a class cohort of junior doctors in the U.K. showing the relationships between working conditions, health and performance. Long hours appear to have short-term consequences in terms of the doctors feeling unwell and reporting poor performance, as measured by the somatic and social dysfunction scales of the General Health Questionnaire, but there are no demonstrated long-term health consequences. Instead, a number of working conditions, number of emergency admissions, number of deaths on the ward and the number of minor menial tasks contribute to a perception of being overwhelmed, as revealed by factor analysis of the Attitudes to Work questionnaire. This factor correlates significantly with a range of long-term physical and mental health measures as well as measure of work performance.

Young doctors' health--II. Health and health behaviour.

There is little published information on the health of young doctors, apart from a number of studies which show increased rates of psychiatric symptoms. Nor is there much known of their health behaviour. Anecdotal accounts suggest that doctors' own health care is poor, especially in terms of their willingness to consult other doctors. This paper presents data from a longitudinal study of a class cohort of young doctors first interviewed when they were students. Data show that they suffer from frequent minor physical ailments, with women reporting more ailments than men. Despite this, they took less sick leave. Overall, the doctors took very little time off work. Using the GHQ-28, with a threshold of 5/6, 30% of doctors fell into the "caseness" category for psychiatric symptoms. This is in keeping with findings elsewhere. From the doctors' own reported health behaviour, both in terms of their response to illness over the past year, as well as their predicted response to hypothetical illness, they have developed maladaptive patterns. These include continuing to go to work when unfit, self-prescribing, and consulting friends and colleagues rather than going for a formal consultation. This is seen as inappropriate, especially in cases of mental illness. A third of the young doctors are not registered with a local general practitioner and the majority have no clear idea of the role of the Occupational Health Service. The results are discussed in terms of the need to change attitudes to health care and to develop guidelines, staffing and services to enable doctors to take better care of themselves.

Diet of wild chimpanzees (Pan troglodytes verus) at Mt. Assirik, Senegal: I. Composition.

The composition of the diet of a savanna-living population of wild chimpanzees (Pan troglodytes verus) at Mt. Assirik in Senegal is presented. The study site had a prolonged dry season, high temperatures, and vegetation dominated by grasses. Data came from direct observation, fecal specimens, and feeding traces; thus, strict criteria for acceptance of the indirect data were specified. Composition of diet was given in terms of species and family of prey, parts eaten, life-form, type of habitat, and criteria for inclusion. Forty-three species of plants with 60 parts were eaten; mostly fruits, from trees, in woodland. Nine species of animal prey were eaten, mostly social insects. An additional 41 species of plants with 53 parts were classed as likely to be eaten by chimpanzees, mostly on the grounds of their being eaten by sympatric anthropoids. Overall, the diet of the apes at Mt. Assirik resembles that of this species elsewhere in Africa, but the size of the dietary repertoire seems small and the proportion of low-quality foodstuffs high. The latter are mostly time-consuming to collect or tedious to obtain or process, and include underground storage organs.

An introduction to critical paths.

A critical path defines the optimal sequencing and timing of interventions by physicians, nurses, and other staff for a particular diagnosis or procedure. Critical paths are developed through collaborative efforts of physicians, nurses, pharmacists, and others to improve the quality and value of patient care. They are designed to minimize delays and resource utilization and to maximize quality of care. Critical paths have been shown to reduce variation in the care provided, facilitate expected outcomes, reduce delays, reduce length of stay, and improve cost-effectiveness. The approach and goals of critical paths are consistent with those of total quality management (TQM) and can be an important part of an organization's TQM process.

Young dentists--work, wealth, health and happiness.

OBJECTIVE: To determine the relationships between working conditions for new dental graduates and their mental and physical health. DESIGN: A cross-sectional postal survey. SUBJECTS: Graduates from the years 1991 and 1994 were selected to provide cohorts before and after the introduction of mandatory vocational training. A total of 232 graduates were sent questionnaires and 183 replied (77%): 90 men (49%) and 93 women (51%). SETTING: The cohorts came from all Scottish dental schools. When surveyed in 1996/1997, 66% were working in Scotland and 28% were in England. The rest were elsewhere in the UK or abroad. MEASURES: Measures included a wide range of conditions at work: number of patients seen, pace of work, hours worked, attitudes to work, financial arrangements, alcohol consumption, sickness-absence, physical and mental health. RESULTS: There were significant differences between those working in general practice and those in hospital in terms of the hours, numbers of patients seen, feelings of competence and senior support. Methods of payment for treatment in general practice also revealed differences in perception of work: most pressure at work was associated with part NHS and part private funding. Mental health and alcohol consumption were equivalent to age-matched junior doctors, but increased psychological symptoms in female dentists were significantly associated with the number of units of alcohol consumed. CONCLUSION: Selected working conditions are associated with reported competence, stress and health among young dentists.

Careers and patterns of work of Scottish dental graduates: 1991 and 1994.

