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The new study fective when treating patients with low back pain and by Manchikanti et al (232) is a publication of the 2-year sciatica. Caudal epidural injections containing steroid results of previous publications (237,834). The (232,237,834) as illustrated in Table 6 assessed the ef number of patients included in this study was small, fectiveness of caudal epidural injections in axial or dis confounding the results further. This study, utilizing 120 patients, 60 of Of the 7 randomized trials meeting inclusion them receiving local anesthetic and the other 60 receiv criteria evaluating caudal epidural steroid injections ing local anesthetic with steroid, followed a practical (233,773,775-780), only 4 of them evaluated long-term approach repeating the procedures only when the pain results (773,775-778). Further, this study also outcomes (233,773,775-778) with 87 patients receiving utilized controlled comparative local anesthetic blocks, local anesthetic with steroids (233,773,776,777) and 60 and excluded facet joint pain and sacroiliac joint pain patients receiving local anesthetic only (233,773,777) prior to starting epidural injections. This study evaluated the results only at the end of one year after providing patients with 2 to 4 epidural injections in the beginning without any repeat injections and without short-term or mid-term follow up. Apart from the 3 studies Parr et al (30) included in the systematic review (236,840-842), the update of central spinal stenosis by Manchikanti et al with 2 year results was identified (235). One retrospective evaluation (841) of one to 3 injections, with limited results available only at one year, which is not ex pected to provide positive results, showed improvement in 35% of the patients, which may be considered positive even though it does not meet the positive criteria of this evidence synthesis. The second non-randomized study (842) showed positive results both in short-term and long-term utilization of local anesthetic and steroids. The studies meeting the inclusion criteria were 2 ran domized trials (234,798,835,843), including one study with 3 publications (234,798,835). One study (234), which was not published at the time of Parr et al’s systematic review (30), is a 2 year follow-up of the study by Manchikanti et al (798,835), with the previous publications included in the systematic review by Parr et al (30). The study also utilized a practical approach in a chronic pain management setting, repeating the injection therapy only with the return of pain. The study showed the results to be superior in patients who were judged to be positive initially. This well conducted study, performed under fluoros copy (234,798,835), included 140 patients with a 2-year follow-up, and showed positive results for both local anesthetic alone and local anesthetic with steroid. In contrast, the second study (843) was of low quality utilizing forceful caudal injections with rather high volumes, which may not only be uncomfortable, but may also be associated with side effects. The sole well conducted randomized trial comparing local anesthetic with ste roids (233,773,777) showed positive results, yielding fair evidence for short and long term relief with local anesthetic only. The common complications are related to either the needle placement or related to the drug activity. These include infection, either local or epidural; abscess; discitis; intravascular injec tion either intervenous or intraarterial with hematoma formation; spinal cord infarction; S78 However, they concluded avascular necrosis of bone, steroid myopathy, epidural that it cannot be ruled out that specific subgroups of lipomatosis, weight gain, fluid retention, and hypergly patients may respond to a specific type of injection cemia (874-878). Armon et al (764) in an assessment of the use neural blockade in the United States, methylpredniso of epidural steroid injections to treat radicular lum lone acetate, triamcinolone acetonide, betamethasone bosacral pain, in a poorly performed evaluation, con acetate, and phosphate mixture, have all been shown cluded that in general, epidural steroid injections for to be safe at epidural therapeutic doses in both clinical radicular lumbosacral pain do not impact the average and experimental studies (878-887). The radiation ex impairment of function, need for surgery, or provide posure is also a potential problem with damage to eyes, long-term pain relief beyond 3 months with a negative skin, and gonads (889). Consequently, opinions for lumbar interlaminar epidural injections the evidence was determined as poor. The old systematic reviews have shown highly dural injections except for radicular pain on a short-term variable evidence for lumbar interlaminar epidural basis (105,112). Tang (857) in describing the efficacy of lumbar epidural Bogduk et al (768) concluded that the results of steroid injections, which also included all 3 approaches, lumbar interlaminar epidural steroids strongly refute showed strong evidence for transforaminal epidural the utility of epidural steroids in acute sciatica. Bogduk steroid injections, but the evidence showed only short (894) updated the recommendations in 1999, recom term efficacy of interlaminar epidural steroid injections mending against epidural steroids by the lumbar route and caudal epidural injections in the management of because effective treatment required too high a num low back and radicular pain. In 1995, Koes et al (763) re bar epidural steroids can be an effective tool in the con viewed 12 trials of lumbar and caudal epidural steroid servative management of low back pain with radicular injections (combined together) and reported positive symptoms. Pinto et al (135) in a recent systematic review results from only 6 studies, concluding that there was and meta-analysis of epidural corticosteroid injections no evidence for epidural steroids in managing lumbar in the management of sciatica, included all types of radicular pain. Their updated review (769) with 15 studies, caudal, interlaminar, transforaminal, and fluo They arrived at the conclusion that based on the dural steroids reported 50% or greater leg pain relief available evidence corticosteroid injections offer only and a positive global perceived effect at one month, short-term relief of leg pain and disability for patients but it was only 50% for those who received saline and with sciatica. However, pla however, they were of smaller size and not statistically cebo in this study is not a true placebo since sodium significant. Landa and Kim (907) in assessing outcomes chloride solution was injected into the epidural space. Among the studies herniation with local anesthetic with or without steroids, using a blind technique without fluoroscopy, 5 were with fluoroscopically guided epidural injections. Placebo con December 2011, we identified 4 more published studies trol was inappropriate in some studies, and most impor (928-931). Others utilized epidural saline, which may epidural injections in managing disc herniation or ra not be appropriate, intramuscular steroid injections, diculitis (239,242,775,799,807,908-919,921) with one or local anesthetic and considered them as placebo duplicate publication (242,799) (Table 9). Placebo effect in clinical studies and their 7 randomized trials were performed under fluoroscopy misinterpretations have been extensively discussed (239,242,775,799,908,918,919,921) and 10 trials per (96,97,111,112,129,236,237,244,250-255,257,798-829). Among the fluoroscopically guided studies, 2 utilized None of the 3 new studies (929-931), assessing ef a total of 100 or more patients (239,242,799). Co one study (242,799) was carried out utilizing a randomized, hen et al (931), in a randomized, multicenter, placebo active-controlled design, providing treatments as needed controlled trial, assessed 84 patients with lumbosacral based on a robust measure of significant improvement radiculopathy administered with 2 epidural injections considered as 50% improvement in pain and function of steroid, etanercept, or saline, mixed with bupivacaine with 120 patients with one and 2-year follow-up with the and separated by 2 weeks. Results showed epidural ste number of injections ranging from one to 5 for one year, roid injections to provide modest short-term pain relief with significantly better results in the successful group, for some adults with lumbosacral radiculopathy. The and performed in contemporary interventional pain man disadvantages of the study include short-term follow agement settings. Among the non-fluoroscopic evalu ations, there were 4 studies with more than 100 patients undergoing interven tions (807,910,912,914). Tables 7 and 8 of the systematic review (31) show characteristics of the included studies. Based on the evaluations separat ing fluoroscopically guided versus non fluoroscopic evaluations, the results were positive for short-term relief in 5 trials performed under fluoroscopy (239,242,775,799,918,919); whereas, they were undetermined or not appli cable in 2 trials (908,921). Among the trials evaluating long-term relief, there were 4 trials evaluating relief of 6 months or longer (239,242,775,799,919) and 2 trials evaluating outcomes for longer than one year (239,242,799). Among these, 4 trials showed positive results (239,242,775,799,919); whereas, in one trial, the results were undetermined or not applicable (921). Among the studies evaluating at least a one year follow-up, 2 trials showed positive re sults (239,242,799); whereas, one trial showed results that were undetermined or not applicable (921). In contrast, with blind randomized trials, the results were highly mixed due to various issues involved. Some of the issues related to providing only one injection or providing injections of 3 in a series and following through with a one-year follow-up. With one injection, one could expect relief of 3 to 4 weeks, however, no more than 3 months. Thus, the follow-up after 3 months does not indicate improvement except for the rare patients who show long-term relief. Overall, of 10 randomized trials with at least moder ate methodological quality, 7 of them showed short-term positive results (909 S84 However, the new study (928) not included in the latest systematic results were uniformly negative after 3 months or not review by Benyamin et al (31). The analysis was per which showed positive results comparing prednisone formed poorly based on an incorrect hypothesis. There were only 69 patients receiving epidural steroid injection; thus, the results may not be applied to 1. Consequently, the study failed to meet inclusion axial or lumbar discogenic pain are illustrated in Table criteria. There were 3 studies meeting the inclusion crite There were 5 randomized trials (244,915, ria (243,800,922,923), with one duplicate (243,800). It included ing the effectiveness of lumbar interlaminar epidural 120 patients with one year follow-up showing posi injections in spinal stenosis. However, none of the well tive results, both with local anesthetic and steroids conducted studies utilized 100 or more patients. There performed in a contemporary interventional pain were 2 randomized trials performed under fluoros management practice. The study by Manchikanti et al (244) were non-randomized; however, they were performed was a preliminary report showing positive results with under fluoroscopy. There were no placebo-controlled local anesthetic as well as steroids for central stenosis trials evaluating axial or discogenic pain. The only in a contemporary interventional pain management randomized trial also excluded facet joint or sacroiliac practice. The other randomized fluoroscopically guid joint pain prior to epidural injections (243,800).

