Aprendizados no enfrentamento à pandemia / Lessons learned in coping with the pandemic

O novo coronavírus (SARSCoV-2) instaurou inúmeros desafios no contexto da gestão pública, não só da saúde pública, mas também da economia e da educação; e ainda nos aspectos da vida social e individual, deixando centenas de milhões de casos e milhões de mortes, transformando a realidade conhecida. Diante deste contexto este e-book buscou agregar e compilar experiências da Secretaria de Estado da Saúde de Goiás (SES/GO) no enfrentamento à pandemia, nos mais diferentes aspectos da gestão em saúde (vigilância, regulação, assistência, transparência, gestão de pessoas, entre outros)

The new coronavirus (SARSCoV-2) has created numerous challenges in the context of public management, not only in public health, but also in the economy and education; and even in the aspects of social and individual life, leaving hundreds of millions of cases and millions of deaths, transforming the known reality. Given this context, this e-book sought to aggregate and compile experiences of the State Department of Health of Goiás (SES/GO) in facing the pandemic, in the most different aspects of health management (surveillance, regulation, assistance, transparency, people management , between others)

Increase in the diagnosis of mycobacteremia after the implementation of semi-automated blood culture at a Brazilian public health laboratory.

INTRODUCTION: The prevalence of hematogenous dissemination of mycobacteria is high in immunosuppressed patients. The isolation of mycobacteria in culture remains the standard procedure. METHODS: This is a cross-sectional study based on the results of solid (Löwenstein-Jensen medium) and semi-automated liquid (BACTEC 9240) blood cultures, obtained from the Lacen-GO database. RESULTS: The implementation of a semi-automated procedure resulted in an increase of 61.5% and 350.0% in the positive results for Mycobacterium tuberculosis complex and nontuberculous mycobacteria, respectively. This technique also accelerated the detection of positive results. CONCLUSIONS: Semi-automated liquid blood culture showed a better performance in the diagnosis of mycobacteremia.

Increase in the diagnosis of mycobacteremia after the implementation of semi-automated blood culture at a Brazilian public health laboratory

Abstract INTRODUCTION The prevalence of hematogenous dissemination of mycobacteria is high in immunosuppressed patients. The isolation of mycobacteria in culture remains the standard procedure. METHODS This is a cross-sectional study based on the results of solid (Löwenstein-Jensen medium) and semi-automated liquid (BACTEC 9240) blood cultures, obtained from the Lacen-GO database. RESULTS The implementation of a semi-automated procedure resulted in an increase of 61.5% and 350.0% in the positive results for Mycobacterium tuberculosis complex and nontuberculous mycobacteria, respectively. This technique also accelerated the detection of positive results. CONCLUSIONS Semi-automated liquid blood culture showed a better performance in the diagnosis of mycobacteremia.

Impact of Implementing 100% Rapid Review as a Quality Control Tool in Cervical Cytology.

OBJECTIVE: We aimed to evaluate the impact of implementing 100% rapid review (100% RR) as a quality control tool in cervical smear cytology. DESIGN: A cross-sectional study was conducted in which cytology findings, false-negative results, and quality indicators were evaluated. The variables were analyzed in 2004, the year in which 100% RR was implemented, and again in 2013, i.e., 10 years on. RESULTS: Detection of atypical squamous cells of undetermined significance (ASC-US) increased from 0.90% in 2004 to 2.47% in 2013 by routine screening. Detection of atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion (ASC-H) increased from 13.33% in 2004 to 36.27% in 2013 by 100% RR. Detection of high-grade squamous intraepithelial lesion (HSIL) increased from 0.64% in 2004 to 4.29% in 2013 by routine screening, and increased from 0% in 2004 to 19.61% in 2013 by 100% RR. There was a significant increase (p = 0.00001) in the identification of false-negative results of ASC-US, low-grade squamous intraepithelial lesion, ASC-H, HSIL, and atypical glandular cells. All quality indicators had increased in 2013 when compared to 2004 results. CONCLUSIONS: Ten years after the implementation of the 100% RR method, improvements were found in the detection of atypia and precursor lesions and in quality indicators.

Reproducibility of cervical cytopathology following an intervention by an external quality control laboratory.

