Challenges Associated With Cervical Cancer Screening and Management in Obese Women: A Provider Perspective.

OBJECTIVES: Obese women are at increased risk of cervical cancer, partly due to missed detection of cervical precancers during routine cervical cancer screening. We administered a clinician survey to better understand specific challenges and identify potential solutions to performing cervical cancer screening and management in obese women. MATERIALS AND METHODS: We administered a web-based survey to 2,319 members of the American Society of Colposcopy and Cervical Pathology including questions related to challenges associated with cervical sampling and visualization in obese compared with normal weight women and potential strategies for improvement. We summarized providers' responses using descriptive statistics and used Fisher exact tests to evaluate associations between provider characteristics and challenges with cervical sampling, visualization, and biopsy. RESULTS: Of the 240 providers that completed the survey, 89% and 93% reported that cervical sampling and visualization are more challenging in obese women, respectively, whereas 80% reported that taking a biopsy was more challenging. Commonly reported barriers included vaginal prolapse, difficulty visualizing and accessing the cervix, and lack of long enough sampling devices and large enough speculums. Frequently used techniques to improve sampling and visualization included use of a condom or examination glove finger to sheath a speculum and using a tenaculum. Most providers identified training for cervical sampling and colposcopy in obese women as a learning gap, and only 8% reported receiving such training. CONCLUSIONS: Cervical cancer screening and management are more challenging in obese compared with normal weight women. Major barriers to cervical sampling and visualization included lack of adequately sized equipment and lack of education and training.

Ingrown Toenail Management.

Ingrown toenails account for approximately 20% of foot problems in primary care. The great toe is most often affected. Ingrown toenails occur most commonly in young men, and nail care habits and footwear are most often contributory factors. No consensus has been reached for the best treatment approach, but ingrown nails may be nonsurgically or surgically treated. Nonsurgical treatments are typically used for mild to moderate ingrown nails, whereas surgical approaches are used in moderate and severe cases. Simple nonsurgical palliative measures include correcting inappropriate footwear, managing hyperhidrosis and onychomycosis, soaking the affected toe followed by applying a mid- to high-potency topical steroid, and placing wisps of cotton or dental floss under the ingrown lateral nail edge. Application of a gutter splint to the ingrown nail edge to separate it from the lateral fold provides immediate pain relief. A cotton nail cast made from cotton and cyanoacrylate adhesive, taping the lateral nail fold, or orthonyxia may also alleviate mild to moderate ingrown toenail. Surgical approaches seek to remove the interaction between the nail plate and the nail fold to eliminate local trauma and inflammatory reaction. These approaches are superior to nonsurgical ones for preventing recurrence. The most common surgical approach is partial avulsion of the lateral edge of the nail plate. Matrixectomy further prevents recurrence and can be performed through surgical, chemical, or electrosurgical means.

ASCCP Colposcopy Standards: Role of Colposcopy, Benefits, Potential Harms, and Terminology for Colposcopic Practice.

OBJECTIVES: The American Society for Colposcopy and Cervical Pathology Colposcopy Standards address the role of and approach to colposcopy and biopsy for cervical cancer prevention in the United States. Working Group 1 was tasked with defining the role of colposcopy, describing benefits and potential harms, and developing an official terminology. METHODS: A systematic literature review was performed. A national survey of American Society for Colposcopy and Cervical Pathology members provided input on current terminology use. The 2011 International Federation for Cervical Pathology and Colposcopy terminology was used as a template and modified to fit colposcopic practice in the United States. For areas without data, expert consensus guided the recommendation. Draft recommendations were posted online for public comment and presented at an open session of the 2017 International Federation for Cervical Pathology and Colposcopy World Congress for further comment. All comments were considered for the final version. RESULTS: Colposcopy is used in the evaluation of abnormal or inconclusive cervical cancer screening tests. Colposcopy aids the identification of cervical precancers that can be treated, and it allows for conservative management of abnormalities unlikely to progress. The potential harms of colposcopy include pain, psychological distress, and adverse effects of the procedure. A comprehensive colposcopy examination should include documentation of cervix visibility, squamocolumnar junction visibility, presence of acetowhitening, presence of a lesion(s), lesion(s) visibility, size and location of lesions, vascular changes, other features of lesion(s), and colposcopic impression. Minimum criteria for reporting include squamocolumnar junction visibility, presence of acetowhitening, presence of a lesion(s), and colposcopic impression. CONCLUSIONS: A recommended terminology for use in US colposcopic practice was developed, with comprehensive and minimal criteria for reporting.