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Colposcopically, three stages of development of squamous metaplasia may be recognized (Coppleson & Reid, 1986). In the earliest stage, the translucence of the columnar epithelial villi is lost and the villi become opaque at their tips; the villi widen and flatten and successive villi fuse in clusters and sheets with a pale pink colour (Figures 6. Consequently the metaplastic epithelium looks like a patchily distributed pale cluster, or sheet-like areas, in the ectopic columnar epithelium. There may be numerous crypt openings and islands of columnar epithelium scattered throughout the metaplastic epithelium. Some crypt openings are Finally, the immature metaplastic epithelium already covered by metaplastic epithelium (c) which may becomes a fully developed mature metaplastic become nabothian cysts soon. Note the distal crypt opening squamous epithelium resembling the original native indicated by the arrow and the pinkish white hue of the squamous epithelium, except for the presence of some metaplastic epithelium compared to the pink colour of the crypt openings (Figure 6. The retention follicles, in the beginning, may appear as white, dot-like, areas before they enlarge with progressive accumulation of mucus within the follicle, presenting as pimple or button-like ivory white or mildly yellowish areas (Figures 1. The typical vessel formations in the metaplastic epithelium include long regular branching vessels with gradually decreasing calibre and a network of regular branching vessels (Figure 6. These vascular patterns may be seen more prominently over the nabothian a follicles (Figure 6. When metaplasia occurs in the epithelium covering the protruding cervical polyp, it is covered by pale a white epithelium (Figure 6. The new squamocolumnar junction has receded into the cervical canal 52 Colposcopic appearance of the normal cervix squamous metaplastic epithelium usually does not stain with iodine or may partially stain if it is partially glycogenated (Figure 6. The vascular features, so easily seen with saline, may be difficult to observe after application of Lugol’s iodine solution. Cervical a polyps do not stain with iodine, as they are usually covered with columnar or immature metaplastic epithelium (Figure 6. If the maturation of the a a metaplastic epithelium varies, one may observe various fields of no uptake or partial to full iodine uptake on the polyp. In postmenopausal women, the ectocervix may not stain fully with iodine, due to atrophy of the epithelium. In this condition, the (narrow arrow) on the polyp with intervening areas of columnar metaplastic epithelium formed during the latter portion epithelium (a), after application of 5% acetic acid. This is helpful in recognize this as a normal condition for which no distinguishing normal from abnormal areas in the treatment is necessary. The columnar epithelium does not will usually take on a mild acetowhite stain and the stain with iodine (Figure 6. It does not take up iodine after to alert the pathologist of the colposcopic diagnosis. If a biopsy is We emphasize that it is always necessary to provide the taken of the tissue to confirm the diagnosis, it is best detailed colposcopic findings to the pathologist. They may be more extensive and complex lesions extending into the endocervical canal. Visualization of one or more borders within an acetowhite lesion or an acetowhite lesion with varying colour intensity is associated with high-grade lesions. This system is useful features: colour tone and intensity of acetowhitening, as a basis for the choice of which area(s) to select for margins and surface contour of acetowhite areas, biopsy. It is essential to biopsy the ‘worst’ area(s) that vascular pattern and iodine staining. Colposcopy with is, the area(s) with the most severe changes in directed biopsy is described as the reference features. It will become obvious during Following application of saline, abnormal epithelium colposcopic practice that considerable skills are may appear much darker than the normal epithelium. The student is encouraged to Using the green (or blue) filter and higher-power obtain biopsies whenever in doubt, and to review the magnification when necessary, the best opportunity to histopathological findings with the pathologist. Close evaluate any abnormal vasculature patterns is before collaboration with pathologists is obligatory and useful the application of acetic acid, the effect of which may in improving one’s diagnostic skills. The terminating process and are not incorporated within the newly vessels in the stromal papillae underlying the thin formed squamous epithelium. Instead, they form a fine epithelium appear as black points in a stippling pattern network below the basement membrane. In mosaic areas, the epithelium 57 Chapter 7 appears as individual small, large, round, polygonal, regular or irregular blocks. When both punctation and mosaic patterns are found to coexist, the same evaluation criteria for colposcopic prediction of disease are used as when they exist separately. Vessels exhibiting punctation and mosaics are usually more strikingly obvious than the normal stromal vessels because these vessels penetrate into the epithelium and are thus closer to the surface. When acetic acid is applied, these abnormal vascular patterns seen to be confined to the acetowhite areas. Fine mosaics are a network of fine-calibre blood vessels that appear in close proximity to one another, as a mosaic pattern, when viewed with the colposcope (Figure 7. Sometimes, the two patterns are superimposed in an area so that the capillary loops occur in the centre of each mosaic ‘tile’. Usually lesions, that are infrequently found on the cervix, but leukoplakia is idiopathic, but it may also be caused by more commonly in the vagina or on the vulva. Condylomatous lesions may have a whorled, heaped-up appearance with a brain not take up iodine stain or may stain only partially like texture, known as an encephaloid pattern (Figure brown. These lesions may be located within, but After the application of 5% acetic acid are more often found outside the transformation zone. A condyloma at the squamocolumnar junction can squamocolumnar junction in the transformation zone sometimes be confused with a prominent area of after application of 5% acetic acid is critical. Both tend to be acetowhite, is the most important of all colposcopic signs, and is the but condyloma is whiter. It is always prudent to obtain hallmark of colposcopic diagnosis of cervical neoplasia. Higher-grade lesions are more likely to turn geographical patterns (resembling geographical dense white rapidly. Abnormal vascular features such as regions) and with irregular, angular or digitating or punctation, mosaicism and atypical vessels are feathery margins (Figures 7. A direct correlation exists between the regular margins, which may sometimes have raised and intensity of the dull, white colour and the severity of rolled out edges (Figures 7. High-grade irregular, elevated and nodular relative to the lesions often tend to involve both the lips (Burghardt et surrounding epithelium (Figures 7. Severe or early malignant lesions the line of demarcation between normal and may obliterate the external os (Figures 7. High-grade lesions tend to have to be less smooth and less reflective of light, as in regular, sharper borders (Figures 7. Visualization of one or more borders within are whiter and wider than the mild, line-like an acetowhite lesion (‘lesion within lesion’) (Figure acetowhite rings that are sometimes seen around 7. They immature squamous metaplasia, the congenital spread centrifugally, pointing away from the external transformation zone, inflammation and healing and os. After application of Lugol’s iodine solution Lugol’s iodine solution is abundantly applied with a cotton swab to the whole of the cervix and visible parts of the vagina. The periphery of the cervix, fornices and vaginal walls must be observed until the epithelium is strongly stained dark brown or almost black by iodine. Normal vaginal and cervical squamous epithelium and mature metaplastic epithelium contain glycogen-rich cells, and thus take up the iodine stain and turn black or brown. Low-grade lesions tend to be thin, less does not stain with iodine and immature metaplasia dense, less extensive, with irregular, feathery, only partially stains, if at all. Atrophic epithelium also geographic or angular margins and with fine punctation stains partially with iodine and this makes and/or mosaic; sometimes, low-grade lesions may be interpretation difficult in post menopausal women. Grading schemes, based tone, margin and surface contour of the acetowhite on these variations may guide the colposcopic diagnosis. The borders are not sharp, with or without fine-calibre vessels (fine punctation and/or fine mosaic), which have ill-defined patterns and short intercapillary distances. There are dilated calibre, irregular shaped or coiled vessels (coarse punctation and/or mosaic).