BACKGROUND: This study assessed the effects of a continued education program on the agreement between cervical cytopathology exams interpreted by local laboratories and interpretation made by an external quality control laboratory (LabMEQ). METHODS: Overall, 9,798 exams were analyzed between 2007 and 2008, prior to implementation of a continued education program, and 10,028 between 2010 and 2011, following implementation. Continued education consisted of theoretical and practical classes held every two months. The chi-square test and the kappa coefficient were used in the statistical analysis. RESULTS: Following implementation of continued education, the rate of false-negative results, and those leading to delays in clinical management fell in eight laboratories and the rate of false-positive results in five. Agreement between the results reported by the laboratories and the findings of LabMEQ, evaluated according to clinical management, remained excellent in three laboratories (kappa >0.80 and <1.0), went from good (kappa >0.60 and <0.80) to excellent in seven and from excellent to good in two. Agreement regarding the identification of metaplastic epithelium was poor (kappa = 0.25) but progressed to excellent following the implementation of continued education (kappa = 0.950). Agreement between cytopathology results improved significantly following implementation of continued education in cases reported as unsatisfactory (P < 0.001), atypical squamous cells of undetermined significance, cannot exclude high-grade squamous intraepithelial lesion (P < 0.001), low-grade squamous intraepithelial lesion (P < 0.001), and glandular atypia (P < 0.001). CONCLUSION: Continued education contributed towards improving the reproducibility of cervical cytopathology, decreased the rates of false-negative and false-positive results, and reduced delays in clinical management.

Internal quality control indicators of cervical cytopathology exams performed in laboratories monitored by the External Quality Control Laboratory.

PURPOSE: To evaluate the impact of continued education provided by an external quality control laboratory on the indicators of internal quality control of cytopathology exams. METHODS: The internal quality assurance indicators for cytopathology exams from 12 laboratories monitored by the External Quality Control Laboratory were evaluated. Overall, 185,194 exams were included, 98,133 of which referred to the period preceding implementation of a continued education program, while 87,061 referred to the period following this intervention. Data were obtained from the Cervical Cancer Database of the Brazilian National Health Service. RESULTS: Following implementation of the continued education program, the positivity index (PI) remained within recommended limits in four laboratories. In another four laboratories, the PI progressed from below the limits to within the recommended standards. In one laboratory, the PI remained low, in two laboratories, it remained very low, and in one, it increased from very low to low. The percentage of exams compatible with a high-grade squamous intraepithelial lesion (HSIL) remained within the recommended limits in five laboratories, while in three laboratories it progressed from below the recommended levels to >0.4% of the total number of satisfactory exams, and in four laboratories it remained below the standard limit. Both the percentage of atypical squamous cells of undetermined significance (ASC-US) in relation to abnormal exams, and the ratio between ASC-US and intraepithelial lesions remained within recommended levels in all the laboratories investigated. CONCLUSION: An improvement was found in the indicators represented by the positivity index and the percentage of exams compatible with a high-grade squamous intraepithelial lesion, showing that the role played by the external quality control laboratory in providing continued education contributed towards improving laboratory staff skills in detecting cervical cancer precursor lesions.

Internal quality control indicators of cervical cytopathology exams performed in laboratories monitored by the External Quality Control Laboratory / Avaliação de indicadores de controle de qualidade interno de exames de citopatologia cervical realizados em laboratórios monitorados pelo Laboratório Externo de Controle de Qualidade

PURPOSE: To evaluate the impact of continued education provided by an external quality control laboratory on the indicators of internal quality control of cytopathology exams. METHODS: The internal quality assurance indicators for cytopathology exams from 12 laboratories monitored by the External Quality Control Laboratory were evaluated. Overall, 185,194 exams were included, 98,133 of which referred to the period preceding implementation of a continued education program, while 87,061 referred to the period following this intervention. Data were obtained from the Cervical Cancer Database of the Brazilian National Health Service. RESULTS: Following implementation of the continued education program, the positivity index (PI) remained within recommended limits in four laboratories. In another four laboratories, the PI progressed from below the limits to within the recommended standards. In one laboratory, the PI remained low, in two laboratories, it remained very low, and in one, it increased from very low to low. The percentage of exams compatible with a high-grade squamous intraepithelial lesion (HSIL) remained within the recommended limits in five laboratories, while in three laboratories it progressed from below the recommended levels to >0.4% of the total number of satisfactory exams, and in four laboratories it remained below the standard limit. Both the percentage of atypical squamous cells of undetermined significance (ASC-US) in relation to abnormal exams, and the ratio between ASC-US and intraepithelial lesions remained within recommended levels in all the laboratories investigated. CONCLUSION: An improvement was found in the indicators represented by the positivity index and the percentage of exams compatible with a high-grade squamous intraepithelial lesion, showing that the role played by the external quality control laboratory in providing continued education contributed towards improving laboratory staff skills ...

