European consensus statement on expert colposcopy.

BACKGROUND: Following the publication of the European consensus statement on standards for essential colposcopy in 2020, the need for standards relating to more complex and challenging colposcopy practice was recognised. These standards relate to colposcopy undertaken in patients identified through cervical screening and tertiary referrals from colposcopists who undertake standard colposcopy only. This set of recommendations provides a review of the current literature and agreement on care for recognised complex cases. With good uptake of human papillomavirus (HPV) immunisation, we anticipate a marked reduction in cervical disease over the next decade. Still, the expert colposcopist will continue to be vital in managing complex cases, including previous cervical intraepithelial neoplasia (CIN)/complex screening histories and multi-zonal disease. AIMS: To provide expert guidance on complex colposcopy cases through published evidence and expert consensus. MATERIAL & METHODS: Members of the EFC and ESGO formed a working group to identify topics considered to be the remit of the expert rather than the standard colposcopy service. These were presented at the EFC satellite meeting, Helsinki 2021, for broader discussion and finalisation of the topics. RESULTS & DISCUSSION: The agreed standards included colposcopy in pregnancy and post-menopause, investigation and management of glandular abnormalities, persistent high-risk HPV+ with normal/low-grade cytology, colposcopy management of type 3 transformation zones (TZ), high-grade cytology and normal colposcopy, colposcopy adjuncts, follow-up after treatment with CIN next to TZ margins and follow-up after treatment with CIN with persistent HPV+, and more. These standards are under review to create a final paper of consensus standards for dissemination to all EFC and ESGO members.

Development of complications during rehabilitation.

BACKGROUND AND METHODS: Although studies have demonstrated that medical rehabilitation patients have many complications that warrant attention, none has attempted to categorize complications by severity. This retrospective cohort study examined the incidence, types, and severity of problems that interrupt rehabilitation and the major risk factors for these events. RESULTS: Of 1075 patients, 359 (33.4%) had acute medical complications on rehabilitation considered severe enough to interrupt treatment. Of the 359 patients, 158 (44%) required an unexpected transfer off rehabilitation. The most common reasons for unexpected transfer were surgical causes (22.8%), followed by infection or fever (17.1%) and by thromboembolic events (16.5%). Logistic regression revealed that major risk factors for complications requiring transfer were a primary diagnosis of deconditioning or nontraumatic spinal cord injury (adjusted odds ratio, 2.7; confidence interval, 1.8 to 4.2), severity of initial disability (adjusted odds ratio, 1.2; confidence interval, 1.1 to 1.3 for every 10-point drop in a Modified Barthel Index), and number of comorbid conditions (adjusted odds ratio, 1.1; confidence interval, 1.0 to 1.2). Risk factors for any complication were similar, but there was an interaction between comorbidity and the degree of functional impairment; in patients who were severely functionally impaired, the number of comorbidities was not as strongly associated with the risk of complications as it was in patients who were less functionally impaired. CONCLUSION: There is a complex relationship among the type of underlying medical impairment, severity of functional limitation, comorbidity, and unanticipated medical or surgical complications that interrupt rehabilitation. The interruptions vary both in type and in severity.

Risk factors for the development of hyponatremia in psychiatric inpatients.

BACKGROUND: When inpatients who are on psychiatry services develop hyponatremia, medical consultation is usually required for evaluation and management, thus halting or delaying psychiatric treatment. Risk factors for the development of hyponatremia in this population have not been studied. METHODS: A case-control study of psychiatric inpatients in a tertiary care facility was performed. Sixty-four patients who had a serum sodium level of less than 130 mmol/L were identified; three control subjects were chosen from the inpatient psychiatry service for each case. Risk factors investigated included medications, psychiatric diagnoses, basic demographic variables, and medical comorbidities. RESULTS: Univariate and logistic regression analyses revealed that, in addition to diuretic use (adjusted odds ratio, 8.2; 95% confidence intervals, 2.2 to 30.8), use of fluoxetine (adjusted odds ratio, 21.4; 95% confidence interval, 5.3 to 86.9), tricyclic antidepressants (adjusted odds ratio, 4.9; 95% confidence interval, 1.6 to 15.2), and calcium antagonists (adjusted odds ratio, 4.0; 95% confidence interval, 1.1 to 14.2) were all associated with the development of hyponatremia. Important comorbidities included elevated creatinine levels, chronic obstructive pulmonary disease, hypertension, systolic blood pressure, and diabetes. Although age was significantly associated with hyponatremia in univariate analyses, it was not significant in multivariate analyses. CONCLUSIONS: Among psychiatric patients, hyponatremia is often associated with factors other than psychogenic polydipsia, including medications and medical comorbidities. Although elderly psychiatric inpatients seem to develop hyponatremia more often than younger patients, once drugs and comorbidities are taken into account, age does not appear to be a significant risk factor for hyponatremia in this population.