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Both the talus and calcaneus articulate with the tarsal bones in the junction between hind and midfoot. There are distinctions between ankle and foot, although both ankle and foot may be injured together, and it may be hard in practice (and in the medical literature), to separate ankle and foot injuries. Axially, the ankle mortise is stabilized by ligaments of the syndesmosis and interosseous membrane fibers between the tibia and fibula. The majority of ankle sprains involve only the lateral ligaments, with approximately 15% involving the medial ankle. These injuries usually result from plantarflexion and inversion of the foot with external rotation of the tibia. As the foot twists medially in relation to the lower leg, a progression of tears in a predictable sequence occurs. A systematic review of the natural history of ankle sprains from 31 prospective studies demonstrated rapid decrease in pain and improvement in function over the first 2-weeks post-injury. Up to one-third of patients experience subsequent sprain that appears related to severity of the sprain. However, a significant proportion of persons will continue to have chronic changes from their pre-injury state. Those with recurrent sprain may exhibit ill-defined radiological differences in the talus and decreased ankle stability. This group may have a disproportionate influence of the outcomes in treatment studies. Mechanical testing demonstrates increased laxity of the lateral ankle ligaments in some patients, but many have no objective findings, but still report functional instability related to what is thought to be a proprioception deficit. A prevailing theory is that an alteration of afferent somatosensory information, reflex responses, and efferent motor measures result from destruction or functional alteration of nerve endings in the soft tissue, cartilage, and joints trauma can occur with ankle sprain trauma. Work-Relatedness the incidence of workplace ankle sprain injuries is not well defined, but is reported in one retrospective study as approximately 3% of work related injuries. Initial Assessment the physician performing an initial evaluation of a patient with ankle sprain should seek a discrete diagnosis. The examination generally needs to focus on the bony structures, ligaments, soft tissue, range of motion, and vascular status. Other trauma may be present and the examiner should be alert for other injuries that may have been sustained in the incident. Differential Diagnosis of Acute Ankle Sprain Lateral ligament sprain Medial ligament sprain Syndesmotic injury Physeal fractures Osteochondral fractures Lateral process fracture of the talus Posterior process fracture of the talus Anterior process fracture of the calcaneus Fracture of the base of the fifth metatarsal Fracture of the base of the fifth metaphyseal-diaphyseal junction (Jones Fracture) Peroneal tendon subluxation/dislocation Malleolar fracture Calcaneocuboid joint sprain Medical History the medical history should elicit information to establish the mechanism of injury, severity of forces, and disability immediately following the injury. The examiner should determine if the injury is a result of inversion versus eversion of foot, the position of the foot at the time of injury, and if rotational forces or direct physical trauma was involved. Previous ankle injury should be noted, including duration of symptoms and any residual symptoms at the time of injury. The examiner should seek co-morbidity including osteoporosis, arthritis, movement disorders, diabetes, peripheral vascular disease, seizure disorder and use of seizure medications, and hyperthyroidism as they are risk factors for falls and weakened joints and bones. However, ankle girth on the injured side of 13 to 15mm greater than on the uninjured side, measured around the medial and lateral malleoli, has been reported to have a positive predictive value for detecting fracture of 83%. Ecchymosis on the medial aspect of the ankle along the posterior tibial ligament suggests deltoid ligament rupture. Ecchymosis from the ankle extending proximally to the distal lower leg suggests syndesmotic injury. However, ecchymosis may track subcutaneously, can be widespread, and is not a good indicator of the type or location of an injury unless it is focused. Palpation of the Achilles tendon is performed to rule out other causes of acute ankle pain. The maneuver is performed by grasping the heel in one hand and pulling it forward while stabilizing the tibia with the other. This maneuver is performed by grasping the heel in one hand and the forefoot with the other hand and moving the foot back and forth from eversion (or pronation) to inversion (or supination). Pain and laxity of more than 5 to 10 compared with the uninjured ankle is indicative of ligament injury. The examiner stabilizes the injured leg laterally with one hand, and externally rotates the foot in the horizontal plain. For the squeeze test, the examiner squeezes circumferentially around the syndesmosis. Pain elicited in the anterior ankle with these maneuvers suggests syndesmotic injury or fracture. The ability to take 4 steps on the injured ankle is evaluated as part of the Ottawa Ankle and Foot Rules. Diagnostic Criteria Classification systems for lateral ankle sprain severity are based on physical examination findings and are used to define the extent of ligament injury. According to the West Point Grading System, Grade I sprains are mild, the most common, and require the least amount of treatment and least time to recovery. Most reviewed studies did not indicate specific schema system used for grading injuries, although Gerber(410) (Gerber 98) and Puffer(380) (Puffer 00) summarize the West Point Ankle Sprain Grading System. Activities that require sure footing such as working on irregular or inclined surface, climbing, or jumping should be avoided if © Copyright 2016 Reed Group, Ltd. Accommodation may be requested for protective footwear or use of ankle-brace, which may impact a patient’s ability to drive. Recommendation: Routine Use of Arthrography in Diagnosis of Acute Ankle Sprain the routine use of arthrography is not recommended for evaluation of acute ankle sprain. Recommendation: Routine Use of Arthrography in Diagnosis of Subacute or Chronic Ankle Sprain There is no recommendation for or against the routine use of arthrography for evaluation of subacute or chronic ankle sprain. Strength of Evidence – No Recommendation, Insufficient Evidence (I) Level of Confidence – Low Rationale for Recommendations There are no quality randomized trials evaluating arthrography for ankle sprain. Arthrography was considered the gold standard for identifying ligament and osteochondral defects. The Ottawa ankle rules state that x-ray films are indicated only if there is pain in malleolar zone: 1. The rule also states that x-ray films of the foot are indicated only if there is pain in the mid-foot and there is: 1. Recommendation: Routine Use of X-ray in Assessment of Acute Ankle Sprain There is no recommendation for or against the routine use of x-ray for evaluation of acute ankle sprain when fracture is not suspected. Indications – Suspicion of fracture (but not in the context of a diagnosis of sprain without an associated fracture) or if the history or physical is clinically suspicious for an injury other than an ankle sprain. The presence of acute edema measured at the malleoli >13 to 15mm compared to uninjured ankle may indicate an occult fracture. Recommendation: X-ray in Assessment of Acute Ankle Sprain when Fracture Suspected X-ray in the case of ankle sprain is recommended if fracture is likely and the differential diagnosis reflects suspicion of fracture. Indications – Suspected or encountered fracture (see Fractures section for further guidance). Recommendation: Routine Stress X-ray for Evaluation of Ligament Rupture in Acute Ankle Sprain Routine use of talar-tilt and anterior drawer stress x-ray is not recommended for evaluation of acute ankle ligament rupture. Strength of Evidence – Not Recommended, Insufficient Evidence (I) Level of Confidence – Moderate 4. Recommendation: Routine Stress X-ray for Evaluation of Ligament Rupture in Subacute or Chronic Ankle Sprain There is no recommendation for or against the use of talar-tilt and anterior drawer stress x rays for evaluation of subacute or chronic ankle pain. Strength of Evidence – No Recommendation, Insufficient Evidence (I) Level of Confidence – Low Rationale for Recommendations There are no quality studies evaluating the diagnostic value of x-ray for ankle sprain. Plain films are not required for the diagnosis of acute ankle sprain as x-ray is poor at diagnosing soft-tissue disorders. The use of plain film x-ray rather is utilized for evaluation of accompanying ankle or foot fracture, orientation of fracture plane(s), and magnitude of the involvement of the articular surfaces, which if present may alter management in favor of surgery. X-ray is indicated based on high clinical suspicion or as guided by the Ottawa ankle and foot rules. There are two quality trials for the use of Ottawa rules, but these do not validate the rules as a tool. However, the applicability of the study results is uncertain as it did not compare inter-discipline rater reliability or validate the rules.

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Pap testing every 3 years is recommended for More frequent screening may be women in their 20s. This longer interval still allows reasons not related to cancer or cell changes to be detected in time to treat them cervical cell changes. However, if needed but reduces treatment of cell changes if your hysterectomy was related that would go away on their own anyway. Older than 65 years Women in this age group should talk with their health care provider to learn if screening is still needed. If you have been screened regularly and your recent test results have been normal, your health care provider will probably advise you that you no longer need screening. However, if your recent test results were abnormal or if you have not been screened regularly, it is important to talk with your health care provider about screening. Next steps after a Pap test may include: Normal Pap test results: Your health care provider will usually recommend another screening exam in 3 to 5 years. Unsatisfactory Pap test results: Your health care provider will ask you to come in for another Pap test. The lab sample may not have had enough cells, or the cells may have been clumped together or hidden by blood or mucus. These cervical cell changes are listed in the table, on the next page, in order from less serious to more serious. These changes may be referred to as dysplasia, neoplasia, or precancer – cells that are abnormal, but are not cancer. Ask your health care provider what your test results mean and what you should do next. It is graded on a scale of 1 to 3, based on how abnormal the cells look under a microscope and how much of the cervical tissue is affected. Other things can cause cells to look abnormal, such as Cells of Undetermined irritation, some infections, such as a yeast infection, growths such as polyps Signifcance or cysts that are benign (not cancer), and changes in hormones that occur during pregnancy or menopause. Although these things may make cervical cells look abnormal, they are not related to cancer. Although the changes may go away on their own, Intraepithelial Lesions further testing is usually done to fnd out whether there are more severe changes that need to be treated. Sometimes cervical cancer cells (squamous cell carcinoma or adenocarcinoma) Cervical are found. However, for women who are screened at regular intervals, it is Cancer Cells very rare for cancer cells to be found on a Pap test. Abnormal cervical cells may also return to normal even without treatment, especially in younger women. She took the time to help me understand the next steps and why I needed to take them. Based on the colposcopy fndings, your health care provider will decide whether further testing or treatment is needed. A colposcopy is an exam that allows your health care provider to take a closer look at your cervix and to remove a sample of cervical cells for a pathologist to examine; this procedure is called a biopsy. Based on the results, your health care provider will decide whether further testing or treatment is needed. Learn more about Pap Test Results on page 6 and about Follow-up Testing on page 10. However, if you have an abnormal test result, it’s important to get the follow-up tests and/or treatment that your health care provider recommends. Possible next steps and treatments are listed in this section to help you learn more and talk with your health care provider. If the cell changes are caused by low hormone levels, applying estrogen cream will make them go away. Colposcopy and biopsy: Your health care provider will examine your cervix using a colposcope and perform a biopsy. During this procedure, your doctor inserts a speculum to gently open the vagina and see the cervix. It has a bright light and a magnifying lens and allows your doctor to look closely at your cervix. A biopsy is done so that the cells or tissues can be checked under a microscope for signs of disease. In addition to removing a sample for further testing, some types of biopsies may be used as treatment, to remove abnormal cervical tissue or lesions. The questions below may be helpful as you talk with your health care provider to learn more. Questions to ask before a test or procedure ●● What is the purpose of this test or procedure? Your doctor will talk with you about which treatment is recommended for you and why. The questions at the end of this section can help you talk with your health care provider to learn more. Some of the tissue is then checked under a microscope for signs of disease, such as cervical cancer. Cryotherapy is a procedure in which an extremely cold liquid or an instrument called a cryoprobe is used to freeze and destroy abnormal tissue. A cryoprobe is cooled with substances such as liquid nitrogen, liquid nitrous oxide, or compressed argon gas. Laser therapy is a procedure that uses a laser (narrow beam of intense light) to destroy abnormal tissue. The second dose is given 1-2 months after the frst dose, and the third dose is given 6 months after the frst dose. What if someone didn’t get the recommended doses at a younger age or complete the series? Our information specialists can answer your questions and help you fnd information. Some early cancers may have signs and symptoms that can be noticed, but that is not always the case. Being aware of anysigns and symptoms of cervical cancer can also help avoid delays in diagnosis. Early detection greatly improves the chances of successful treatment of pre-cancers and cancer. A population-based evaluation of cervical screening in the United States: 2008-2011. Last Medical Review: January 3, 2020 Last Revised: January 3, 2020 the American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer the American Cancer Society recommends that women follow these guidelines to help find cervical cancer early. Following these guidelines can also find pre-cancers, which can be treated to keep cervical cancer from starting. Another reasonable option for women 30 to 65 is to get tested every 3 years with only the Pap test. Women who have had a hysterectomy without removal of the cervix (called a supra-cervical hysterectomy) should continue cervical cancer screening according to the guidelines above. The American Cancer Society guidelines for early detection of cervical cancer do not apply to women who have been diagnosed with cervical cancer or cervical pre-cancer. These women should have follow-up testing and cervical cancer screening as recommended by their health care team. Importance of being screened for cervical cancer Cervical cancer was once one of the most common causes of cancer death for American women. The cervical cancer death rate dropped significantly with the increased use of the Pap test for screening. Screening tests offer the best chance to have cervical cancer found early when treatment can be most successful. Screening can also actually prevent most cervical cancers by finding abnormal cervical cell changes (pre-cancers) so that they can be treated before they have a chance to turn into a cervical cancer. Most cervical cancers are found in women who have never had a Pap test or who have not had one recently. Women without health insurance and women who have recently immigrated are less likely to have cervical cancer screening.