OBJETIVOS: Verificar o impacto da educação continuada realizada pelo Laboratório de Monitoramento Externo da Qualidade nos indicadores de monitoramento interno da qualidade dos exames citopatológicos. MÉTODOS: O estudo avaliou os indicadores de monitoramento interno da qualidade dos exames citopatológicos de 12 laboratórios monitorados pelo Laboratório de Monitoramento Externo da Qualidade, totalizando 185.194 exames, sendo 98.133 referentes ao período antes da educação continuada e 87.061 após a educação continuada. Os dados para avaliar os indicadores foram obtidos por meio do Sistema de Informações do Câncer do Colo do Útero disponibilizados pelo Departamento de Informática do Sistema Único de Saúde. RESULTADOS: Verificou-se que, após a educação continuada, quatro laboratórios mantiveram o índice de positividade (IP) dentro do recomendado, quatro que estavam abaixo passaram a ter o IP dentro do recomendado, um permaneceu baixo, dois permaneceram muito baixo e um passou de muito baixo para baixo. Em relação ao indicador percentual de exames compatíveis com lesão intraepitelial escamosa de alto grau, cinco laboratórios mantiveram o índice dentro do recomendado, três que estavam abaixo do recomendado passaram a ter esse índice acima de 0,4 e quatro permaneceram abaixo do recomendado. Os indicadores atipias de significado indeterminado/alterados e razão atipias de significado indeterminado/lesões intraepiteliais mantiveram-se dentro do recomendado em todos os laboratórios. CONCLUSÃO: Observou-se melhora nos indicadores de positividade e percentual de exames compatíveis com lesão intraepitelial de alto grau, mostrando que o papel desempenhado pelo Laboratório de Monitoramento Externo da Qualidade contribui para o aprimoramento ...

External quality control of cervical cytopathology: interlaboratory variability.

OBJECTIVE: To compare the variability of screening tests held at laboratories with the Unit for External Quality Control (UEQC), checking the frequency of cases that were discordant, false-positive, false-negative, unsatisfactory or that had a delay in clinical management and diagnostic agreement. MATERIALS AND METHODS: The study analyzed 10,053 screening tests from January 2007 to December 2008, including all positive cases, all those that fall under unsatisfactory and at least 10% of negative screening tests. The magnitude of the agreement was analyzed using the kappa coefficient. RESULTS: Out of the 10,053 cases analyzed, 7.59% were considered disagreeing, and it was estimated that 1.1% were false-negative. There was a delay in the clinical procedure regarding 2.44% cases. There were 2.82% of cases identified as false-positive and 1.24% as unsatisfactory. The diagnostic agreement was excellent (kappa = 0.81). The agreement of most laboratories concerning screening tests was classified as very good. The agreement of the sample adequacy was reasonable (kappa = 0.30) and the agreement regarding the representation of epithelia was considered excellent. CONCLUSION: Most laboratories showed very good agreement; however, it is worthy of note that to establish the standardization of diagnostic criteria, and enhance the accuracy of screening and improve the quality of cytopathology test results, it is necessary to perform external quality control.

Tendência de mortalidade por câncer do colo do útero no estado de Goiás no período de 1989 a 2009 / Trend of Mortality from Cervical Cancer in the State of Goiás in the Period

Introdução: O câncer do colo do útero é um problema de saúde pública devido aos altos índices de morbimortalidade.Objetivo: Analisar a evolução da mortalidade por câncer do colo do útero em Goiás entre os anos de 1989 e 2009. Método: Estudo retrospectivo de série temporal. Os dados foram obtidos do Sistema de Informação sobre Mortalidade, pesquisados na base de dados do Departamento de Informática do Sistema Único de Saúde, e os da população do Instituto Brasileiro de Geografia e Estatística. Para a análise de tendência, foi utilizado o programa joinpoint. Resultados: Na faixa etária de 30 a 59 anos, as taxas são crescentes e evoluem acompanhando o envelhecimento. A análise de tendência para óbitos por câncer do colo do útero em mulheres dos 50 aos 59 anos de idade mostrou uma redução da mudança percentual anual a partir de 2004 e tendência de estabilidade para as outras faixas etárias. No Estado de Goiás, houve uma estabilização da mudança percentual anual para o primeiro período analisado, com posterior redução após a implantação do Programa Viva Mulher. Conclusão: Concluiu-se, neste estudo, que houve tendência de estabilidade da mortalidade por câncer do colo do útero ao longo da série analisada; porém, ao observar antes e após a implantação do Programa, houve uma diminuição da mudança percentual anual, com valores de p significativos, o que reflete certa eficiência das ações de prevenção, diagnóstico e tratamento impulsionadas em Goiás a partir Programa Viva Mulher.