Celiac disease among Ashkenazi Jews from Israel. A study of the HLA class II alleles and their associations with disease susceptibility.

The immunogenetics of celiac disease demonstrates a highly significant association with the HLA class II alleles DQA1*0501 DQB1*0201 encoded in either a cis- or trans-configuration. In Northern Europe, these alleles are found in linkage disequilibrium with DRB1*0301 while in Southern Europe an additional secondary association through linkage disequilibrium is seen with the combination DRB1*1101/0701. This study examines 34 Ashkenazi Jews with celiac disease and 36 ethnically matched controls to determine alleles at the DRB, DQA1, DQB1, and DPB1 loci using SSO probes in conjunction with gene amplification by the PCR. The results confirm a highly significant association with the DQA1*0501 DQB1*0201 allelic combination (71% celiac vs 8% control individuals; p = 0.00005; chi 2 = 21.4). Of celiac subjects, 29% were negative for the proposed DQ susceptibility alleles, the majority of whom were DRB1*0402 positive (20% overall celiac group). No additional susceptibility was associated at the DRB3 and DPB loci. This study confirms that the MHC-linked celiac disease susceptibility among Ashkenazi Jews is closely associated with the presence of the combination of alleles DQA1*0501 DQB1*0201. However, within this population of relatively high-prevalence celiac disease, 30% of celiac patients do not carry these alleles and are therefore not covered by a single "unifying" hypothesis.

Chemical nature and immunotoxicological properties of arachidonic acid degradation products formed by exposure to ozone.

Ozone (O3) exposure in vivo has been reported to degrade arachidonic acid (AA) in the lungs of rodents. The O3-degraded AA products may play a role in the responses to this toxicant. To study the chemical nature and biological activity of O3-exposed AA, we exposed AA in a cell-free, aqueous environment to air, 0.1 ppm O3, or 1.0 ppm O3 for 30-120 min. AA exposed to air was not degraded. All O3 exposures degraded > 98% of the AA to more polar products, which were predominantly aldehydic substances (as determined by reactivity with 2,4-dinitrophenylhydrazine and subsequent separation by HPLC) and hydrogen peroxide. The type and amount of aldehydic substances formed depended on the O3 concentration and exposure duration. A human bronchial epithelial cell line (BEAS-2B, S6 subclone) exposed in vitro to either 0.1 ppm or 1.0 ppm O3 for 1 hr produced AA-derived aldehydic substances, some of which eluted with similar retention times as the aldehydic substances derived from O3 degradation of AA in the cell-free system. In vitro, O3-degraded AA induced an increase in human peripheral blood polymorphonuclear leukocyte (PMN) polarization, decreased human peripheral blood T-lymphocyte proliferation in response to mitogens, and decreased human peripheral blood natural killer cell lysis of K562 target cells. The aldehydic substances, but not hydrogen peroxide, appeared to be the principal active agents responsible for the observed effects. O3-degraded AA may play a role in the PMN influx into lungs and in decreased T-lymphocyte mitogenesis and natural killer cell activity observed in humans and rodents exposed to O3.

Accuracy of and reasons for frozen sections: a correlative, retrospective study.