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Formation of droplets should be avoided: so do not spray too much [Buntinx, 1989]. The top of the container should be removed beforehand so that no precious seconds are lost. Inadequate fixation reduces the specificity of the examination [Buntinx, 1992a; Arbyn, 1997]. Transport to the cytology laboratory After fixation (spray fixation or by immersion), the specimen is allowed to dry fully in air. It is then put into a cardboard or plastic holder for transport to the laboratory. The holder is labelled with identifying details matching those on the request form (see Figure 14). Biopsies in formalin are not sent in the same package as smears because the vapour can affect the fixation of the smears. Feedback on the quality evaluation of the specimen Research has demonstrated that systematic feedback to the physician on the quality of the smears he/she has taken can significantly improve the quality [Boon, 1986; Buntinx, 1993]. Periodic notification of the average quality score of an individual doctor compared with the general or regional distribution of smears taken by all doctors is an important incentive element in quality assurance of the screening process [Buntinx, 1993; Wilson, 1999]. In the future, a central register can take on the task of providing physicians with feedback. Training of physicians the experience and dedication of the person taking the smear also plays a crucial role in achieving a good smear [Lundberg, 1989b; Boon, 1993; Szarewski, 1993; Bar-Am, 1997]. According to some authors, the collector effect is even more important than the choice of equipment [Wolfendale, 1991]. Accompanying illustrations these guidelines are illustrated with figures (see Annex 1), made by H. These illustrations are available in colour in the form of slides and overhead transparencies. The Working Group Sampling presents a standard request form with a minimum list of essential details that can contribute to the diagnostic value of the cytology report and the pertinence of any follow-up advice. This form can be used for screening purposes, and also for follow-up or clinical indications. Correctly completed identification and dating of the request and specimen are obviously indispensable to the processing of the sample. The identification details of the patient can also be provided in the form of a sticker or badge. The cytopathologist needs relevant clinical information in order to increase the reliability of the cytology result. Based on the clinical data, specimens can also be selected for specific review. Advice relating to further management depends both on the cytological appearance and on clinical details. The Working Group Sampling recommends the use of specific request forms for cervix cytology. Requests for clinical biological investigation are usually unsuitable for this particular purpose and provide insufficient space for the clinical details required. Date of birth and date of last menstrual period must always be provided; other details should be included if they apply to the patient. The use of the standard request form (Annex 3) allows all the pertinent details to be listed simply and efficiently. The minimum clinical data needed (origin of sample, gynaecological status, interventions) can be provided by means of a check-box system. In this way, data relating to screening history and reason for smear can also be specified. So as not to overload the request form, space is provided for free text for reporting relevant data that may influence the cell picture but are less frequently encountered. Finally, correct identification and signature of the requesting doctor are required. To aid communication between the first and second echelon, the requesting doctor is recommended to indicate whether a colleague (general practitioner or attending gynaecologist) is to receive a copy of the report. Thin-layer cytology Thin-layer cytology is a new technique for transferring the cellular material to the microscope slide. The sampling device carrying the material is immersed in a container with a special liquid transport medium. Only ThinprepR (Cytic) and CytorichR (Autocyte) have so far been approved in the United States by the Food and Drug Administration. With the first system, the liquid is sucked through a membrane and the cellular material sticks to the filter, which is then stamped onto a slide in the form of a monolayer. With the more automated AutocyteR machine, the material is sedimented through a density gradient [Howel, 1998]. A primary advantage of these methods is that almost all the sampled cells are rinsed into the liquid while with the conventional smear a selective portion of the cellular material may remain stuck to the sampling device [Rubio, 1977; Hutchinson, 1993]. The altered background requires a degree of adaptation on the part of the cytologist, however. Red blood cells and mucus are for the most part absent and leukocytes are more evenly distributed. Epithelial fragments, which are difficult to interpret on a classical smear, are for the most part disaggregated during the preparation, while diagnostic clusters of columnar or metaplastic cells are usually preserved. The microscopic visualisation of a calibrated thin line of beautifully distributed cells is more comfortable for cytological interpretation, which should improve the evaluability and diagnostic quality of the investigation [Linder, 1997; Austin, 1998]. A significant disadvantage is the high cost both the capital investment and the operating costs. The cost-benefit ratio needs further investigation before this technique can be recommended for general use. Recently, endocervical brushes have also become available with a notch, which facilitates snapping. Consensus omtrent follow-up adviezen bij cytologische screening naar baarmoederhalskanker. Second Symposium on Cervical Cancer Screening, Belgian Society of Clinical Cytology, Flemish Community, Europe Against Cancer, Ghent 22th of March. Increased detection of epithelial cell abnormalites by liquid-based gynecologic cytology preparations. De Cytobrush-methode: een middel ter verbetering van de kwaliteit van door huisartsen gemaakte uitstrijken. Consequences of the introduction of the combined spatula and cytobrush sampling for cervical cytology. Comparison of cytobrush sampling, spatula sampling and combined cytobrush-spatula sampling of the uterine cervix. Doctoraatsproefschrift Rijksuniversiteit Limburg the Maastricht, Thesis Publischers, Amsterdam. The effect of different sampling devices on the presence of endocervical cells in cervical smears. Relation between sampling device and detection of abnormality in cervical smears: a meta-analysis of randomised and quasi-randomised studies. Latest aspects of precancerous lesions in squamous and columnar epithelium of the cevix. Comparison of the Cytobrush plus plastic spatula with the Cervex brush for obtaining endocervical cells. The organisation of cervical cancer screening in Flanders: uniform cytology reporting. The significance of endocervical cells in the diagnosis of cervical epithelial changes. Should smears in a colposcopy clinic be taken after the application of acetic acid? Influence of smear qualtity on the rate of detecting significant cervical cytologic abnormalities. Cervex-brush and Cytobrush: comparison of their ability to sample abnormal cells for cervical smears. Homogeneous sampling accounts for the increased diagnostic accuracy using the ThinprepR processor.