Capacitação do agente comunitário de saúde visando reorganização do rastreamento do câncer do colo do útero / Training of community health agent seeking reorganization of the uterine cervical cancer screening

O componente mais importante da atenção primária para prevenção do câncer do colo do útero é a alta cobertura da população alvo. Nosso cenário, no entanto, é de excessos de controles num percentual pequeno das mulheres-alvo. Nas regiões onde a Estratégia Saúde da Família foi implantada, há um cenário favorável à reorganização do rastreamento do câncer do colo do útero. O objetivo deste estudo foi avaliar a aquisição de conhecimento de Agentes Comunitários de Saúde após capacitação acerca da prevenção do câncer do colo do útero. Após a capacitação, houve melhora significativa do conhecimento dos Agentes Comunitários de Saúde sobre a finalidade do exame citopatológico, condições ideais para realização, agente causador e fatores de risco para o câncer do colo do útero e sobre os resultados dos exames citopatológicos (p < 0,05). Não houve melhora do conhecimento sobre a população alvo e a periodicidade correta de realização do exame citopatológico.

The most important component of primary prevention of uterine cervical cancer is the high coverage of target population, however, our scenario is in excess of controls in a small percentage of women target. In regions where the Family Health Strategy was implemented there is a favorable scenario for the reorganization of screening for uterine cervical cancer. The aim of this study was to evaluate the acquisition of knowledge of Community Health Workers after training on the prevention of uterine cervical cancer. After the training significantly improved the knowledge of Community Health Agents about the purpose of Pap smear testing, ideal conditions for realization, the causative agent and risk factors for uterine cervical cancer and the results of cervical screening (p <0, 05). There was no improvement of knowledge about the target population and the frequency of correct implementation of the Pap test.

[Women with atypical, precursor lesions and invasive cervical cancer: behaviors according to the recommendations of the Ministry of Health]. / Mulheres com atipias, lesões precursoras e invasivas do colo do útero: condutas segundo as recomendações do Ministério da Saúde.

PURPOSE: To verify whether women with atypias of undetermined significance and precursor lesions or invasive cervical outcomes were referred to Medium Complexity Units (MCU) following the guidelines recommended by the Brazilian Ministry of Health. METHODS: Retrospective study based on the cytopathological outcomes of users of the Unified Health System, seen at Basic Health Assistance Units (BHAU) and referred to MCUs in the municipality of Goiânia, state of Goiás, from 2005 to 2006. We assessed 832 records according to the recommendations of the Brazilian Ministry of Health, as established by the Brazilian Nomenclature for Cervical Cytopathologic Outcomes and Recommended Clinical Practice. To check the distribution of variables such as reasons for referral, results of colposcopy and histopathology and clinical procedures we calculated absolute and relative frequencies, mean, minimum and maximum values. RESULTS: We understood 72.7% of the referrals were not in accordance with the recommendations of the Ministry of Health. There were 605 women with test results classified as atypical squamous cells of undetermined significance, possibly non-neoplasms, and squamous intraepithelial lesion of low level which were sent to MCU, and of these 71.8% were submitted to colposcopy, and 64.7% had histopathological examination which results were classified as 31.0% with non-neoplasms and 44.6% as NIC I. Out of 211 women with results classified as more severe squamous lesions, 86.3% were submitted to colposcopy and 68.7% of these had histopathological examinations. CONCLUSIONS: The results of this study revealed high rates of inappropriate referrals to MCU, which required a high percentage of unnecessary procedures. The recommendations of the Ministry of Health were followed by BHAU and the majority of women received counseling/treatment as recommended.

Mulheres com atipias, lesões precursoras e invasivas do colo do útero: condutas segundo as recomendações do Ministério da Saúde / Women with atypical, precursor lesions and invasive cervical cancer: behaviors according to the recommendations of the Ministry of Health

OBJETIVO: Verificar se as mulheres com atipias de significado indeterminado e lesões precursoras ou invasivas do colo do útero foram encaminhadas para uma Unidade de Média Complexidade (UMC) conforme as condutas recomendadas pelo do Ministério da Saúde. MÉTODOS: Estudo retrospectivo com base nos resultados dos exames citopatológicos de mulheres usuárias do Sistema Único de Saúde, atendidas nas Unidades de Atenção Básica de Saúde (UABS), encaminhadas para a UMC do município de Goiânia (GO) no período de 2005 a 2006. Foram analisados 832 prontuários seguindo-se como padrão de avaliação as recomendações do Ministério da Saúde expostas na Nomenclatura Brasileira para Laudos Cervicais e Condutas Clínicas Preconizadas. Para verificar a distribuição das variáveis motivos de encaminhamento, resultados dos exames colposcópicos e histopatológicos, e condutas clínicas utilizou-se o cálculo de frequências absolutas e relativas, média, valores mínimo e máximo. RESULTADOS: Observou-se que 72,7% dos encaminhamentos não estavam em conformidade com as recomendações do MS. Das 605 mulheres com resultados classificados como células escamosas atípicas de significado indeterminado, possivelmente não neoplásicas, e lesão intraepitelial de baixo grau encaminhadas à UMC, 71,8% foram submetidas à colposcopia e 64,7% submetidas a exames histopatológicos cujos resultados foram classificados como sem neoplasias em 31,0% e NIC I em 44,6%. Das 211 mulheres com resultados classificados como lesões escamosas mais graves, 86,3% foram submetidas à colposcopia e destas 68,7% a exames histopatológicos. CONCLUSÕES: Os resultados deste estudo mostraram elevada frequência de encaminhamentos inadequados para Unidade de atendimento secundário, o que demandou alto percentual de procedimentos desnecessários. As recomendações do MS foram seguidas pelas Unidades secundárias e a maioria das mulheres recebeu orientação/tratamento preconizados.