OBJECTIVE: To describe current patterns of employment, career intentions and factors that influence career choice in young graduates. DESIGN: A cross-sectional postal survey. SUBJECTS: Graduates from the years 1991 and 1994 were selected to provide cohorts before and after the introduction of mandatory vocational training. A total of 232 graduates were sent questionnaires and 183 replied (77%): 90 men (49%) and 93 women (51%). SETTING: The cohorts all came from Scottish dental schools. When surveyed in 1996/1997, 66% were working in Scotland and 28% were in England. The rest were elsewhere in the UK or abroad. MEASURES: A questionnaire which had been piloted, applied to medical graduates and then adapted for dentists, was used. RESULTS: The most common post held was that of Associate in General Dental Practice (61% of the sample) and the majority (85%) were working full-time. Only small numbers indicated that they wished to undertake a career in academia (6) or the hospital dental service (17). In choosing a career, males were more influenced by financial factors (P = 0.009) and women by the availability of part-time employment (P = 0.000). CONCLUSION: Despite the recent adverse publicity about general dental practice, most young dentists see their future in this sector of the profession. More worrying is the comparatively small number who wish to work within the hospital service or in academia. Results also indicate the need to develop schemes to retain women in the workforce.

Postgraduate dental education and the 'new' graduate.

It is notoriously difficult to evaluate educational initiatives. Nevertheless, with the introduction of mandatory vocational training, it seems curious that there has been no formal, structured assessment of whether dental vocational training is perceived as having fulfilled its aims. Nor is there information on how participation in continuing dental education relates to feelings of competence or confidence in clinical practice. This paper reports on the experience of two cohorts of 'new' dental graduates from Scotland and provides evidence to inform the debate on vocational training, general professional training and recertification for the dental profession.

Senior house officers in medicine: postal survey of training and work experience.

OBJECTIVES: To describe working conditions for senior house officers in medicine in Scotland and to relate these to the quality of clinical training they receive. DESIGN: Postal questionnaire survey. SUBJECTS: All senior house officers in medicine and related specialties in post in Scotland in October 1995 (n = 437); 252 (58%) respondents. MAIN OUTCOME MEASURES: Questionnaires covered hours, working patterns, measures of workload, an attitudes to work scale, and experience of education and training. RESULTS: In the week before the questionnaire, doctors on rotas had worked a mean of 7.4 (95% confidence interval 5.8 to 9.0) hours in excess of their contracts, compared with 3.7 (2.0 to 5.5) hours for those on partial shifts. The most common reason for this was "the needs of the patients or the service." Those on partial shifts reported significantly less continuity of care with patients than those on rotas (Mann-Whitney U test, z = -4.2, P < 0.0001) or full shifts (z = -2.08, P = 0.03). Doctors in general medicine reported significantly higher measures of workload (number of acute admissions, number of times called out, and fewest hours' uninterrupted sleep) than those in subspecialties. Consultants' clinical teaching and style of conducting a ward round were significantly related to factors extracted from the attitudes to work scale. CONCLUSIONS: The quality of senior house officers' training is detrimentally affected by a variety of conditions, especially the need for closer support and supervision, the need for greater feedback, and the lack of time that consultants have to dedicate to clinical training. Efforts should be made to improve these conditions and to reinforce a close working relationship between trainee and supervising consultant.

A collaborative effort in using telecommunications to enhance learning.

A consortium of three educational institutions was developed to respond to a possible need for educational programs in the workplace through teleconferencing technology. Based on survey findings, a pilot project of three educational programs was presented. Evaluation of the adequacy of such programming indicated its success in the use of such technology. The effort was unique because there was unprecedented collaboration among nurse executives, nurse educators, the Pennsylvania Nurses Association, the Hospital Association of Pennsylvania, and WITF, the publicly owned telecommunications center.

Nursing care of the elderly person with an acute cardiovascular problem.

Cardiovascular disease is the leading cause of morbidity and mortality of the older person. It is the disease that most frequently causes hospitalization. Patients with cardiovascular dysfunction are generally admitted to an acute care setting, the cardiac care unit. These units provide excellent care to the patient. However, the unique environment poses many potential problems for the older patient. It is very important that careful nursing assessment of needs is made and that a plan of care is individualized for each patient. Throughout the period of immediate care and rehabilitation, it is essential that one nurse be responsible for assuring that all needs are met and that provision is made to assure continuity of care from the hospital to the community. This professional nursing approach will promote successful outcomes and reasonable styles of living for the older cardiovascular patient.

Prime-boost vaccination strategy in women with high-grade, noncervical anogenital intraepithelial neoplasia: clinical results from a multicenter phase II trial.

The objective of this study was to determine the clinical effectiveness of a prime-boost human papillomavirus (HPV) vaccine regimen. A nonrandomized phase II prime-boost vaccine trial was conducted. Women with biopsy-proven anogenital intraepithelial neoplasia (AGIN) 3 were vaccinated with three doses of a recombinant fusion protein comprising HPV 16, E6/E7/L2 (TA-CIN) followed by one dose of a recombinant vaccinia virus encoding HPV 16 and 18 E6/E7 (TA-HPV). Clinical responses were evaluated by serial photographs, symptomatology, and biopsies before and after vaccination. Twenty-nine women were vaccinated; 27 with vulval intraepithelial neoplasia 3 and 2 with vaginal intraepithelial neoplasia grade 3. Clinical responses were seen in five women (17%), with one complete and five partial responses. Fifteen women (62%) had symptomatic improvement. No serious adverse effects were recorded. This is the first trial of a prime-boost vaccination regimen using heterologous HPV vaccines (TA-CIN followed by TA-HPV) in the management of AGIN. Since the prime-boost approach in this cohort offered no significant advantages over single TA-HPV vaccination, there are no further studies planned using this protocol. Future studies are warranted to define responders to immunotherapy.