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Consulting the local drug formulary, we find that oxycodone is available in 10-, 20-, 40, and 80-mg controlled-release tablets. After discontinuing the fentanyl patch, titrate the new opioid according to the patient’s level of pain relief and tolerability. Do not use this table to convert from fentanyl transdermal system to other opioid analgesics because these conversion dosage recommendations are conservative. Use of table E5 for conversion from fentanyl to other opioids can overestimate the dose of the new agent and may result in overdosage of the new agent. Take into consideration that serum fentanyl concentrations decline gradually after removal of the patch, decreasing about 50% in approximately 17 (range 13-22) hours. Use conservative conversion doses and provide the patient with supplemental short-acting opioids to be taken as needed. Am J Clin Pathol (1983) 79:582-586 13 Creatine Kinase (Netherlands) Study with 1411 subjects Brewster et al. Medicine (2016) 95:33 17 18 Exercise Effect of 3 days of 45 min aerobic exercise sessions on 15 medical students Nicholson et al. Muscle Nerve (1986) 9:820-824 19 Exercise Study of 499 recruits undergoing basic military training Kenny et al. Muscle Nerve (2012) 45:356-362 20 Exercise Study of 499 recruits undergoing basic military training Kenny et al. Stop the exercise and let your doctor or therapist know right away if you have either of these problems: o Any change in your bowel or bladder control. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. OvOverviewerview this guideline covers assessing and managing low back pain and sciatica in people aged 16 and over. It outlines physical, psychological, pharmacological and surgical treatments to help people manage their low back pain and sciatica in their daily life. Exclude specifc causes of low back pain, for example, cancer, infection, trauma or infammatory disease such as spondyloarthritis. Include: information on the nature of low back pain and sciatica encouragement to continue with normal activities. Surgical intervSurgical interventionsentions Surgery and prSurgery and prognostic factorsognostic factors 1. Changes recommended for clinical practice that can be done quickly – like changes in prescribing practice – should be shared quickly. Raise aRaise awarenesswareness through routine communication channels, such as email or newsletters, regular meetings, internal staff briefngs and other communications with all relevant partner organisations. Identify a leadIdentify a lead with an interest in the topic to champion the guideline and motivate others to support its use and make service changes, and to fnd out any signifcant issues locally. Carry out a baseline assessmentCarry out a baseline assessment against the recommendations to fnd out whether there are gaps in current service provision. Think about what data yThink about what data you need to measure improou need to measure improvvementement and plan how you will collect it. You may want to work with other health and social care organisations and specialist groups to compare current practice with the recommendations. DeDevvelop an action planelop an action plan, with the steps needed to put the guideline into practice, and make sure it is ready as soon as possible. Big, complex changes may take longer to implement, but some may be quick and easy to do. ReReview and monitorview and monitor how well the guideline is being implemented through the project group. Share progress with those involved in making improvements, as well as relevant boards and local partners. Episodes of back pain usually do not last long, with rapid improvements in pain and disability seen within a few weeks to a few months. Although most back pain episodes get better with initial primary care management, without the need for investigations or referral to specialist services, up to one-third of people say they have persistent back pain of at least moderate intensity a year after an acute episode needing care, and episodes of back pain often recur. One of the greatest challenges with low back pain is identifying risk factors that may predict when a single back pain episode will become a long-term, persistent pain condition. When this happens, quality of life is often very low and healthcare resource use high. This guideline gives guidance on the assessment and management of both low back pain and sciatica from frst presentation onwards in people aged 16 years and over. This guideline does not cover the evaluation or care of people with sciatica with progressive neurological defcit or cauda equina syndrome. All clinicians involved in the management of sciatica should be aware of these potential neurological emergencies and know when to refer to an appropriate specialist. WhWhy this is importanty this is important Guidelines from many countries have said that muscle relaxants should be considered for short term use in people with low back pain when the paraspinal muscles are in spasm. Because of this, there is a need to fnd out if diazepam is clinically and cost effective in the management of acute low back pain. WhWhy this is importanty this is important Codeine, often together with paracetamol, is commonly prescribed in primary care to people presenting with acute low back pain. Although there is evidence that opioids are not effective in chronic low back pain, there are relatively few studies that look at their use for acute low back pain (a problem commonly seen in primary care). Also, it is not known if using paracetamol and codeine together has a synergistic effect in the treatment of back pain. WhWhy this is importanty this is important Radiofrequency denervation is a minimally invasive and percutaneous procedure performed under local anaesthesia or light intravenous sedation. Radiofrequency energy is delivered along an insulated needle in contact with the target nerves. This may allow axons to regenerate with time, requiring the repetition of the radiofrequency procedure. Data from randomised controlled trials suggest relief is at least 6–12 months but no study has reported longer-term outcomes. Pain relief for more than 2 years would not be an unreasonable clinical expectation. The economic model presented in this guideline suggested that radiofrequency denervation is likely to be cost effective if pain relief is above 16 months. If radiofrequency denervation is repeated, we do not know whether the outcomes and duration of these outcomes are similar to the initial treatment. If repeated radiofrequency denervation is to be offered, we need to be more certain that this intervention is both effective and cost effective. WhWhy this is importanty this is important Epidural injection of treatments, including corticosteroids, is commonly offered to people with sciatica. Epidural injection might improve symptoms, reduce disability and speed up return to normal activities. Several different procedures have been developed for epidural delivery of corticosteroids. Some practitioners inject through the caudal opening to the spinal canal in the sacrum (caudal epidural), but others inject through the foraminal space at the presumed level of nerve root irritation (transforaminal epidural). Some people believe transforaminal epidurals might be most effective because they deliver corticosteroids directly to the region where the nerve root might be compromised. But because transforaminal epidural injection needs imaging, usually within a specialist setting, this potentially limits treatment access and increases costs. Caudal epidural injection can be done without imaging, or with ultrasound guidance in a non-specialist setting. Use of the 2 methods varies between healthcare providers, and people whose sciatica does not respond to caudal corticosteroid injection might go on to have image-guided epidural injection. WhWhy this is importanty this is important An increasing number of procedures have been proposed for surgically managing low back pain. One of these procedures is surgical fxation with internal metalwork applied from the back, front, side, or any combination of the 3 routes.

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As such, be hyper vigilant about looking for subtle indicators of exceptionality in students. Characteristics of Gifted Students with Disabilities the following characteristics2 may be among those observed in twice-exceptional students, particularly those with learning disabilities (Higgins, Baldwin & Pereles, 2000; Weinfeld, Barnes-Robinson, Jeweler, & Shevitz, 2006). Struggle with basic skills due to cognitive processing difficulties; need to learn compensatory strategies in order to master basic skills. Show high verbal ability but extreme difficulty in written language area; may use language in inappro priate ways and at inappropriate times. Excel in solving “real-world” problems; have outstanding critical thinking and decision-making skills; often independently develop compensatory skills. Show attention deficit problems but may concentrate for long periods in areas of interest. Have strong questioning attitudes; may appear disrespectful when questioning information, facts, etc. Also, specific characteristics may be stronger in some students than they are in others. May be perceived as loners since they do not fit typical model for either a gifted or a learning disabled student; sometimes have difficulty being accepted by peers due to poor social skills. Is often a leader among the more nontraditional students demonstrating strong “street-wise” behavior; or the disability may interfere with the student’s ability to exercise leader ship skills. Show a wide range of interests but may be thwarted in pursuing them due to processing or learning problems. Very focused interests, for example, a passion about certain topics to the exclusion of others, often not related to school subjects. When teaching these stu dents in their areas of strength, offer them the same compacting and differentiation opportunities available to other gifted students. When teaching in their areas of challenge, teach them directly whatever strategies they need to increase their learning success. Never take time away from their strength areas to create more time on their deficiencies (Winebrenner, 2003, p. Responsibilities of the Classroom Teacher ncovering student interests and recognizing learning differences is effective classroom practice for teaching all students. To fully understand student needs, it is important to use both formal and informal assessments and to gather or request information from fami lies about the student’s interests and performance outside of school. Having access to expert consultation is helpful support for educators and families. Experts could include individuals involved in gifted education, special education, and counseling/school psychology. Educators should consider referral for formal services, including special education and gifted and talented education programming, as well as access to other opportunities such as afterschool activities, clubs, independent study, and related arts programs. Appropriate educational services for students who are twice-exceptional require simultaneous provision of gifted instruction and the specialized instruction, adaptations, and accommodations needed by students with special needs (Nielsen, Higgins, & Hammond, 1995). The extent to which appropriate instructional practices are delivered can either eliminate or create obstacles for these students. Key Issues There are five key issues to consider for this special population of students. Addressing Behavioral Issues 11 the Twice-Exceptional Dilemma Accommodating Academic Strengths/Gifts Successful educational experiences for twice-exceptional students should focus on developing personal strengths as well as higher order thinking and reasoning skills. Best practice in the classroom always uses stu dents’ strengths and skills to teach new concepts. Therefore teachers must use a variety of techniques to find each student’s strongest learning style. The following are recommendations for accommodating the academic strengths of twice-exceptional students (Baum & Own, 2004; Brody & Mills, 1997; Nielson & Higgins, 2005; Olen chak & Reis, 2002; Weinfeld, Barnes-Robinson, Jewler & Shevitz, 2006). Use an interdisciplinary curriculum to allow the student to find connectedness between topics. Accommodating for Academic Weaknesses/Disabilities Like other students with disabilities, twice-exceptional students need to learn how to accommodate and com pensate for their areas of relative weakness. This may be done in a variety of ways (Baum & Own, 2004; Brody & Mills, 1997; Olenchak & Reis, 2002; Weinfeld, Barnes-Robinson). These improved skills allow students even greater success in the development of their gifts (Weinfeld, Barnes Robinson, Jeweler, & Shevitz, 2002). Skills instruction can be accomplished through direct instruction and/or content instruction and may include one or more of the following areas. Test Taking Strategies Addressing Social/Emotional Issues Twice-exceptional students can have social/emotional issues that interfere with their ability to make friends and sustain social relationships. Additionally, the social/emotional difficulties of twice-exceptional students are often linked with educational concerns (Reis & Colbert, 2004). Frequently, these social/emotional issues, such as feelings of failure, worthlessness, anger, depression, isolation/thoughts of suicide, mask their giftedness. Stu dents need tools to overcome