PURPOSE: To verify whether women with atypias of undetermined significance and precursor lesions or invasive cervical outcomes were referred to Medium Complexity Units (MCU) following the guidelines recommended by the Brazilian Ministry of Health. METHODS: Retrospective study based on the cytopathological outcomes of users of the Unified Health System, seen at Basic Health Assistance Units (BHAU) and referred to MCUs in the municipality of Goiânia, state of Goiás, from 2005 to 2006. We assessed 832 records according to the recommendations of the Brazilian Ministry of Health, as established by the Brazilian Nomenclature for Cervical Cytopathologic Outcomes and Recommended Clinical Practice. To check the distribution of variables such as reasons for referral, results of colposcopy and histopathology and clinical procedures we calculated absolute and relative frequencies, mean, minimum and maximum values. RESULTS: We understood 72.7% of the referrals were not in accordance with the recommendations of the Ministry of Health. There were 605 women with test results classified as atypical squamous cells of undetermined significance, possibly non-neoplasms, and squamous intraepithelial lesion of low level which were sent to MCU, and of these 71.8% were submitted to colposcopy, and 64.7% had histopathological examination which results were classified as 31.0% with non-neoplasms and 44.6% as NIC I. Out of 211 women with results classified as more severe squamous lesions, 86.3% were submitted to colposcopy and 68.7% of these had histopathological examinations. CONCLUSIONS: The results of this study revealed high rates of inappropriate referrals to MCU, which required a high percentage of unnecessary procedures. The recommendations of the Ministry of Health were followed by BHAU and the majority of women received counseling/treatment as recommended.

Desempenho da metodologia de revisão rápida de 100% em esfregaços citopatológicos do colo do útero com e sem informações clínicas / Performance of the 100% rapid review methodology on cervix Pap smears with and without clinical information

Neste estudo foi avaliada a metodologia de revisão rápida de 100% em esfregaços com e sem informações de critérios de risco clínicos utilizando-se o tempo médio de um e dois minutos. Um total de 5.395 esfregaços foi analisado, dos quais 274 foram classificados como alterados e 5.121 como negativos após análise de rotina. Das amostras negativas, 958 continham informações de critérios de risco clínicos, as quais foram submetidas a revisão rápida, que identificou 10 (1,04%) como alteradas quando foi utilizado o tempo de um minuto e 9 (0,93 %) com o tempo de dois minutos. Dos 4.163 esfregaços negativos sem informações de critérios de risco clínicos, após revisão rápida utilizando tempo de um e dois minutos, 35 (0,84%)foram identificados como alterados em ambos os tempos. Em esfregaços com informações de critérios de risco clínicos, a metodologia de revisão rápida apresentou sensibilidade de 83% e 75%, respectivamentepara o tempo de um minuto e dois minutos. Não houve diferença significativa na detecção de resultados falso-negativos em esfregaços com e sem informação de critérios de risco clínicos. Observou-se também que não houve diferença no desempenho da revisão rápida na detecção de resultados falso-negativos, utilizando-se os tempos de um e dois minutos.

Fatores que comprometem a adequabilidade da amostra citológica cervical / Factors that compromise the adequacy of cytological cervical sample

O exame citopatológico é o método mais difundido mundialmente para o rastreamento do câncer do colo do útero e de suas lesões precursoras, porém sua vulnerabilidade a erros de coleta e preparação da lâmina e a subjetividade na interpretação dos resultados podem comprometer a sua sensibilidade e especificidade. Os fatores relacionados à adequabilidade da amostra têm sido considerados responsáveis por resultados falso-negativos, como a não representação de células endocervicais e/ou zona de transformação, a presença de sangue, o infiltrado leucocitário e os artefatos de fixação. Esses fatores retratam os erros da coleta e contribuem para os resultados falso-negativos relacionados a erros de escrutínio e de interpretação. Dessa forma, considerando esses fatores que podem comprometer a adequabilidade da amostra citológica cervical, o presente artigo revisa a literatura e discute estudos sobre o tema.