A common clinical dilemma: Management of abnormal vaginal cytology and human papillomavirus test results.

OBJECTIVE: Vaginal cancer is an uncommon cancer of the lower genital tract, and standardized screening is not recommended. Risk factors for vaginal cancer include a history of other lower genital tract neoplasia or cancer, smoking, immunosuppression, and exposure to diethylstilbestrol in utero. Although cervical cancer screening after total hysterectomy for benign disease is not recommended, many women inappropriately undergo vaginal cytology and/or human papillomavirus (hrHPV) tests, and clinicians are faced with managing their abnormal results. Our objective is to review the literature on vaginal cytology and hrHPV testing and to develop guidance for the management of abnormal vaginal screening tests. METHODS: An electronic search of the PubMed database through 2015 was performed. Articles describing vaginal cytology or vaginal hrHPV testing were reviewed, and diagnostic accuracy of these tests when available was noted. RESULTS: The available literature was too limited to develop evidence-based recommendations for managing abnormal vaginal cytology and hrHPV screening tests. However, the data did show that 1) the risk of vaginal cancer in women after hysterectomy is extremely low, justifying the recommendation against routine screening, and 2) in women for whom surveillance is recommended, e.g. women post-treatment for cervical precancer or cancer, hrHPV testing may be useful in identification of vaginal cancer precursors. CONCLUSION: Vaginal cancer is rare, and asymptomatic low-risk women should not be screened. An algorithm based on expert opinion is proposed for managing women with abnormal vaginal test results.

A Common Clinical Dilemma: Management of Abnormal Vaginal Cytology and Human Papillomavirus Test Results.

OBJECTIVE: Vaginal cancer is an uncommon cancer of the lower genital tract, and standardized screening is not recommended. Risk factors for vaginal cancer include a history of other lower genital tract neoplasia or cancer, smoking, immunosuppression, and exposure to diethylstilbestrol in utero. Although cervical cancer screening after total hysterectomy for benign disease is not recommended, many women inappropriately undergo vaginal cytology and/or human papillomavirus (HPV) tests, and clinicians are faced with managing their abnormal results. Our objectives were to review the literature on vaginal cytology and high-risk HPV (hrHPV) testing and to develop guidance for the management of abnormal vaginal screening tests. MATERIALS AND METHODS: An electronic search of the PubMed database through 2015 was performed. Articles describing vaginal cytology or vaginal hrHPV testing were reviewed, and diagnostic accuracy of these tests when available was noted. RESULTS: The available literature was too limited to develop evidence-based recommendations for managing abnormal vaginal cytology and hrHPV screening tests. However, the data did show that (1) the risk of vaginal cancer in women after hysterectomy is extremely low, justifying the recommendation against routine screening, and (2) in women for whom surveillance is recommended, e.g., women posttreatment for cervical precancer or cancer, hrHPV testing may be useful in identification of vaginal cancer precursors. CONCLUSIONS: Vaginal cancer is rare, and asymptomatic low-risk women should not be screened. An algorithm based on expert opinion is proposed for managing women with abnormal vaginal test results.

Photographic art in exam rooms may reduce white coat hypertension.

INTRODUCTION: Blood pressure (BP) elevation in medical office settings in patients who are normotensive in nonmedical settings is an effect known as 'white coat hypertension'. This phenomenon is thought to be due to situational anxiety caused by the experience of visiting a doctor and the anxiety-inducing nature of the medical office. Our study was designed to determine if carefully selected photographic art could counter the anxiety that causes white coat hypertension and lead to lower BP recordings in some patients. METHODS: 117 adults, non-pregnant patients from the Louisiana State University Health Sciences Center Family Medicine Resident Clinic participated in this study. After the triage nurse measured the BP, the patients were randomly placed in either an exam room with standard medical posters (control room) or in an exam room with photographic art (photo room). The BP was measured in the exam room. After the medical visit, the patients switched rooms and the BP was measured a third time. The patients were asked to fill out a questionnaire to identify room preference. RESULTS: On average, the BP obtained in the control rooms was higher than that obtained in the photo rooms. There was a statistically significant difference between the mean arterial pressure, systolic BP and diastolic BP between the control room and the photo room. CONCLUSIONS: Landscape photographic art may have the beneficial effect of reducing BP in medical office examination rooms.