these issues and to see themselves as successful learners. Addressing Behavioral Issues Difficult behavior typically has two purposes: avoidance or attention-gaining. Teach appropriate behaviors to use in place of inappropriate behavior (such as raising a hand to get the teacher’s attention rather than shouting out in class). His teachers have difficulty seeing him as “gifted” as he is often uncooperative and reluctant to perform academic tasks in class. He participates in a weekly community program with students who are not disabled to design a functioning robot and does so with a tremendous amount of ingenuity. He is also an avid reader outside of school and can offer a very keen oral analysis of the works he has read. Community and Local Issues ames is fortunate to have the opportunity to participate in the robotics program at his school with stu dents from the general education class. It gives him the chance to enhance his social skills and show his Jadvanced cognitive capabilities. This is not possible for many twice-exceptional students because commu nity programs of this kind don’t exist in their communities or are not readily available to students who are iden tified as disabled. Twice exceptional students may go undiagnosed as either gifted, disabled, or both. Due to a lack of appropriate edu cational programming that addresses both components of giftedness and disability, these students may be underachieving and their underachievement can affect the school and community in significant ways. Twice-exceptional students may underestimate their own capabilities and choose not to pursue a col lege or other postsecondary education. Looking at the “big picture,” twice-exceptional students are important to the future of our communities. Their unrealized potential can mean immeasurable societal costs: inspiring community leaders who are never elected, cures for diseases that are never discovered, revolutionary inventions that are never patented; thrilling novels that are never written; and ground-breaking theories that are never conceived. Best practices include special education program ming and classroom accommodations that address both giftedness and disability. Unfortunately, there are only a few model programs of this type currently in existence in the country. One exemplary program is provided by the Montgomery County Public Schools in Maryland (see Montgomery Public Schools, 2003, in resources sec tion for more information). In school districts across the country there is a range of professionals who should be responsible for meeting the needs of twice-exceptional students, including special education teachers, related service providers, teachers of the gifted/talented, and mental health professionals. It is the responsibility of the district educational leaders to ensure that a variety of supports and services are available to meet the complex needs of twice-exceptional stu dents and their teachers. Professional Development School staff should participate in professional development to raise awareness of the characteristics of twice exceptional learners, services available in the district, and identification procedures used to identify these stu dents. Professional development activities might focus on definitions of the twice-exceptional population, identification, programming, and classroom practices. Training on learning strategies, accommodations, and communication would also be beneficial. Additionally, there should be shared planning time to allow gifted/talented and special education personnel, content experts, and school-based mental health professionals to collaborate. General education teachers should have the opportunity for meaningful communication with colleagues regarding particular students. Talent Development Opportunities Although this guide is focused on the needs of those twice-exceptional students who are academically gifted and disabled, it is important to keep in mind that they may also have special talents. Twice-exceptional stu dents must have the opportunity to develop and to excel in talent areas, such as arts, music, or dance. This could include mentorships, internships, independent study experience, nonacademic competition, community college programs, art and music programs, clubs (such as chess, language), and other enrichment activities.

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Comprehensiveness: the plan present the population burden of countries exist in South and Central should address all members of cancer and can do so by time, key America and India. Scope: the plan should address cases), cancer site/type, impact of enhanced over time to incorporate cancer control from the perspec interventions as affecting stage dis more detailed data on diagnosis tives of human development, risk tribution, 5-year survival, disability, and treatment. Along with projec factor control, and health and dis the presence or absence of health tion and modelling methodologies, ease management. Evidence base: the plan should graphical, political, economic, eth es, programme evaluation, and in be based on evidence or best nic, and heritage status [2,7,9]. In the vestments, thereby allowing health practices and should incorporate United Kingdom and the European systems to maintain optimal cancer indicators and metrics of perfor Union, comparative presentation of control outcomes. Estimates of the propor into account measures to defne recognition of the global variation tion of the population covered by standards and ensure consis in incidence, mortality, and 5-year cancer registries range from more tent application, such as access, survival, and reasons for this varia than 80% in North America, Europe, timeliness, quality of care, and tion – which include access to care, and Australia to approximately 30% safety. Regional registries also tors infuencing compliance improving cancer burden, mitigating vary in their comprehensiveness, with therapy: the plan should variation, and addressing disparities. Integration and continuity: countries are challenged by having recording standards. Irrespective of the plan should strive for conti neither registries nor a systematic their coverage and quality, registries nuity across states of health and ability to collect data. Thus, even in munity, and tertiary or specialist cal facilities, low cancer awareness, regions without functioning regis poor follow-up, poorly maintained environments. Potential solutions with input and support from the to rationalize activities, investments, include establishing the culture of public, patients, providers, poli and performance of cancer control evidence, supported by data, be cy-makers, and payers. Ultimately, ef this plan is relatively straightforward tion of being self-suffcient and forts to establish reliable population as it is based on best practices, the sustainable. What interventions for cancer are most important: risk factor control, early detection, diagnosis, treatment, and care? How interventions will be implemented, and how the process of implementation will be monitored and evaluated. How will human, technology, facilities, and organizational resources be aligned to the implementation? When activities will be undertaken according to priority, what is the capability and the resource avail ability (the operational plan). How the national cancer control plan and its implementation will be fnanced (the business plan). How will outputs and outcomes be measured (system performance), linked to a changing burden of cancer, and aligned with resource allocation to determine value? Published plans are accessible grated manner that leads to perfor tors include resources and priorities. A set of core are present in 35% of low-income include human resources, and principles have been recognized countries, 35–60% of countries in specifcally qualifed personnel; as guiding acceptance and imple the lower-middle and upper-middle technology, which includes infor mentation (Box 6. The plan must income groups, and 75% of high mation technology; drugs, and diag describe how benefcial change in income countries. However, sub nostic and therapeutic equipment; cancer control will occur; address stantial variation exists within re facilities, with reference, for exam purpose, content, context, relation source settings with respect to the ple, to access to transportation and specific components of the plans ships, and resources; present a busi affordable in-patient and ambula (see Chapter 6. Protect and using aspirin for myocardial economics is not the sole criterion yourself! Treatment is easy tions involving clinical care – such prevention interventions relates to if it is detected early through testing. If you as surgery and provision of radiation whether they are environmental are 50 or older, get tested today! Typically such measures strategies address factors common are achieved through policy and reg to more than one such disease, ulation – examples are smoke-free such as tobacco use, alcohol con laws or food regulations addressing sumption, unhealthy diet, and lack fortifcation or control of unhealthy of physical activity. The “Nobody’s Immune to Breast Cancer” campaign of Associação da Luta the “pull” of patients and the public Contra o Cancro (Association for the Fight Against Cancer), Mozambique: “When we (sociopolitical imperative) [22]. Fight with us against this enemy and, when in doubt, talk Such an approach involves social with your doctor. There are roles for advocate and stakeholder participation, together with the en gagement of relevant networks and coalitions. Collaboration across networks and coalitions will increase their impact and may extend from infor mation exchange to agreed coor dination and cooperation. The lat ter requires trust, mutual respect, a sensitivity to issues of authority, and understandings about roles, responsibilities, and accountabili ties. Examples of such networks include national organizations, such as the Canadian Partnership Against Cancer; regional entities for cancer control, such as the Thus, causality can be approximated factors [24]. This evidence de and adoption of treatment innova key to effective collaboration are rives from several sources. Conditions underlying the probability of a successful national cancer control plan. Political and professional consistency and resolve to address the population cancer burden. Use of data and a commitment to support and maintain cancer registration and surveillance. Contextual relevance, defned priorities, achievable implementation, and an appropriate time frame to achieve goals. Trust, mutual respect, and willingness to achieve commonly defned goals through collaboration by all key actors. Scalability, incorporation into the health system, self-suffciency, and sustainability. Applicability to, and coordination and cooperation with, other population disease control plans. Sound governance, evaluation, communication, and ongoing adaptation to meet future needs. J Health 2008: a systematic analysis of disability-ad Care Law Policy, 14:119–151. The evaluation of comprehen Global cancer transitions according to the at. The National Health Service Cancer of non-communicable diseases: 25 years 27 sites in the adult population in 2008. Plan: a plan for investment, a plan for experience with North Karelia project Int J Cancer, 132:1133–1145. The National Staging possible areas for improvement in organization charged with the im Initiative has successfully achieved each jurisdiction. These measures plementation of the national cancer the goal of making collaborative are placed with others to provide control strategy [1,2]. While the de stage information available in a sus a view across the cancer control velopment of the strategy was built tainable way for more than 90% of continuum, including population on many years of collaborative the four major cancers (lung, colo measures of risk factors, of screen work, there were challenges that rectal, breast, and prostate) starting ing, and of patient experience. For many years, routine inter joint leadership of senior representa Many of the initial challenges provincial comparisons had been tives of each provincial cancer agen concerned creating the appropriate done on incidence, mortality, and, cy and the Canadian Partnership measures needed to stimulate and to a lesser extent, prevalence and Against Cancer, and has been used assess the impact of such a strat survival. Canada had the same excellent measures were able to shine a initiatives in their own jurisdictions. Canadian Partnership Against Cancer high-quality data throughout most reporting in this area where limited (2012). Thus, provincial cancer Sustaining-Action-Toward-a-Shared staging data, which was absent at agencies and health departments Vision-Full-Document. Curr Oncol, the frst initiatives of the Canadian sus on indicators that would be most 19:70–77. Available at gists) to identify an approach to a few provinces were able to pro Odedina (reviewer) by each country, of a national current preparedness of countries to Summary cancer policy and plan is an im undertake cancer control. Although 85% of the participat With increasing awareness by pol integral part of the survey. The questionnaire policies have been developed, dresses an urgent requirement to used in the 2013 Noncommunicable such policies are not always provide the information relevant to Disease Country Capacity Survey comprehensive. Cancer control capacity adoption and implementation, Capacity Survey [1] indicate the is defned as the availability of plans, 538 Fig.