The cytopathological test is the most widely used method worldwide for screening of cervical cancer and its precursor lesions, but their vulnerability to errors of collection, preparation of the blade and subjectivity in the interpretation of results may jeopardize its sensitivity and specificity. Factors related to suitability of the sample have been considered as responsible for false-negative results, such as the non-representation of endocervical cells and/or transformation zone, the presence of blood, leukocyte infiltration and artifacts of attachment. These factors usually portray the errors of collection, which may also lead to false-negative results associated with scrutiny and interpretation errors. Therefore, considering the factors that may compromise the cervical cytological sample adequability, this article reviews the literature and brings a discussion on studies on the subject.

Influência da adequabilidade da amostra sobre a detecção das lesões precursoras do câncer cervical / Influence of adequacy of the sample on detection of the precursor lesions of the cervical cancer

OBJETIVO: avaliar se a adequabilidade da amostra influencia na detecção das lesões precursoras do câncer do colo do útero. MÉTODOS: este foi um estudo de corte transversal, realizado no período de Janeiro de 2004 a Dezembro de 2005. Foram incluídos 10.951 resultados de exames citopatológicos cervicais, tendo como base usuárias do Sistema Único de Saúde de Goiânia, Goiás. Essas mulheres procuraram, espontaneamente, os serviços do Programa Saúde da Família ou Unidades Básicas de Saúde. A coleta foi feita por médicos e enfermeiros por meio da técnica convencional para rastreamento de câncer do colo do útero. Os esfregaços analisados foram classificados de acordo com o Sistema Bethesda, sendo a adequabilidade da amostra definida durante o escrutínio de rotina e categorizada como: satisfatória; satisfatória, porém apresentando fatores que prejudicam parcialmente a análise; e insatisfatória. Os resultados obtidos foram armazenados no programa Epi-Info 3.3.2. Para a comparação entre os resultados alterados e a adequabilidade da amostra dos esfregaços citopatológicos utilizou-se o teste do χ². Foram consideradas significantes as diferenças em que a probabilidade de rejeição da hipótese de nulidade foi menor que 5% (p<0,05). RESULTADOS: do total de 10.951 esfregaços, 51,1% foram classificados com adequabilidade satisfatória para análise, 46,6% como satisfatórios, mas apresentando algum fator limitante, e 2,3% como insatisfatórios. Os principais fatores que prejudicaram parcialmente a análise foram: ausência de células endocervicais (52,2%), esfregaços dessecados (22,8%), purulentos (14,9%) ou com áreas espessas (9,5%). Observou-se uma maior freqüência de esfregaços alterados quando a amostra foi classificada como satisfatória para análise e com representação de células endocervicais, ASC-US (2,3%), ASC-H (0,6%), LSIL (3,2%), HSIL (1,7%) e 0,3% de AGC; as diferenças foram significativas com p=0,001...

PURPOSE: to evaluate whether the sample adequacy influences the detection of precursor cervical cancer lesions. METHODS: a transversal study from January 2004 to December 2005. A number of 10,951 results of cervical cytotopathological exams from users of the National Health System (Sistema Único de Saúde, SUS) in Goiânia, Goiás, Brazil, was studied. These women had spontaneously looked for the services from the Family Health Program or from the Basic Units of Health. Samples were collected by medical doctors and nurses, through the conventional technique to detect cervical cancer. The analyzed smears were classified by the Bethesda System, the sample adequacy being defined along the routine screening and categorized as: satisfactory, satisfactory but presenting factors that might partially jeopardize the analysis, and unsatisfactory. Results were stored in the Epi-Info 3.3.2 program. The χ² test was used to compare altered results with the adequacy of the samples from cytopathological smears. Differences with probability of rejection of the null hypothesis lower than 5% (p<0.05) were considered as significant. RESULTS: From 10,951 smears, 51.1% were classified as having satisfactory adequacy for analysis, 46.6% as satisfactory, but presenting some limiting factors, and 2.3%, as unsatisfactory. The main factors which have partially jeopardized the analysis were: lack of endocervical cells (52.2%), dried smears (22.8%), purulence (14.9%), or smears with some thick areas (9.5%). There was a higher rate of altered smears when the sample had been classified as satisfactory for analysis and with representation of endocervical cells ASC-US (2.3%), ASC-H (0.6%), LSIL (3.2%), HSIL (1.7%) and 0.3% of AGC. Differences were significant when p=0.001. The rate of low and high grade lesions was higher when the smears were satisfactory for analysis...