Oral lesions you can't afford to miss.

Being able to promptly recognize and diagnose oral lesions is critical to heading off several potentially serious conditions. This article and photo guide can help.

Parent comprehension of polio vaccine information pamphlets.

BACKGROUND: Medical information pamphlets often are written using language that requires a reading level higher than parents of many pediatric patients have achieved. Anecdotal reports suggest that many parents may not readily understand the federally mandated Public Health Service vaccine information pamphlets prepared by the Centers for Disease Control and Prevention (CDC) in 1991. The level at which the pamphlets need to be written for low-reading-level parents is undetermined, as is whether parents reading at higher levels will accept low-reading-level materials. METHODS: To determine whether a simple pamphlet prepared at a low reading level using qualitative and adult education techniques would be preferable to the available CDC polio vaccine information pamphlet, we conducted an integrated qualitative-quantitative study. We compared the parent reading time and comprehension of a simplified pamphlet (Louisiana State University, LSU) comprising 4 pages, 322 words, 7 instructional graphics, and a text requiring a 6th grade reading ability with the equivalent 1991 CDC vaccine information pamphlet comprising 16 pages, 18,177 words, no graphics, and a text requiring a 10th grade reading level. We measured the reading ability of 522 parents of pediatric patients from northwest Louisiana seen at public clinics (81%) and in a private office (19%). Of the entire group, 39% were white, 60% African-American, and 1% Hispanic; the mean age was 29 years; the mean highest grade completed was 12th grade 3 months; and the reading level was less than 9th grade in 47% of parents and less than 7th grade in 20%. After parents were given one of the pamphlets to read, their reading time, comprehension, and attitude toward the pamphlet were measured. RESULTS: Mean comprehension was 15% lower for CDC than for LSU (56% vs 72% correct; P < .001) and reading time was three times longer for CDC than for LSU (13 minutes 47 seconds vs 4 minutes 20 seconds; P < .0001). These trends were significant for parents reading at all but the lowest levels. Mean comprehension and reading time did not differ among parents reading at the third grade level or less. However, mean comprehension was greater and reading time lower for LSU among parents at all reading abilities greater than the third grade. Parents in the private practice setting took the longest time to read the CDC (20 minutes 59 seconds vs 5 minutes 46 seconds, LSU), yet their comprehension on the LSU was significantly higher than on the CDC (94% vs 71%; P < .0001). Two focus groups of high-income parents were unanimous in preferring the LSU. CONCLUSIONS: A short, simply written pamphlet with instructional graphics was preferred by high- and low-income parents seen in private and public clinics. The sixth grade reading level appears to be too high for many parents in public clinics; new materials aimed at third to fourth grade levels may be required. The new 1994 CDC immunization materials, written at the eighth grade level, may still be inappropriately high. The American medical community should adopt available techniques for the development of more effective patient-parent education materials.

Reading ability of parents compared with reading level of pediatric patient education materials.

OBJECTIVES: To test the reading ability of parents of pediatric outpatients and to compare their reading ability with the ability necessary to read commonly used educational materials; to compare individual reading grade levels with the levels of the last grade completed in school; and to further validate a new literacy screening test designed specifically for medical settings. DESIGN: Prospective survey. SETTING: Pediatrics outpatient clinic in a large, public university, teaching hospital. PARTICIPANTS: Three hundred ninety-six parents or other caretakers accompanying pediatric outpatients. MEASUREMENTS: Demographics and educational status were assessed using a structured interview. Reading ability was tested using the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Wide Range Achievement Test-Revised. Written educational materials were assessed for readability levels with a computer program (Grammatik IV). RESULTS: The mean score on the REALM for all parents placed them in the seventh to eighth grade reading range, despite the mean self-reported last grade completed in school being 11th grade 5th month. Wide Range Achievement Test-Revised scores correlated well with REALM scores (0.82). Eighty percent of 129 written materials from the American Academy of Pediatrics, the Centers for Disease Control, the March of Dimes, pharmaceutical companies, and commercially available baby books required at least a 10th grade reading level. Only 25% of 60 American Academy of Pediatrics items and 19% of all materials tested were written at less than a ninth grade level, and only 2% of all materials were written at less than a seventh grade level. CONCLUSION: This study demonstrates that parents' self-reported education level will not accurately indicate their reading ability. Testing is needed to screen at-risk parents for low reading levels. In a public health setting, a significant amount of available parent education materials and instructions require a higher reading level than most parents have achieved. In such settings, all materials probably should be written at less than a high school level if most parents are to be expected to read them. The REALM can easily be used in busy public health clinics to screen parents for reading ability.