Previous studies on the accuracy of frozen sections (FS) were not based on the reasons for which the FS was performed. By omitting this important information, those studies reported FS accuracy of 94% to 97.4%. The current study analyzes the accuracy of FS diagnoses based on the reasons for which they were conducted. Of 482 specimens examined by FS in 1986, 41 were performed for evaluation of section margins of tumors, 29 for identification of unknown tissue, and 43 for detection of lymph node metastases. All 113 of these examinations proved to be 100% accurate. The remaining 369 FS were performed for diagnosis of an unknown pathologic process. Of these, 83.47% were precisely diagnosed; in 10.30%, the pathologic process was correctly, but not precisely, diagnosed; in 3.79%, the diagnosis was deferred; and the remaining 2.44% were incorrectly diagnosed (with no harmful consequences to the patients). By eliminating the cases of deferred diagnoses, the accuracy rate increased to 86.76%. Therefore, we suggest that the pathologist and the surgeon should not draw any conclusion from an inconclusive interpretation of FS and should proceed as though an FS had not been performed. When combining results of "precise diagnoses" with those of "correct pathologic process," the overall accuracy rate increased to 97%. The investigators conclude that FS should be used for a general diagnosis of a pathologic process rather than for an exact or precise diagnosis. Finally, we suggest that a similar survey of FS be periodically performed in every pathology department as part of its quality assurance program.

The CARE Program: a nurse-managed collaborative outpatient program to improve function of frail older people. Collaborative Assessment and Rehabilitation for Elders.

BACKGROUND AND OBJECTIVES: Frail older adults are especially vulnerable in a health system that is fragmented and fails to focus on preservation or restoration of function. The School of Nursing at the University of Pennsylvania, together with the School of Medicine and the Hospital of the University of Pennsylvania, established the Collaborative Assessment and Rehabilitation for Elders (CARE) Program to meet the needs of this population. We used the British Day Hospital as a model because it provides a comprehensive approach to care and a bridge between acute, home-based, and institutional long-term care. We have designed our program to provide innovative, interdisciplinary care as well as to be reimbursable under current and future payment structures. This nurse-managed, collaborative practice seeks to maximize independent functioning, promote health, and enhance quality of life for chronically ill, frail older adults living in the community whose needs are left unmet by existing services. The program was certified as a Comprehensive Outpatient Rehabilitation Facility (CORF) in December 1993 to maximize reimbursement of services through Medicare and other third party payers. With a Gerontological Nurse Practitioner as care manager, clients receive an intensive, individualized, time-limited program of nursing, rehabilitation, mental health, social, and medical services in one setting several days each week. Additional geriatric services, such as primary care, are available in the same location when needed. SETTING: The program is housed in renovated space devoted to the care of older people. The academic and clinical offices of the University of Pennsylvania's nursing and medical gerontologic and geriatric faculty are in the same building. PARTICIPANTS: We have targeted those persons older than age 65 who have complex health problems and are living at home. Individuals must need multiple services, including at least one rehabilitation therapy, and they must be unsuitable-for inpatient rehabilitation. DESCRIPTION OF THE POPULATION: In its first 8 months of operation, the program received 97 referrals and admitted 53 clients. Clients were, on average, 78 years of age. Over three-fourths (77%) were women and 58% were black. The average stay in the program was 6 weeks. FIM scores, which improved a mean of 2.4 points, were found to lack sensitivity to the functional improvements achieved by clients. CONCLUSION: Under existing Medicare and third party reimbursement policies, it is feasible to establish a nurse-managed comprehensive outpatient rehabilitation program designed to meet the needs of frail older persons. Preliminary data support the beneficial effects of the program as well as the economic feasibility of this approach.

Effects of a restraint reduction intervention and OBRA '87 regulations on psychoactive drug use in nursing homes.