[Influence of adequacy of the sample on detection of the precursor lesions of the cervical cancer]. / Influência da adequabilidade da amostra sobre a detecção das lesões precursoras do câncer cervical.

PURPOSE: to evaluate whether the sample adequacy influences the detection of precursor cervical cancer lesions. METHODS: a transversal study from January 2004 to December 2005. A number of 10,951 results of cervical cytopathological exams from users of the National Health System (Sistema Unico de Saúde, SUS) in Goiânia, Goiás , Brazil, was studied. These women had spontaneously looked for the services from the Family Health Program or from the Basic Units of Health. Samples were collected by medical doctors and nurses, through the conventional technique to detect cervical cancer. The analyzed smears were classified by the Bethesda System, the sample adequacy being defined along the routine screening and categorized as: satisfactory, satisfactory but presenting factors that might partially jeopardize the analysis, and unsatisfactory. Results were stored in the Epi-Info 3.3.2 program. The chi2 test was used to compare altered results with the adequacy of the samples from cytopathological smears. Differences with probability of rejection of the null hypothesis lower than 5% (p<0.05) were considered as significant. RESULTS: From 10,951 smears, 51.1% were classified as having satisfactory adequacy for analysis, 46.6% as satisfactory, but presenting some limiting factors, and 2.3%, as unsatisfactory. The main factors which have partially jeopardized the analysis were: lack of endocervical cells (52.2%), dried smears (22.8%), purulence (14.9%), or smears with some thick areas (9.5%). There was a higher rate of altered smears when the sample had been classified as satisfactory for analysis and with representation of endocervical cells ASC-US (2.3%), ASC-H (0.6%), LSIL (3.2%), HSIL (1.7%) and 0.3% of AGC. Differences were significant when p=0.001. The rate of low and high grade lesions was higher when the smears were satisfactory for analysis. CONCLUSIONS: the rate of precursor uterine cervix cancer lesions varies according to the sample adequacy, and the main adequacy limitations of the sample are mainly related to the collection condition.

Controle de qualidade em citopatologia cervical: revisão de literatura / Quality control in cervical cytopathology: a literature review

O exame citopatológico é importante ferramenta para a detecção das lesões precursoras do câncer do colo uterino que, naquele momento, são tratáveis, resultando em significante decréscimo da mortalidade. Entretanto, o exame citopatológico apresenta falhas, pois a taxa de resultados falso-negativos pode variar de 2 por cento a 50 por cento. Os resultados falso-negativos ocorrem principalmente devido a erro de coleta, de escrutínio e de interpretação. O controle interno e o externo da qualidade na rotina dos laboratórios têm como objetivo final melhorar o desempenho diagnóstico do exame citopatológico, além de possibilitar a avaliação do desempenho do escrutinador e a identificação de causas de erros relacionados à coleta. O controle interno da qualidade pode ser realizado regularmente e abrange o monitoramento da adequabilidade da amostra, a observação do tempo de escrutínio, o controle da carga de trabalho do escrutinador, a revisão hierárquica dos esfregaços e a revisão dos esfregaços negativos. O controleinterno de qualidade também pode compreender a análise da correlação cito-histológica, a revisão de exames anteriores, o monitoramento estatístico da freqüência das lesões e da adequabilidade da amostra, a inclusão proposital de esfregaços anormais na rotina. Educação continuada, qualificação do pessoal e exame de proficiência periódico são estratégias a serem adotadas. Revisão aleatória ou total dos exames, revisão rápida ou detalhada sãométodos que têm vantagens e desvantagens na detecção dos resultados falso-negativos. Cabe ao laboratório definira melhor estratégia de controle interno da qualidade que permita a melhoria do processo técnico e, conseqüentemente, da qualidade do serviço dos laboratórios de citopatologia.

A revisão rápida de 100 por cento é eficiente na detecção de resultados falsos-negativos dos exames citopatológicos cervicais e varia com a adequabilidade da amostra: uma experiência no Brasil / The 100 percent rapid rescreening is efficient in the detection of false-negative results and varies according to the quality of the sample: a Brazilian experience