Why first-year family practice residents choose their residency programs.

BACKGROUND AND OBJECTIVES: This study identifies some of the factors that influenced program selection by first-year family practice residents. METHODS: In a national survey, 660 new first-year residents from 159 family practice programs responded to a questionnaire that asked them to cite the most important factors in choosing their program and rejecting other programs. RESULTS: The most important factors in selecting a program were location, reputation, faculty, and residents. The most important factors in deciding against other programs were location, reputation, residents, and curriculum. CONCLUSION: Our findings suggest that recruiters of first-year family practice residents need to address these factors in their recruiting efforts.

Effectiveness and safety of esophagogastroduodenoscopy in family practice: experience at a university medical center.

BACKGROUND AND OBJECTIVES: As the use of esophagogastroduodenoscopy (EGD) by family physicians increases, a need exists to further demonstrate the procedure's clinical effectiveness and safety and the general experience of family physicians performing the procedure. This study examines the general experience of a group of family physicians performing EGDs in the university setting. METHODS: An analysis was done of all patients undergoing EGDs performed by family physicians at a university hospital during a consecutive 27-month period. Demographics, indications, findings, diagnoses, therapy, complications, and biopsies were analyzed. Clinical effectiveness was measured by recording whether an EGD resulted in changes in diagnosis, medical therapy, or clinical management. Endoscopic diagnoses also were correlated with biopsy pathological diagnoses. RESULTS: During the study period, 188 EGDs were performed. Clinical management of patients was changed in 88.6% of cases. The diagnosis was changed in 81.8% of cases, and drug therapy was changed in 55.7% of cases. Endoscopic impressions were confirmed by biopsy in 93.2% of cases. Procedures were completed in 98.3% of cases with no complications. CONCLUSIONS: This study demonstrates the clinical effectiveness of EGDs performed by family physicians. The feasibility of family practice endoscopy in the university medical center setting has been demonstrated, and continued benefits from this practice are anticipated.

Colonoscopy experience at a family practice residency: a comparison to gastroenterology and general surgery services.

BACKGROUND AND OBJECTIVES: Colonoscopy training is receiving greater emphasis in family practice residencies. However, no standards have been established to measure the adequacy of this training. This study assessed the colonoscopy experience of family practice residents at Louisiana State University Medical Center at Shreveport (LSUMC-S). METHODS: We included all colonoscopies performed by the family practice service between August 1992 and December 1994 and matched them by gender and age with cases from the gastroenterology (GI) and general surgery (GS) services performed during the same time period. Family practice and GI were compared using 143 cases from each service; 166 cases were used to compare family practice to GS. RESULTS: The cecum was intubated in 87% of patients on all services. The average time to complete the procedure was 35 minutes by the family practice service, 44 minutes by GI, and 25 minutes by GS. No significant differences were found between family practice and GI in the number of patients with polyp, normal colon, or biopsy performed. In comparison to GS, there were significantly fewer patients on the family practice service with normal colon and more with multiple polyps and biopsy performed. Significantly more cancers were found by the family practice service than by either GI or GS. There were no complications reported for any of the services. Results compared favorably with data in the current literature. CONCLUSIONS: The colonoscopy experience available to family practice residents at LSUMC-S is acceptable within the parameters studied.

Rapid estimate of adult literacy in medicine: a shortened screening instrument.