Higher specialist training--teething problems. Working Minds Research Project.

An interview survey was conducted to ascertain the views of the first cohort of doctors in Scotland completing Higher Specialist Training under the new Calman arrangements. It was intended that this information would influence plans for the future training of Specialists in Scotland, building on strengths and addressing weaknesses. A team of interviewers saw 140 out of the 168 Senior/Specialist Registrars who were due to receive their Certificate of Completion of Specialist Training (CCST) in the year leading to August 1999. The response rate was 83 per cent. The median age of respondents was 34 years (range of 29-51 years), with a third of the cohort being female. Overall the doctors had spent between nine and 13 years in training after graduation with a median of 10 years by the time they entered their final year of higher specialist training. On average, eighteen months had been spent in another specialty. Psychiatry and Surgery stand out as specialties that trainees enter immediately after gaining full registration. Most of the doctors (84 per cent) wish to remain in Scotland for their career posts. Although the majority (69 per cent) plan to work full-time, two thirds of the women said they might or would work part-time in the future. When asked whether they perceived gaps in their clinical training, 39 per cent said they did. No consistent pattern emerged according to the specialty and dual certification did not appear to create difficulties. On balance, the doctors felt as prepared for the role of Consultant as those appointed to Consultant posts five years ago. However, they had experienced both old and new style training and were concerned that the next generation of Specialist Registrars would not be so well prepared and might find the transition from Specialist Registrar to Consultant difficult. The benefits of an explicit and detailed curriculum were recognised but there were doubts expressed as to whether such a structure could be implemented. In craft specialties, doctors felt that it was impossible to acquire the skills and experience to become a competent Consultant within five or six years of higher specialist training. A second major concern is a perceived lack of flexibility under the new training arrangements both in geographical location and in catering to the training needs of individuals. Responses to questions exploring the nature of clinical supervision, appraisal, assessment and mentoring emphasised the fundamental importance of the relationship between supervising Consultant and the trainee. Good supervision, regular appraisal and mentoring are seen as highly desirable and extremely valuable when carried out well. This high standard was not perceived to be the norm. Only one third of the sample felt that they had had a continuing mentor or supervisor throughout the training programme. Trainees have reservations about their annual formal RITA assessments with some feeling that they lack objectivity as far as assessment of their own performance is concerned. They were more positive about the impact of Specialty Committees on the quality of training posts.

Validity of surgical simulation for the assessment of operative skill.

BACKGROUND: Surgical simulators are being promoted as a means of assessing a surgeon's technical skills. Little evidence exists that simulator performance correlates with actual technical ability. This study was undertaken to determine the criterion and construct validity of currently available surgical simulations in the evaluation of technical skill. METHODS: Simulator assessment was carried out on 36 basic surgical trainees, 37 surgically naïve first-year medical students and 16 experienced general surgical consultants. Some 26 trainees and 36 students underwent repeat assessment after 6 months. A previously validated, 19-point technical skill assessment form, based on direct observation of trainee performance in the operating theatre, was also completed by each trainee's supervising consultant. RESULTS: An insignificant or weak correlation was found between simulator performance and both duration of basic surgical experience and consultant assessment of technical skill. Six months of basic surgical training led to an improvement in performance, not seen in an untrained control group, in only one of the six simulations tested. Discrimination between surgically naïve and experienced subjects was only demonstrated, in part, for four of the six tasks. CONCLUSION: The assessment of technical skill needs to be improved. Work is needed to establish the reliability and validity of currently available simulation models before they are formally introduced for high-stakes assessment.

Consultant surgeons' opinion of the skills required of basic surgical trainees.

BACKGROUND: Accurate and appropriate assessment of surgical trainees requires clear determination of the skills needed for surgical competence. This study was designed to identify those skills, rank them in order of importance and translate them into behavioural terms. METHODS: A Delphi technique, using anonymous postal questionnaires, was used. All consultant surgeons in South-East Scotland were asked to identify the skills they expected of surgical trainees. Skills identified were then returned to all consultants for weighting. Differences among specialties in the importance of each item were identified using analysis of variance. RESULTS: The qualities identified fell into five domains: technical skills, clinical skills, interaction with patients and relatives, teamwork, and application of knowledge. Consultants from all specialties gave high weightings to the generic domains of clinical skills, teamwork, and interaction with patients and relatives. CONCLUSION: This study has identified the skills considered necessary by consultant surgeons in Scotland for a successful surgical career. Contrary to expectation, consultant surgeons value many generic skills more highly than technical skills, indicating that they value well rounded doctors, not just those with technical ability. The characteristics identified are being used to develop an assessment tool for use on basic surgical trainees.