Informed consent: exploring surgical residents' beliefs, attitudes and practices.

Patients rely on the knowledge and skill of the physician proposing treatment to relay information and inform their decision-making. In academic medical centres (AMCs), surgical trainees frequently request consent on behalf of an attending surgeon. There is a paucity of knowledge regarding the frequency of this practice and any associated impacts on surgical trainees. This study poses the following queries: (1) Are surgical residents requesting informed consent (IC) while perceiving themselves to possess insufficient knowledge to facilitate the IC process? (2) If yes, what motivates a resident to request IC with inadequate knowledge? (3) Do residents experience an emotional response? (4) What, if any, support mechanisms are sought? Surgical residents in a Canadian urban AMC (n = 38) completed a survey designed to assess how surgical trainees complete the process of IC as well as probe beliefs and attitudes associated with its execution. This study finds that surgical residents frequently seek consent from patients while perceiving themselves insufficiently informed to discuss the risks and benefits of proposed procedures. The majority of participants (82%) indicated that they had personally requested consent while believing themselves inadequately aware of relevant surgical risks. Surgical trainees see this as a significant issue, feel motivated to complete the IC process due to perceived pressures, experience emotional distress and commonly seek collegial support. A cohort of residents from various surgical departments reported requesting IC while possessing inadequate knowledge to inform patient decision-making. Management of this reality could better ensure that the surgical environment both safeguards patients and enhances trainee education.

What is the adequate margin of surgical resection in oral cancer?

OBJECTIVE: The "adequate surgical margin" has always remained an enigma in the minds of head and neck surgeons. This study systematically analyses the impact of the width of the clear surgical margin on survival in oral cancer. STUDY DESIGN: A historical cohort of 277 surgically treated patients with oral cancer were followed for a median period of 36 months. Cox proportional hazard models were used to determine the independent effect of the clear surgical margin, in millimeters, on 5-year survival. RESULTS: Patients with margins of 5 mm or more had a 5-year survival rate of 73% when compared to those with margins of 3 to 4 mm (69%) , 2 mm or less (62%), and involved margins (39%, P = .000). After controlling for confounding variables (age, gender, stage) each 1-mm increase in clear surgical margin decreased the risk of death at 5 years by 8% (HR 0.92; 95% CI 0.86, 0.99; P = .021). Based on this model, patients with positive surgical margins had a 2.5-fold increase in risk of death at 5 years and those with close (

Treatment outcomes in squamous cell carcinoma of the maxillary alveolus and palate: a population-based study.

OBJECTIVE: This population-based historical cohort study evaluates the treatment outcomes of primary squamous cell carcinoma of the maxillary alveolus and hard palate. METHODS: A historical cohort of 37 cases of previously untreated biopsy-proven squamous cell carcinoma of the upper jaw registered in the Province of Manitoba from January 1975 to January 2004 was analyzed. RESULTS: The tumor epicenter involved the maxillary alveolus in 26 patients and the hard palate in 11 patients. The mean age of the study population was 72.8 years and 67% were women with a documented tobacco use rate of 50%. Forty-one percent had stage I or II disease, 51% stage III or IV, and 8% could not be staged. Treatment included radiotherapy as a single modality (13.5%), surgery (38%), surgery and radiotherapy (24%), and palliative treatment (24%). Local recurrence was observed in 10 patients with 6 failing at the primary site. The absolute and disease-free survival at 5 years was 33% and 62% respectively. The 5-year disease-free survival was 82% for stage I and II and 48% for stage III and IV (P = .056). No patient treated with radiotherapy as a single treatment modality survived 5 years. Disease-free survival for patients treated with surgery, and surgery +/- radiotherapy, was 69% and 73% at 5 years, respectively (P = .001). CONCLUSIONS: Squamous cell carcinoma of the maxillary alveolus and palate differs from other oral cancers in that the patients are relatively older with a slight female predilection. Treatment with surgery, with or without radiotherapy, appears to improve disease control.

Population-based study of treatment outcomes in squamous cell carcinoma of the retromolar trigone.

BACKGROUND: Carcinoma of the retromolar trigone is relatively uncommon. High rates of local recurrence account for a relatively poor prognosis. STUDY DESIGN: A population-based historical cohort of 76 cases with biopsy-proven squamous cell carcinoma of the retromolar trigone were studied as a case series. Kaplan-Meier survival curves and log rank test were used for statistical analysis. RESULTS: The mean age was 67.2 years. Fifty-six patients were male, 45% had T1 or T2 tumors, and 61% were staged as N0. Treatment included radiotherapy in 35%, surgery alone in 26%, surgery and radiotherapy in 23%, and 16% received palliative treatment. The absolute and disease-specific survivals at 5 years were 51.4% and 67.7%, respectively. In patients treated with surgery, the resection margin status predicted the overall 5-year survival (P = .027), with 75% of patients with negative margins surviving 5 years versus a survival of 0% of patients with involved margins. CONCLUSIONS: Squamous cell carcinoma of the retromolar trigone has a poor survival rate for early-stage disease. Adequate surgical margins can improve survival.

The clinical significance of the positive surgical margin in oral cancer.

The objective of surgical management of squamous cell carcinoma of the oral cavity is adequate resection with a clear margin. This study examines the significance of the positive surgical margin. An historical cohort of 425 patients from the cancer registry of the Province of Manitoba with squamous cell carcinoma of the oral cavity treated with surgery +/-radiotherapy was examined. A Cox's proportional hazard model was used to examine the independent effect of surgical margins on five-year survival. Seventy-two percent of tumors involved the tongue and floor of mouth, and 43% of patients presented with Stage III and IV disease. The 5-year absolute and disease specific survivals were 62% and 74.5% respectively. Survival was related to age >65 years (P=0.0177), T-Stage (P=0.0002), and N-Stage (P=0.0465). Patients with clear margins had a survival rate of 69% at 5 yrs (median survival >60 mos) compared to 58% with close (median survival >60 mos) and 38% with involved margins (median survival 31 mos, P=.0000). After controlling for significant prognostic factors, involved surgical margins increased the risk of death at 5 years by 90% (HR 1.9, 95% CI 1.2,2.9, P=0.0026). The status of the surgical margin is an important predictor of outcome. The surgical margin, in contrast to the other prognostic indicators, is under the direct control of the surgeon.

Accuracy of telemedicine in detecting uncontrolled hypertension and its impact on patient management.

This study was aimed at assessing the diagnostic accuracy of telemedicine among hypertensive patients. This was a cross-sectional analysis of patients attending a hypertension clinic over a year-long study. Patients were seen both by telemedicine and in-person on the same day with order of the encounters randomly determined. A telemedicine system, which utilized phone lines, was employed. For each type of encounter, whether telemedicine (TM) or in-person (IP), clinical data on blood pressure (BP) control as well as physician ordering patterns were collected. Receiver Operator Characteristic (ROC) curves were used to assess the validity of TM as compared to IP in the assessment of uncontrolled hypertension. Sixty-two patients participated resulting in 107-paired visits over the year-long study period. The mean age of the 62 participants was 67.1 +/- 11.4 years; 56.6% were men. ROC curves for detecting elevated mean blood pressure provided an area under the curve (auc) of 0.87 (95% CI, 0.80-0.95). ROC curves for the detection of uncontrolled systolic hypertension provided an auc of 0.86 (95% CI, 0.78-0.93). Telemedicine-determined BP differed slightly, but statistically significant (p < 0.05), from IP assessments. Meanwhile, there was no difference in ordering diagnostic tests or therapeutics detectable between the two encounter types. Telemedicine proved to be a valid means for detecting uncontrolled BP among hypertensive patients.