OBJETIVO: avaliar a eficiência da revisão rápida de 100 por cento para detecção de resultados falsos-negativos dos exames citopatológicos cervicais e verificar se esses resultados variam com a adequabilidade da amostra e com a idade da mulher. MÉTODOS: para avaliar a eficiência da revisão rápida, os 5.530 esfregaços classificados como negativos pelo escrutínio de rotina, após serem submetidos à revisão rápida de 100 por cento, foram comparados com as revisões dos esfregaços com base em critérios clínicos e aleatória de 10 por cento. Para análise estatística, as variáveis foram estudadas de maneira descritiva e, quando houve comparação, foram aplicados o teste do chi2 e o teste Cochran-Armitage. RESULTADOS: dos 141 esfregaços suspeitos pela revisão rápida, 84 (59,6 por cento) foram confirmados pelo diagnóstico final; desses, 36 (25,5 por cento) foram classificados como células escamosas atípicas de significado indeterminado, cinco (3,5 por cento) como células escamosas atípicas, não podendo excluir lesão de alto grau, 34 (24,1 por cento) como lesão intra-epitelial escamosa de baixo grau, seis (4,3 por cento) como lesão intra-epitelial de alto grau e três (2,1 por cento) como células glandulares atípicas. Dos 84 esfregaços suspeitos e confirmados pelo diagnóstico final, 62 (73,8) foram classificados como satisfatórios e 22 (26,2 por cento) satisfatórios, porém com alguma limitação, mas não se observou diferença significativa com a idade da mulher. CONCLUSÕES: os resultados deste estudo mostraram que a revisão rápida é uma alternativa eficiente como método de controle interno da qualidade na detecção de resultados falsos-negativos dos exames citopatológicos cervicais. Observou-se, também, que a revisão rápida apresentou melhor desempenho quando a amostra foi classificada como satisfatória para análise, porém não variou com a idade da mulher.

PURPOSE: to evaluate the efficiency of the 100 percent rapid rescreening in the detection of false-negative results and to verify whether the results vary according to the adequacy of the sample and the woman’s age group. METHODS: to evaluate the efficiency of the rapid rescreening, the 5,530 smears classified as negative by the routine screening, after being submitted to the rapid rescreening of 100 percent, were compared with the rescreening of the smears on the basis of clinical criteria and 10 percent random rescreening. For statistical analysis, the variables were evaluated descriptively and the c² test and the Cochran-Armitage test were applied to compare results. RESULTS: of the 141 smears identified as suspicious according to the rapid rescreening method, 84 (59.6 percent) cases were confirmed in the final diagnosis, of which 36 (25.5 percent) were classified as atypical squamous cells of undetermined significance, five (3.5 percent) as atypical squamous cells that cannot exclude high-grade squamous intraepithelial lesion, 34 (24.1 percent) as low-grade squamous intraepithelial lesion, six (4.3 percent) as high-grade squamous intraepithelial lesion, and three (2.1 percent) as atypical glandular cells. Of the 84 suspect smears confirmed in the final diagnosis, 62 (73.8 percent) smears were classified as adequate and 22 (26.2 percent) as adequate but with some limitation, but no significant difference was observed with the woman’s age. CONCLUSIONS: the results of this study show that rapid rescreening is an efficient option for internal quality control for the detection of false-negative cervical smear results. In addition, it should be noted that rapid rescreening performed better when the sample was classified as adequate for analysis; however, it did not vary according to the woman’s age group.

Revisão rápida de 100 / 100 rapid rescreening: an efficient method at detecting false negative cervical cytopathology

Este estudo teve como objetivo comparar o desempenho da revisão rápida de 100%, revisão aleatória de 10% como métodos de controle interno da qualidade dos esfregaços cervicais negativos no escrutínio de rotina. Foram analisados 3.149 esfregaços desses, 173 foram classificados como positivos, 2.887 como negativos e 89 esfregaços insatisfatórios. Os esfregaços classificados como negativos foram submetidos aos métodos de revisão rápida de 100% e revisão aleatória de 10%. A revisão rápida de 100% identificou 92 esfregaços suspeitos, desses 42 foram considerados positivos pelo diagnóstico final. Dos 289 esfregaços encaminhados para arevisão de 10%, quatro foram considerados alterados, mas apenas um foi confirmado como positivo pelo diagnóstico final. A revisão rápida de 100% é mais eficiente na detecção de resultados falso-negativos do que a revisão aleatória de 10% e pode ser recomendado como método de controle interno da qualidade.

The aim of this study was to compare the performance of the 100% rapid rescreening and the 10% random rescreening as methods for internal quality control of cervical smears classified as negative during routine screening. A total of 3,149 smears were analyzed, 173 were classified as positive and 2,887 as negative, while 89 smears were considered unsatisfactory. The smears classified as negative were submitted to the 100% rapid rescreening and the 10% random rescreening. The 100% rapid rescreening method identified 92 suspect smears, where 42 were considered positive as final diagnosis. Of the 289 smears submitted to the 10% rescreening method, 4 were considered abnormal, but only one was confirmed positive as the final diagnosis. The 100% rapid rescreening method is more efficient to detect false negative results than the 10% random rescreening and should be recommended as an internal quality control method.