OBJECTIVES: To describe the changes in psychoactive drug use in nursing homes after implementation of physical restraint reduction interventions and mandates of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87). METHODS: A secondary analysis was conducted using data from a controlled clinical trial that took place in three nursing homes: a control home, one that received an educational intervention, and one that received an educational/consultation intervention. All three homes were influenced by the OBRA mandates. Complete pre- and 6 months' post-intervention data on use of psychoactive drugs and physical restraints were available for 446 resident subjects. Changes were first analyzed with the resident subjects as the unit of analysis and then using the nursing home ward (n = 16) as the unit of analysis. RESULTS: While physical restraint use declined in the home that received the educational/consultation intervention, neither neuroleptic nor benzodiazepine use increased in any of the homes after the interventions. The percentage of residents taking neuroleptics declined in the control home (18.6% to 11.3%, P = .014). Benzodiazepine use, which was more prevalent than described previously in the literature, declined in all three homes (P < .001). Of those residents whose physical restraints were discontinued, only 2% were started on neuroleptics. When the effect of OBRA mandates on appropriateness of neuroleptic use was examined, the percentage of residents on neuroleptics who lacked an OBRA-approved indication declined from 21.3% to 14.6% in the total sample, and from 39.9% to 8% in the control home. CONCLUSIONS: Interventions to reduce physical restraint did not lead to an increase in psychoactive drug use; further, reduction in both can occur simultaneously. OBRA mandates regarding psychoactive drug use were not uniformly effective, but appear, at minimum, to have increased awareness of the indications for neuroleptics.

The medical interview: differences between adult and geriatric outpatients.

BACKGROUND: There is a perception that primary care physicians spend less time with older patients and little is known about physician and older patient satisfaction during clinical encounters. OBJECTIVE: To determine how primary care interviews of geriatric patients differ from those of other adults. DESIGN: Descriptive, analytic study. SETTING: Ten primary care sites in the United States and one in Canada, including public, voluntary, and private clinics and practices. PARTICIPANTS: Of the 544 patients, 45.6% were 65 and older and 17.8% were 75 or older. There were 127 participating physicians. MEASUREMENTS: Encounters were audiotaped and analyzed. Patients and physicians also completed exit questionnaires. RESULTS: Interview length increased significantly with age for men but not for women. Physician satisfaction did not change as patient age increased. Patient satisfaction, on the other hand decreased with age among women but not for men. Although physicians' and younger patients' perceptions of health were moderately associated, there was no association for men ages 75 and over. CONCLUSIONS: There is no evidence that physicians spend less time or are more uncomfortable with older patients. Both physician and male patient satisfaction remain stable with increasing patient age, despite greater disparity in patient and physician perceptions of health. Older female patients are less satisfied with physician visits than their younger counterparts, in the absence of changes in interview length or disparities between older female patients and their physicians in health perception.

Antimicrobial resistance patterns in long term geriatric care. Implications for drug therapy.

There is a high prevalence of bacterial infections in long term care facilities (4.4 to 16.2%). This, together with the fact that antimicrobial resistance is a big concern in current medical practice, makes infection control so important in nursing home care. This article covers the mechanisms of antibacterial resistance and focuses on 4 major antibacterial-resistant bacteria. Vancomycin is the treatment of choice for methicillin-resistant Staphylococcus aureus (MRSA). Colonisation with MRSA is not uncommon in nursing homes and eradication is probably not necessary. Any clinically important enterococcal infection should be tested for high-level resistance. An infectious disease consultation should be sought for vancomycin-resistant enterococcal infections. Gram-negative bacilli have developed multi-resistance. Susceptibility testing can identify the most appropriate therapy. Multiresistance should also be considered when treating Streptococcus pneumoniae. Overall, handwashing is highly recommended. Barrier precautions, minimising hospitalisations and avoiding unnecessary personnel rotation can reduce the chance of resistance spread.

Interferon-induced alterations in membrane functions and the growth of Daudi lymphoma and Friend leukemia cells.

The Friend murine erythroleukemia cell system and the Daudi Burkitt's lymphoma cell system were used to study the effect of growth-inhibitory concentrations of interferon on membrane functions. Experiments with Friend-cell clones sensitive and resistant to interferon indicated that a number of changes in membrane transport occur rapidly after the addition of interferon to sensitive cells. While no change was observed in the activity of the (Na+/K+) ATPase in Friend cells sensitive or resistant to interferon, a piretanide-inhibitable Na+,K+, 2Cl- co-transport system was specifically inhibited after interferon treatment of sensitive cells. In contrast, treatment of Daudi cells with purified molecularly cloned or standard preparations of human leukocyte interferon gave rise to no early changes in the transport of amino acids, 32Pi, sugars, or 86Rb+. The major change observed in Daudi cells was a marked reduction in the uptake and incorporation of thymidine, which begins to decrease after 8-10 h of exposure to interferon.

