Consenting Practice of ENT Trainees: To What Extent Is Trainee Involvement Disclosed?

AIM: To assess to what extent ENT trainees disclose their involvement in operations to their patients when obtaining consent. BACKGROUND: It is not clear how the trainees are conducting the consenting process, although it could lead to a medico-legal conflict. DESIGN AND PARTICIPANTS: A 6-question questionnaire was sent via email to 22 ENT trainees in Northern Deanery, and 14 ENT registrars in Yorkshire Deanery. MAIN OUTCOME MEASURES: Seniority of the participants. Disclosure of the main operating surgeon and trainee involvement in the consenting process. Influence of operation complexity in trainee involvement disclosure. RESULTS: The response rate was 69%. Of the respondents, 46% consistently informed patients about trainee involvement in operations. Only 28% felt the complexity of operations influenced their decision to disclose trainee involvement. Subgroup analysis showed there was no statistically significant difference between junior and senior trainees in trainee involvement disclosure. If the trainees informed patients about who the operator would be, it was more likely for them to also disclose their own involvement. Many trainees also felt that the 'no guarantee of a particular surgeon' clause in the National Health Service consent form implied possible trainee involvement even if they did not specify it verbally. CONCLUSION: The rate of trainee involvement disclosure is not related to the seniority of trainee or complexity of operations, but is related to operator disclosure. This may suggest trainee involvement disclosure is not dependent on the level of confidence of trainees but on the approach and attitude towards the consenting process.

Is POSSUM predictive of morbidity and mortality in laryngectomy patients?

OBJECTIVES: To test the validity of the comparative audit tool of POSSUM (Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity) against a cohort of 92 consecutive laryngectomies at a major tertiary referral centre for head and neck cancer. The major outcome measurements were 30-day mortality rates, formation of a pharyngo-cutaneous fistula, and length of hospital stay. METHODS: By means of a prospective and retrospective case note analysis. RESULTS: No significant difference between the mean POSSUM morbidity scores of those patients who did, or did not develop a fistula, was found (p=0.535, 95% C.I. -4.36 to 8.33). No significant correlation was observed between POSSUM predicted morbidity and bed occupancy [r=0.137 (95% C.I. -0.070 to 0.334)]. The Portsmouth POSSUM equation for mortality however did accurately predict the mortality rate (observed to expected ratio of 1.05). CONCLUSION: The authors propose that whilst there are many similar factors linked to mortality between cohorts of general surgical and head and neck patients, there are several highly specific risk factors in open surgery of the upper aero-digestive tract in the head and neck which are linked with wound breakdown and morbidity which are omitted from the POSSUM scoring system. The authors warn against the use of this comparative audit tool in its current state for such surgical procedures and recommend the creation of a specific POSSUM for head and neck cancer surgery.

Raman spectroscopy in head and neck cancer.

In recent years there has been much interest in the use of optical diagnostics in cancer detection. Early diagnosis of cancer affords early intervention and greatest chance of cure. Raman spectroscopy is based on the interaction of photons with the target material producing a highly detailed biochemical 'fingerprint' of the sample. It can be appreciated that such a sensitive biochemical detection system could confer diagnostic benefit in a clinical setting. Raman has been used successfully in key health areas such as cardiovascular diseases, and dental care but there is a paucity of literature on Raman spectroscopy in Head and Neck cancer. Following the introduction of health care targets for cancer, and with an ever-aging population the need for rapid cancer detection has never been greater. Raman spectroscopy could confer great patient benefit with early, rapid and accurate diagnosis. This technique is almost labour free without the need for sample preparation. It could reduce the need for whole pathological specimen examination, in theatre it could help to determine margin status, and finally peripheral blood diagnosis may be an achievable target.

Detection of synchronous lung tumors in patients presenting with squamous cell carcinoma of the head and neck.

BACKGROUND: Screening for synchronous pulmonary tumors in patients presenting with squamous cell carcinoma of the head and neck (SCCHN) is important, because detection may alter subsequent management. METHODS: We conducted a retrospective review, comparing effectiveness of pulmonary screening using thoracic CT or chest X-ray, in 1882 patients presenting with SCCHN. RESULTS: The overall rate of synchronous pulmonary tumors was 4.3%. The number needed to scan, ie, the number of thoracic CTs required to detect 1 pulmonary tumor, is reported for recurrent primary tumors, primary disease load (T and N classification), and individual primary sites. The incidence of pulmonary metastases is related to locoregional disease load while the incidence of bronchogenic carcinoma is sporadic. CONCLUSION: Although it is possible to propose a pragmatic screening protocol for pulmonary metastases, this is not possible for bronchogenic carcinomas. Therefore, we recommend that thoracic CT is used in all cases to screen for coexistent pulmonary pathology.

Surface area of chorionic villi of placentas: an index of intrauterine growth restriction of fetuses.

AIM: Histomorphometric studies of placentas from idiopathic intrauterine growth restricted (IUGR) fetuses as well as normal-weight (control) fetuses were performed to determine surface area of chorionic villi (mostly terminal and few intermediate) using stereological technique. The results were compared to determine the difference in the values of surface area of chorionic villi, and to establish any relationship between placental histomorphometric changes and IUGR. METHODS: Placentas from fifty (50) full-term, uncomplicated deliveries were collected; twenty eight (28) of them were associated with IUGR babies and twenty two (22) were from normal-weight babies. Placental weights and volumes were measured. Pieces of placental tissues were formalin-fixed, processed and embedded in paraffin. Seven-micron sections were cut and stained with HE stain. Histomorphometric and stereological studies were performed. RESULTS: IUGR placental weights and volumes were lower than those of controls. Surface areas of villi of IUGR placentas had a mean of 8.19 m(2) (SD +/- 2.88). For control placentas, the mean was 10.02 m(2) (SD +/- 1.83). The mean value of the surface area of villi of the IUGR group was significantly lower than that of the control group. CONCLUSION: These findings pointed to a defect in the normal interaction between trophoblast and maternal tissue, leading to a reduced surface area of villi. Because the surface area of the villi presents the interface between maternal and fetal circulation, its reduction might be the cause of idiopathic intrauterine growth restriction.

Fine-needle aspiration cytology in a regional head and neck cancer center: comparison with a systematic review and meta-analysis.

BACKGROUND: Fine-needle aspiration cytology (FNAC) is used to diagnose masses presenting in the head and neck region. No systematic review of FNAC in this group has yet been performed. METHODS: A systematic review of the published literature and meta-analysis of data extracted from the included studies were compared with a 10-year review of head and neck FNAC from our institution. RESULTS: Systematic review identified 30 studies; 3459 FNAC aspirates from all head and neck sites were included. Overall results were as follows: sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were 89.6%, 96.5%, 93.1%, 96.2%, and 90.3%, respectively. Two thousand seven hundred two head and neck aspirates were included in our institutional review. Sensitivity, specificity, PPV, NPV, and accuracy were 89.5%, 98.5%, 97.3%, 94.0%, and 95.1%, respectively. CONCLUSION: Meta-analysis and comparative systematic review confirm that FNAC is highly effective in the diagnosis of head and neck masses, with some limitations.