BACKGROUND: This study was conducted to validate a shortened version of the Rapid Estimate of Adult Literacy in Medicine (REALM). This screening instrument is designed to be used in public health and primary care settings to identify patients with low reading levels. It provides reading grade estimates for patients who read below a ninth-grade level. The REALM can be administered in one to two minutes by personnel with minimal training. METHODS: Two hundred and three patients in four university hospital clinics (internal medicine, family practice, ambulatory care, and obstetrics/gynecology) were given the REALM and three other standardized reading tests: the reading recognition section of the Peabody Individual Achievement Test-Revised (PIAT-R), the Wide Range Achievement Test-Revised (WRAT-R), and the Slosson Oral Reading Test-Revised (SORT-R). One hundred inmates at a state prison were also given the REALM twice, one week apart, to determine test-retest reliability. RESULTS: The REALM correlated well with the three other tests. (Correlation coefficients were 0.97 [PIAT-R], 0.96 [SORT-R], and 0.88 [WRAT-R].) All correlations were significant at P < .0001. Test-retest reliability was 0.99 (P < .001). CONCLUSIONS: The REALM provides an estimate of patient reading ability, displays excellent concurrent validity with standardized reading tests, and is a practical instrument for busy primary care settings.

Literacy and self-reported educational levels in relation to Mini-mental State Examination scores.

BACKGROUND AND OBJECTIVES: Because of its brevity and ease of use, the Mini-mental State Examination (MMSE) is commonly used to screen and follow patients with cognitive impairment. This pilot study attempted to determine the relationships between literacy, age, and self-reported educational level and the total MMSE score. METHODS: Cross-sectional analysis of all patients was followed by a family practice group at five local nursing homes. The associations between the patients' MMSE scores; literacy, as measured by the Rapid Estimate of Adult Literacy in Medicine (REALM); self-reported educational level; and age were determined using Pearson's correlation coefficient and stepwise multivariate linear regression. RESULTS: A total of 105 patients completed the study. Linear regression analysis showed that MMSE scores were significantly predicted by REALM score (P < .001) and the patient's age (P < .02). However, after accounting for REALM score and age, the self-reported educational level was not related to the MMSE score (P < .8). A significant relationship was seen between the REALM score and the subjects' self-reported educational levels (r = .44, P < .001) but not the subjects' ages (r = -.17, P < 0.09). A significant linear correlation was found between the MMSE and REALM scores (r = .71, P < .0001) and a significant inverse correlation was seen between MMSE scores and the patients' ages (r = -.28, P < .004). The correlation coefficient between the patients' MMSE scores and the self-reported educational levels was .33 (P < .0007). CONCLUSIONS: Practitioners who rely on the MMSE should be aware that patients may score in the demented range because they cannot read well enough to accurately complete the test. Literacy testing with REALM or other instruments may help identify such patients.

Nail disorders.

Nail lesions can be related to a number of disease states. These may be intrinsic to the nail, caused by infection, or reflect systemic disease. Careful history and examination often is necessary for accurate diagnosis. Anatomy and gross changes of the nail are reviewed. The diagnosis and treatment of disease process such as psoriasis, lichen planus, paronychia, onychomycosis, myxoid cysts, and pincer nails are reviewed.

Current concepts in postmenopausal hormone replacement therapy.

As more women are living longer, there is an increasing need for women to discuss hormone replacement therapy (HRT) with their physicians. This task is complicated by areas of scientific uncertainty and evolving data concerning the risks and benefits of HRT. Benefits of HRT that are supported by strong scientific evidence include relief from menopausal symptoms such as hot flashes, prevention of osteoporosis, cardioprotective effects, relief of urogenital atrophy, and decreased urinary incontinence. Benefits supported by observational evidence include improvement of emotional lability and depression, improved sense of well-being in patients with rheumatoid arthritis, increased dermal and total skin thickness, improved verbal memory skills, and decreased risk of colon cancer. Risks to consider include a possible increase in the incidence of breast cancer and an increase in endometrial cancer in women who have an intact uterus and do not receive a progestin. Women in various risk groups, such as those at risk for coronary artery disease, osteoporosis, or breast cancer, must consider the risk-to-benefit ratio for their own individual circumstances.

Loop electrosurgical excisional procedure.