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In the development of comprehensive Declaration on noncommunicable a recent survey, only 43% of low national cancer control plans needs diseases that was adopted [5], to income countries reported having press for increased efforts to reduce operational national cancer control the cancer burden, particularly in low plans (see Chapter 6. The situation edge about cancer burden, as well may be addressed by initiatives in as a means to evaluate the impact advocacy, research, workforce, of implemented activities; and (iii) care, and funding. Cancer advocates to ensure that governments fnance in Africa, for example, may look to Chapter 6. This model of a cigarette, an the greatest impact is achieved for municable diseases and spearhead inflated balloon, was displayed in Hyder the funds allocated. World No Tobacco Day is marked on There are cost-effective evi in the adoption of an omnibus resolu 31 May each year, to create awareness dence-based interventions that can tion on noncommunicable diseases about the harmful effects of tobacco and signifcantly reduce the cancer bur at the 66th World Health Assembly, smoking. These include screening for which will beneft the millions of peo cervical cancer and breast cancer, ple worldwide who are at risk of, or liv and vaccination against hepatitis B ing with, noncommunicable diseases. Neglecting both the views of patients and their loved ones and the compelling What does success look like? The Convention pro three core components, effective ad vides a robust framework to confront vocacy for cancer control needs to the efforts of the tobacco industry, occur at the local, national, regional, which employs lawyers and market and global levels. These efforts can ing and communications experts to be enhanced through strong part counter health advocates around the nerships between local and global globe. The recent major achievement advocates, as well as across groups involving Australia’s adoption of legis concerned with related diseases, lation for plain packaging of tobacco specifcally including other noncom products highlights the impact that municable diseases, and involv a persistent, united, and vocal civil ing multiple sectors, including the society may have. The development of ef cal cancer is a good example of the ing the four main noncommunicable fective strategies may be grounded links between research, policy, and diseases (cardiovascular disease, diabetes, cancer, and chronic re in the experience of local practition practice. Over the previous decades, spiratory disease), played a pivotal ers, policy-makers, and advocacy advocacy has helped to drive the re role in the lead-up to the United leaders. The evidence base generated recognize that noncommunicable the necessary information for ad through these trials, particularly in diseases are a global development vocates to raise awareness of the low-income settings, has resulted priority requiring an urgent response. One half of those who Cancer patients, survivors, and their care communities’ efforts towards die from noncommunicable diseases families are not only key to docu increased access to opioid analge are in their most productive years, menting the impact of policies on sics. During this period, the United meaning that the social costs and individuals; these same individuals Nations’s drug policy-making organ, economic consequences in terms can also be highly effective and pow the Commission on Narcotic Drugs, of lost productivity are consider erful advocates for the adoption of has adopted two resolutions [15,16], able. This is despite and works to improve disease out In 2012, commendable advoca the fact that nearly 80% of the pre comes for lung cancer patients glob cy efforts led by the palliative care ventable deaths from these diseases ally [14]. The Case study: access to opioids liative care, assessed by morphine fnancial case for investing in cancer for cancer pain relief equivalent consumption of strong is strong, and is one that can and Bringing the patient voice to policy opioid analgesics per cancer death, must be used by cancer advocates discussions, and emphasizing the in the Global Monitoring Framework at all levels to support adequate and need for a rights-based approach for the Prevention and Control of sustained resourcing of national to address the global inequities Noncommunicable Diseases [12]. Since the World Economic Forum has the United Nations Political Decla 2009, the Union for International identifed noncommunicable dis ration on noncommunicable diseas Cancer Control has worked with its eases, including cancer, as the sec es clearly articulated the need for members to add the cancer voice ond greatest risk to global economic multisectoral partnerships, engaging Chapter 6. Cancer Council Australia provides a range of resources related to evidence an omnibus resolution on noncom based cancer control policy and advocacy on its website. This emerging framework for non communicable diseases will carve out a new global advocacy space for the cancer community, and an opportunity to ensure that noncom municable diseases, including can cer, continue to occupy a place on the global health and development agenda. Ensuring that cancer is part of the 2013 Millennium Development Goal review and the emerging de both health and non-health actors, Responsibility, 40% of companies bate on universal health coverage, including civil society and the private expect to increase their commit the sustainable development goals, sector, to promote and support the ment to global health partnerships and other development issues will provision of services for noncommu focused on noncommunicable dis also be vital to ensuring that cancer eases in the next 5 years [21]. Global control remains central to future nicable disease prevention and con health partnerships could play an thinking. In addition to bolstering global important role in improving primary both new opportunities and chal and national advocacy efforts, such health-care systems, which are the lenges as “latecomers” to the devel partnerships are essential for the im front lines – particularly in low and opment discourse. Now more than plementation of cancer interventions middle-income countries – for en ever, innovative partnerships that go at the country level. Given today’s f gaging communities with prevention, beyond traditional health groups and nancial climate, engagement of parts embrace partners in the develop of the private sector, with appropriate diagnosis, and treatment across a ment sphere, including reproductive, range of diseases, including cancer. There is a clear willingness in Advocacy for cancer control: are critical if the currently predicted the private sector to engage at this the road ahead cancer burden for future generations level; according to a recent survey In May 2013, Member States at the is to be reduced. Human papillomavirus and cancer of voluntary global targets for the preven Countries (2011). Closing the Cancer prevention: gaps in knowledge and pros tion and control of noncommunicable dis Divide: A Blueprint to Expand Access in pects for research, policy, and advocacy. Global Lung Cancer Coalition (2012) insights/report-view/working-toward-trans York: United Nations. Global Status Report on Promoting adequate availability of interna to the Political Declaration of the High Noncommunicable Diseases 2010. In second most frequent cause of King Hussein Institute for Cancer 2004, Jordan was the second coun death, after heart disease. In January 2012, the International was 29% (male, 51%; female, 7%) in the rank order of the fve Atomic Energy Agency, upon off 2007. The prevalence among youth most common cancers affecting cial request of the Ministry of Health, (13–15 years) was 11. The major rate of all cancers among Jordanians of lungs and smoking is required on partners are the Ministry of Health, is 79. Available existed previously, but the idea of a preventable, by reducing exposure at. Global Youth Tobacco tended by many parties, including the youth should be a priority to Survey: Country Fact Sheet – Jordan. Domestically, law laws and norms, with profound (Australia); is constituted by a combination of implications for cancer control. All As this Report goes to press, chal brand names are specified in a standard colour, position, font size, and style. In November 2011, the Australian Parliament enacted the Tobacco Plain Packaging Act 2011 [4]. As of 1 December 2012, all tobacco prod ucts sold in Australia were required to comply with the legislation. The legislation bans the use of logos, brand imagery, symbols, other im ages, colours, and promotional text on tobacco products and tobacco product packaging, and requires packaging to be a standard drab dark-brown colour in matte fnish. Products are differentiated by the brand and product name, displayed in a standard colour, position, font size, and style. Indeed, the investment treaties – as well as a Energy Agency, and the International “plain” in “plain packaging” is some wide range of “softer” normative Labour Organization. The United Against this broader backdrop, and labelling (Article 11) [5] and the Nations Political Declaration on this chapter focuses on three topi other on tobacco advertising, pro the Prevention and Control of Non cal and important areas, relating to motion, and sponsorship (Article 13) communicable Diseases [1] under prevention, treatment, and research, [6]. The guidelines for the implemen lines that prevention and control of respectively. The Australian leg a large number of international trade liberalization and direct foreign islation includes as one of its objects agencies whose work directly or investment”. It has been reported that the two multinational tobacco com panies, Philip Morris and British American Tobacco, have been pro viding support to countries to chal lenge plain packaging [7]. In practice, exceed the requirements of the Administrative Region – like many this balance has not been achieved, Single Convention and that operate other investment treaties – enables with poor availability in much of the as barriers to availability. They include insuffcient opioid medications, and overly bur propriation” of its investment and de training of health-care profession densome administrative and bureau nial of “fair and equitable treatment”. These challenges to plain their families about the safety of dressed at the international level. The Single Convention seeks to licences for international transac affordability, and control of con strike a balance between the two aims tions; licensing and record-keeping trolled medicines; of ensuring the availability of opioids for trade or distribution; and medical. Marked differences between countries in relation to medicinal opioid consumption (2010), assessed by morphine-equivalent consumption (in milligrams) of strong opioid analgesics per cancer death. High-quality research – clinical, appropriate balance between en this contrasts with the previous behavioural, and epidemiological – suring adequate access to interna wording, which referred to “strict is key to effective cancer control. At the plants having a medical use” and a wealth of information that is es 2013 session of the Commission on “substances with a high potential sential for planning, resource alloca Narcotic Drugs, the United Nations risk to public health but having a tion, programme development and Offce on Drugs and Crime released medical use” (emphasis added). An opium poppy field in Tasmania, Australia, where opium is grown for me closure of which can have a range of dicinal morphine. The opium poppies are usually genetically modified so that extraction consequences for individuals. De-identifed data are not suffcient for the individual–data linkages re quired for epidemiological research designed to investigate more intri cate interactions between exposure, lifestyle, preventive interventions, treatment, and outcomes [17]. Even after research has been conduct ed, data may need to remain re identifable to allow for the correc tion of errors or updating of new data, and for the review of scientifc work, thereby guarding against sci entifc fraud [18]. It is not feasible to condition the use of personal health information in public health research on individual of individuals, who are the ultimate their proper legal context, and should consent in all cases. When informa benefciaries of public health re ultimately infuence the way in which tion is collected, it is seldom possi search [21], it is curious that the right public health research is regulated. When dealing with large data this is the case notwithstanding pears as an afterthought exception sets, it may not be feasible to obtain the recognition that fulflment of the in regimes aimed at strengthening consent from each individual whose right to health depends on the con privacy protection, often driven by data is proposed to be used [19].

