Task-shifting for point-of-care cervical cancer prevention in low- and middle-income countries: a case study from Uganda.

Cervical cancer remains the leading cause of female cancer deaths in sub-Saharan Africa. This is despite cervical cancer being both preventable and curable if detected early and treated adequately. This paper reports on a series of action-research 'cycles' designed to progressively integrate a comprehensive, task-shifted, point-of-care, prevention program in a community-based public health facility in Uganda. The work has been undertaken through a UK-Ugandan Health Partnership coordinated by Knowledge for Change, a UK-registered Charity. The intervention demonstrates the effectiveness of task-shifting responsibility to Community Health Workers combined with the use of Geographic Information Systems to strategically guide health awareness-raising and the deployment of medical devices supporting respectful and sustainable point-of-care screen-and-treat services. The integration of this with public human immunodeficiency virus services demonstrates the ability to engage hard-to-reach 'key populations' at greatest risk of cervical cancer. The findings also demonstrate the impact of external influences including the Results Based Financing approach, adopted by many foreign Non-Governmental Organizations. The model presents opportunities for policy transfer to other areas of health promotion and prevention with important lessons for international Health partnership engagement. The paper concludes by outlining plans for a subsequent action-research cycle embracing and evaluating the potential of Artificial Intelligence to enhance service efficacy.

Primary care sector versus treatment centre follow up for post-treatment cervical squamous intraepithelial neoplasia (SIL).

OBJECTIVE: The NHSCSP 2004 guideline recommends that the best practice for the follow up of post-treatment squamous intraepithelial neoplasia (SIL) is by cytological surveillance in the treatment centre or alternatively, in the primary care sector as a minimum standard. We undertook this study to test this recommendation. SETTING: In a colposcopy clinic of a district general hospital of UK. POPULATION: Retrospective analysis of 418 patients treated for squamous intraepithelial neoplasia whose post treatment cytological surveillance was followed up for 18 months after treatment. A prospective patient preference questionnaire was also undertaken in 50 randomly chosen patients having treatment to elicit their preferences for the place of follow up. RESULTS: At 8 months 66.4% had their first smear in the primary care sector as compared to 88.6% in the treatment centre. The post-treatment follow up smear performance graph seems to be different for the primary care sector compared to treatment centre. In 12 months nearly 90% of the patients had at least one smear and by 18 months 96.9% of the treated patients had a follow up smear in the community which would detect residual disease. There was no statistically significant difference in the detection of residual disease in the community compared to the treatment centre during the follow up period. A total of 76% of patients preferred to have their follow up smears in the primary care. CONCLUSION: Targets set by the NHSCSP of UK were not met either by the primary care sector or the treatment centre in the 8 months but was satisfactorily achieved by both in 12 months. RECOMMENDATION: These preliminary results indicate a need for a larger multi centre randomised trial to establish if the primary sector is truly a satisfactory alternative for patient follow up. Cytological surveillance is best carried out in the place desired by the patients to allow good compliance with the monitoring process.

Granulomatosis with polyangiitis causing subglottic stenosis-two cases and their management.

Granulomatosis with polyangiitis (GPA) is characterised by vasculitis of small and medium sized blood vessels and granulomatous lesions of the respiratory tract. The aetiology is unclear, however it is thought to be due to an autoimmune process with about 92% of patients with the disease being antineutrophilic cytoplasmic antibodies (ANCA) positive. Patients normally present in early adulthood, more commonly in the winter months. Seventy percent of patients with GPA present with ear, nose or throat symptoms. These include nasal congestion, crusting, epistaxis, nasal septal perforation and nasal saddle deformity. Lesions in the airway can lead to subglottic stenosis with resultant airway obstruction. Treatment of the disease complicated by subglottic stenosis is not straightforward and the benefits and risks of options including medical and surgical management need to be weighed up and tailored to each individual case. We describe two cases of GPA complicated by airway obstruction due to subglottic stenosis and their management.

Prevalence of high-grade squamous intraepithelial neoplasia (HiSIL) in symptomatic women referred to the colposcopy clinic with negative cytology.

OBJECTIVE: We have evaluated patients who were referred to the colposcopy clinic with postcoital and/or intermenstrual bleeding and suspicious looking cervix with normal smear tests (negative cytology) mainly to establish the incidence of underlying high-grade squamous intraepithelial neoplasia in these groups and also to look at our intervention rate. DESIGN: Retrospective study. SETTING: Colposcopy clinic in a District General Hospital in the United Kingdom. POPULATION: A total of 134 patients out of 812 new referrals to our colposcopy clinic during the study period were due to clinical indications only. RESULTS: Main indication for referral with negative cytology was post coital bleeding (47.8%). The main causes of postcoital and intermenstrual bleeding were cervical ectropions and polyps. The incidence high-grade squamous intraepithelial neoplasia (HiSIL) was 2.2% out of all the patients, which was determined after 66 biopsies. CONCLUSION: In the majority of cases the pathology is benign. However the underlying prevalence of high-grade cervical disease in symptomatic women with normal smears necessitates colposcopy in selected cases. Prior assessment in the gynaecology clinic, to rule out common pathology like polyps and ectropions would reduce patient anxiety and inappropriate referrals to the clinic.