Loop electrosurgical excisional procedure, or LEEP, also known as loop diathermy treatment, loop excision of the transformation zone (LETZ), and large loop excision of the transformation zone (LLETZ), is a new technique for outpatient diagnosis and treatment of dysplastic cervical lesions. This procedure produces good specimens for cytologic evaluation, carries a low risk of affecting childbearing ability, and is likely to replace cryotherapy or laser treatment for cervical neoplasias. LEEP uses low-current, high-frequency electrical generators and thin stainless steel or tungsten loops to excise either lesions or the entire transformation zone. Complication rates are comparable to cryotherapy or laser treatment methods and include bleeding, incomplete removal of the lesion, and cervical stenosis. Compared with other methods, the advantages of LEEP include: removal of abnormal tissue in a manner permitting cytologic study, low cost, ease of acquiring necessary skills, and the ability to treat lesions with fewer visits. Patient acceptance of the procedure is high. Widespread use of LEEP by family physicians can be expected.

Cryotherapy of the uterine cervix.

Cryotherapy is a time-proven ablative method of treating lower grades of dysplasia of the uterine cervix. Women who need cryotherapy typically have had an abnormal Papanicolaou smear tha has led to colposcopy, biopsy, and a diagnosis of cervical dysplasia. The basic procedure, indications, and outcomes of cryotherapy are reviewed. The procedure is easy to learn and perform, and can easily be applied in outpatients settings.

Healing experiences after cervical cryosurgery.

BACKGROUND: Treatment for cervical intraepithelial neoplasia with cryosurgery is uncomfortable for many women. The subsequent healing process is also thought to bring discomfort. The purpose of our study was to describe women's experiences after cryosurgery, and how obesity, age, and gravidity affected, the healing process. METHODS: We developed a survey from focus group results to measure the unpleasantness of hydrorrhea (watery discharge) from cryosurgery, the pad protection required, and the odor associated with the hydrorrhea. The cryosurgical experiences were compared with normal menses for the use and frequency of pad protection, medications used, and any activity restrictions. RESULTS: Cryosurgical experiences were unpleasant for 78.3% of the women because of the pain and cramping of the procedure and the resulting hydrorrhea, odor, and necessity of wearing pads for protection. These experiences after cryosurgery caused 38.6% to restrict their activities and 67.1% to take medications, a significantly greater proportion than the 16.9% whose activities were restricted normal menses and the 26.8% who took medications for normal menses (P=-.004, P <.001, respectively). In addition to these experiences, obese, multigravid, and older women were more bothered by the duration of wearing pads than their counterparts (P=.0246, =.0061, and P=.0159, respectively). CONCLUSIONS: Our study showed that the cryosurgical healing process was not pleasant, and was least tolerable for obese, multigravid, and older women. As many as 50% of women undergoing cryosurgery will perceive the hydrorrhea, its odor, and the wearing of pads to be worse than normal menses, especially if their menses are usually light.

A comparison of the reliability of repeat cervical smears and colposcopy in patients with abnormal cervical cytology.

BACKGROUND: To determine the reliability of repeat cervical smears (Papanicolaou smears) in patients who have had an abnormal initial smear, prospective data were collected on patients being followed up for a previously abnormal cervical smear. METHODS: All 428 patients who were referred for colposcopy because of abnormal cervical smears underwent simultaneous cervical smears and coloposcopy with directed biopsy. Patients with colposcopic evidence of invasive carcinoma or a history of prior colposcopy were excluded. Cervical smear results were compared with the histologic findings on colposcopically directed biopsy. The ability of cervical smears to identify cervical intraepithelial neoplasia (CIN) and high-grade lesions (CIN 2 and 3) were also calculated for the repeat cervical smear. RESULTS: The sensitivity of repeat Papanicolau screening for CIN was 48%. When differentiating high-grade lesions from low-grade and benign biopsies, the sensitivity of the repeat cervical smear was only 25%. Of 110 patients with biopsy-proven high-grade lesions, 68% had low-grade initial cervical smears and 73% had low-grade or benign repeat cervical smear cytology. CONCLUSIONS: This study demonstrates that repeated Pap smears often fail to identify high-grade lesions and that the sensitivity of a repeat cervical smear is very low in patients with low-grade abnormalities found on routine screening examinations. Using follow-up cervical smears to monitor patients who have low-grade squamous intraepithelial lesions (LGSIL) carries unacceptable risks. A more reliable diagnostic test such as colposcopy is indicated.