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The workshop in 2001 was the first to utilize the Internet in order to provide everyone an opportunity for input; over 2,000 comments were considered prior to the meeting, which then brought together over 400 participants including rep resentatives from over two dozen countries [4]. Developments in laboratory practice and the transition for many to liquid-based cytology led to incorporating images and criteria specific to these preparations in the 2004 atlas [3]. Cytologic findings may be equivo cal, resulting in frustration for clinicians who need to be able to make clear-cut man agement decisions. At a time when there were few test options for screening and evaluation of abnormal findings, management algorithms consisted of linear branch points based on a sequence of test results. With the multiplicity of testing options currently available, as well as additional assays on the horizon, various combinations of cytologic, molecular, and/or his topathologic test findings must now be integrated in order to determine an indi vidual woman’s risk for precancer/cancer and – based on that level of risk – her ritagoreti26@gmail. Beyond the field of cervical cytology, standardized terminology systems have now been developed for cytology of other body sites including thyroid [7] and pan creas [8], and most recently urine [9]. Terminology must evolve to keep pace with our insights into the basis of disease, to be responsive to the needs of the laboratory and clinician for clear communica tion, and ultimately to best serve women’s health. The Bethesda system 2001: terminology for reporting the results of cervical cytology. Pancreaticobiliary tract cytology: journey toward “Bethesda” style guidelines from the Papanicolaou Society of Cytopathology. The quest for standardization of urine cytology reporting– the evolu tion of the Paris system. Thus 2014 seemed to be the appropriate time for a review and update of the 2001 Bethesda System terminology and incorporation of revisions and additional information into this third edition of the Bethesda Atlas for cervical cytology. Additionally, in many settings, cervical cytology will continue to be the first line screening test based on resources and local preferences. Hence, updating and fur ther refinement of morphologic criteria for the great variety of entities seen in cervi cal cytology, both neoplastic and non-neoplastic, is an important function of this edition. Wide dissemination of this comprehensive and relatively inexpensive atlas will therefore serve to maximize the overall value of the test in all practice settings. Following literature review and formulation of the pro posed new and expanded content for the atlas, a widely advertised Internet-based public open comment period was initiated within the international cytopathology community for a 3. A total of 2454 responses were received from individuals in 59 countries spread over a broad demographic, on proposals from each of the atlas’s 12 chapter-based ix ritagoreti26@gmail. Excellent feedback was gathered on the proposed updates, which was com piled and reviewed by the chapter-based task force working groups. This process culminated in refinement of positions and content, which were then incorporated into the 2014 Bethesda System and this accompanying atlas. This new edition of the atlas expands on the popular features of the prior editions [1, 2]. A portion of the text and images from the first and second editions have been retained for this edition, and credit is attributed to the individuals who participated in the 1988, 1991 and 2001 Bethesda Workshops and those who contributed to the resultant 1994 and 2004 Bethesda atlases (see Acknowledgments section). This edi tion has 12 chapters, 6 of which correspond to the major Bethesda interpretive cat egories, with the remainder being dedicated to other malignant neoplasms, anal cytology, reporting of adjunctive testing, computer-assisted screening, educational notes, and a new chapter on cervical cancer risk assessment. Each chapter consists of a background discussion, a description of definitions and cytologic criteria, brief explanatory notes that cover difficult morphologic patterns and mimics of epithelial lesions (where applicable), sample reports, and selected references. Cytologic crite ria are described in general for all specimen types in every chapter, followed by any significant differences related to specific preparation types. New to this edition are increased content on basic disease biology as it pertains to each entity and dis cussions of the current clinical management guidelines. Over 1000 images were evaluated for this atlas, including the 186 images from the second edition. The images went through a multistage review process; first by the relevant chapter group, and secondly by a cytopathologist/cytotechnologist sub group of the Bethesda 2014 Task Force. Daniel Kurtycz is credited with the management of images collected for this edition of the atlas. Some images represent classic examples of an entity whereas others were selected to illustrate interpretive dilemmas or “borderline” morphologic features that may not be interpreted in the same way by all cytologists. A greater number and variety of “normal” findings as well as mimics of classic epithelial abnormalities are included in the third edition in order to provide a more complete representation of the morphologic variations that can be appreciated in cervical cytology specimens. Prior to the publication of the second edition [2], selected images were posted on a website open to cytopathologists and cytotechnologists worldwide. This process was designed to evaluate inter-observer variability and to provide an educational tool for cytologists. Data from this effort, in which over 850 participants submitted their answers online prior to the publication of this atlas, provides a realistic gauge of interpretive reproducibility. While knowledge of normal morphology, its variations and epithelial abnormalities is essential, some degree of interobserver and interlaboratory variability in interpretation will always remain a reality [4, 5]. In addition to displaying all the illustrations that are used in this atlas, the website will contain many other examples of presentations and entities that could not be provided in this print version. The website group will also be exploring new avenues for delivery of the content which has been assembled during this update process. For further information on the Bethesda web atlas please go to the educational resources page on the American Society of Cytopathology website [6]. Although the Bethesda System was developed primarily for cervical cytology, specimens from other sites in the lower anogenital tract, such as the vagina and anus, may be reported using similar terminology. As in the 2001 Bethesda System, the terms “interpretation” or “result” are recommended instead of “diagnosis” in the heading of the cervical cytology report. This terminology is preferred because cer vical cytology should be viewed primarily as a “screening test, which in some instances may serve as a medical consultation by providing an interpretation that contributes to a diagnosis. As in prior editions, the current editors and authors have committed to making the third edition affordable, and hence, widely accessible to all including practitio ners in low resource environments. The editors, the 2014 Bethesda System Task Force members, and all the dedicated cytologists who have contributed to this wonderful project over the past quarter of a century are delighted to come together to thank Drs. Diane Solomon and Robert Kurman for their pioneering vision in initiating the organization and implementation of the Bethesda System in 1988 [7, 8]. Indeed Bethesda’s contributions and impact on the field of cervical cancer go far beyond just standardized reporting terminology. And finally, Bethesda brought the world together with one cytologic voice – now able to effectively communicate scientific and clinical data where previously such was difficult, if not impossible. Because of Bethesda, the interpretation of a high grade squamous intraepithelial lesion in the United States is based on exactly the same criteria as in India or anywhere else. On behalf of the American Society of Cytopathology, we, as a group are pleased to be ritagoreti26@gmail. Definitions, criteria, and explanatory notes for terminology and specimen adequacy. Definitions, Criteria, and Explanatory Notes for ter minology and Specimen Adequacy. The 2001 Bethesda System Forum Groups and Bethesda Atlas, Second edition (Solomon D, Nayar R. Birdsong and Diane Davis Davey Adequacy Categories Satisfactory Satisfactory for evaluation (describe presence or absence of endocervical/transformation zone component and any other quality indicators. Rejected specimen: Specimen rejected (not processed) because (specimen not labeled, slide broken, etc. The first two ver sions of the Bethesda terminology included three categories of adequacy: satisfac tory, unsatisfactory, and a “borderline” category initially termed “less than optimal” and then renamed “satisfactory but limited by” in 1991. The 2001 Bethesda system eliminated the borderline category, in part, because of confusion among clinicians as to the appropriate follow-up for such findings and also due to the variability in criteria used to report “satisfactory but limited by” among laboratories [1]. To pro vide a clearer indication of adequacy, specimens are now designated as either “sat isfactory” or “unsatisfactory. Laboratory implementation of some of these criteria was shown to be poorly reproducible [2–4]. In addition, the increasing use of liquid-based cytol ogy necessitated developing criteria applicable to these preparations. The 2001 Bethesda adequacy criteria were based on published data to the extent possible and were tailored to both conventional and liquid-based preparations. Providing clinicians/spec imen takers with regular feedback on specimen quality promotes heightened atten tion to specimen collection with consideration for the use of improved sampling devices and preparation technologies. If there is concern that the specimen is compromised, a note may be appended indicating that a more severe abnormality cannot be excluded. Unsatisfactory specimens that are processed and evaluated require considerable time and effort on the part of the laboratory. Although an epithelial abnormality cannot be excluded in such specimens, reporting of information such as the pres ence of organisms, or endometrial cells in women 45 years of age or older, etc. Note that the presence of benign endometrial cells at any age does not make an otherwise unsatisfactory specimen satisfactory.


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