Physician-older patient communication at the end of life.

Communication with dying patients and their families requires special skills to assist them in this extremely stressful period. This article begins with a case that illustrates many of the challenges of communicating with the dying. It then reviews the literature about communication with older patients at the end of life, focusing on physician-patient discussions, decision-making, advance directives, and cultural factors. The article concludes with a practical discussion of problems that physicians may encounter when working with older patients at the end of life and their families and recommendations to improve communication.

The influence of increased seismic activity on pregnancy outcome.

The influence of increased seismic activity on pregnancy outcome was evaluated. A significant increase in delivery rate was noted during the 48 hours following an earthquake on all instances. In two out of five events, a significant increase in premature delivery rate was noted (p less than 0.05). Possible signs of fetal distress in utero were documented following these events.

Prevention and other special management issues in the postacute care of the geriatric stroke patient.

Rehabilitation of older stroke patients does not take place isolated from social and medical problems. Nurses and internists are crucial members of the interdisciplinary team, maintaining health and preventing long- and short-term complications in the stroke survivor. This review describes our research interests and clinical approaches to some of the special medical and nursing needs of the population, using prevention as a model for caring for these chronically ill patients and their families.

Fine needle aspiration cytology of the pancreas.

A review is presented of 205 fine needle aspirations of the pancreas performed on 149 patients. Clinical follow-up was available for 134 patients (88%). Aspirates from 71 patients (53%) were correctly diagnosed as malignant while those from 43 patients (32%) were correctly diagnosed as negative. Ten patients (7%) were falsely diagnosed as negative, and ten patients (7%) were diagnosed as suspicious. There were no false-positive diagnoses. This resulted in a specificity of 100%, a sensitivity of 87%, a diagnostic efficiency of 92%, a predictive value of a positive test of 100% and a predictive value of a negative test of 80%. The cytologic criteria of malignancy can be easily recognized. The complications are very few. Comparisons with the results of needle and wedge pancreatic biopsies are presented.

Fine needle aspiration cytology of neuroendocrine tumors of the pancreas. A cytologic, immunocytochemical and electron microscopic study.

We report the fine needle aspiration cytology findings in six cases of neuroendocrine tumor of the pancreas. Three cases were from the pancreas, two from hepatic metastases and one from a peripancreatic lymph node metastasis. The cytologic features that permitted a preoperative diagnosis of pancreatic neuroendocrine tumor were: a cellular aspirate; numerous isolated cells and irregular, loose, dyshesive cellular aggregates; minimal nuclear pleomorphism; infrequent mitoses; fine, evenly dispersed nuclear chromatin with occasional inconspicuous nucleoli; a scant-moderate amount of granular, amphophilic, well-defined cytoplasm; clustering of tumor cells around segments of capillaries; and rosette formation. The differential diagnosis includes cells derived from normal pancreatic acini, islet cell hyperplasia, acinic cell carcinoma, well-differentiated pancreatic adenocarcinoma, metastatic small cell undifferentiated carcinoma of the lung, pancreatic small cell anaplastic carcinoma and malignant lymphoma. The application of immunocytochemistry to cytologic smears can be easily and reliably performed to confirm the neuroendocrine nature of the tumor and identify the specific type of polypeptide hormone or hormones produced by these tumors. Four aspirates showed immunoreactivity for chromogranin, and one was positive for gastrin. Cells of a lipid-rich neuroendocrine tumor were negative for chromogranin; however, the tissue section contained neuron specific enolase, and neurosecretory granules were demonstrated by electron microscopy.

How to get the most benefit from a changing home health care system.

By 1998, a Medicare prospective payment system for home care is expected to be in place. Physicians must become more involved in home care, because they will be held accountable for the patients they refer and the services they order.