Cervical Colposcopy: Indications and Risk Assessment.

The practice of colposcopy, a diagnostic procedure to evaluate for vaginal, vulvar, and cervical dysplasia, has evolved to incorporate patient risk factors for high-grade cervical intraepithelial neoplasia (CIN) and cancer. Changes in cervical cancer screening and guidelines, human papillomavirus (HPV) vaccination recommendations, and colposcopy standards from the American Society for Colposcopy and Cervical Pathology (ASCCP) have implications for all primary care clinicians, not only those who perform colposcopies. Primary care clinicians should offer HPV vaccination to all patients between the ages of nine and 26, in addition to cervical cancer screening and follow-up guidance. Primary care clinicians should recognize the degrees of risk of high-grade CIN and cancer conferred by cytology, HPV subtype, and persistence of HPV infection. Clinicians should address modifiable risk factors such as tobacco use, and provide counseling to patients about colposcopy based on their individual risks. Clinicians should conduct shared decision-making about immediate loop electrosurgical excision procedure vs. colposcopy with multiple biopsies and endocervical sampling for patients with the highest risk of cervical cancer, and for patients who are older than 25 years with at least two of the following: HPV-16, HPV-18, and high-grade squamous intraepithelial lesion cytology. Primary care clinicians should be familiar with the 2019 ASCCP guidelines and develop clinic-based systems to ensure appropriate follow-up of abnormal cytology, positive high-risk HPV testing, diagnosed CIN, and cervical cancer. Patients with an abnormal cervical cancer screening history require surveillance, which differs from routine screening for patients with normal prior screening results. Long-term surveillance is recommended for patients with CIN 2 or worse.

Developing the future Indigenous health workforce: The feasibility and impact of a student-led placement programme in remote Indigenous communities.

OBJECTIVE: To describe and evaluate a programme where medical students designed and implemented Indigenous health placements for students with an interest in rural/Indigenous health. DESIGN, SETTING AND PARTICIPANTS: In 2011, a student-led programme at the University of Adelaide was set up to give medical students the opportunity to undertake outreach trips and clinical placements in remote Indigenous communities. Twenty-four medical students attended trips to remote communities between 2012 and 2014. Here we evaluate our programme using a single-arm experimental design. MAIN OUTCOME MEASURES: Responses to questionnaire items before and after attending an outreach placement, scored on 6-point Likert scales. RESULTS: Following their remote Indigenous health placement, participants expressed a significantly higher mean likelihood of working in an Indigenous community in the future (3.17 (2.69-3.64) versus 4.00 (3.65-4.35); P < 0.007). Furthermore, after their placement participants felt better prepared to work in Indigenous communities (mean 1.79 (1.44-2.14) versus 3.21 (2.88-3.54); P < 0.001). CONCLUSIONS: A placement programme initiated and run by medical students can provide meaningful exposure to Indigenous health. Implementation of this student-led model in other medical schools may encourage nationwide development of the Indigenous health workforce.

Trachoma in remote Indigenous Australia: a review and public health perspective.

OBJECTIVES: Trachoma remains a major health concern in many remote Indigenous Australian communities, despite behaviour-modifying and biomedical strategies. This review aims to examine the social epidemiology of trachoma in remote Indigenous communities and identify practical, sustainable strategies to alter the social determinants of the disease. METHODS: A systematic search and critical review explored the proximal, intermediate and distal determinants of trachoma. The impact of swimming pools in remote Indigenous communities on trachoma and other infectious diseases was further examined. RESULTS: Having a clean face was found to be protective for trachoma, but face-washing education programs have produced no significant benefits. Sanitation infrastructure in a community was the key determinant of facial cleanliness. Installation of swimming pools in remote Indigenous communities has been demonstrated to reduce the prevalence of several common childhood infections. However, minimal research has explored the impact of pools on trachoma rates. CONCLUSIONS: The locally supported construction of pools in remote Indigenous communities may contribute to a decline in trachoma. A prospective, controlled trial is needed to test this hypothesis in endemic communities. IMPLICATIONS: If validated by a well-designed study, pool construction may provide a much sought-after practical government strategy to combat trachoma in remote Indigenous communities.

Clinical Inquiry: What's the best way to predict the success of a trial of labor after a previous C-section?

Seven validated prospective scoring systems, and one unvalidated system, predict a successful TOLAC based on a variety of clinical factors. The systems use different outcome statistics, so their predictive accuracy can't be directly compared.

Care of the well newborn.

The birth of an infant is one of the most memorable experiences a family shares. Pediatric health care professionals are privileged to participate in this experience and recognize it as a time to promote the health of the newborn and family. Ideally, a well-designed care system would be replete with comprehensive supports during the prenatal period, birth, and transition to home. Opportunities exist to improve the care we deliver with universal screening of all pregnant women; coordinated assessments of family health, including mental health; and access to coordinated supports and services for mother and infant. If 90% of US families could comply with medical recommendations to breastfeed exclusively for 6 months, it is estimated the United States would save billions of dollars per year and prevent more than 900 deaths, nearly all of which would be in infants. All infants, whether breastfed or formula fed, should receive 400 IU supplemental vitamin D. Influenza and TdaP vaccination of postpartum mothers and other caregivers helps cocoon the vulnerable infant from influenza and pertussis until he or she can be fully vaccinated. When children reach the highest weight or length allowed by the manufacturer of their infant-only seat, they should continue to ride rear-facing in a convertible seat. It is best for children to ride rear-facing as long as possible to the highest weight and height allowed by the manufacturer of their convertible seat.

Cervical cancer screening and updated Pap guidelines.

Cervical cancer and its dysplasia precursors account for significant morbidity and mortality in women worldwide. Human papillomavirus infection is common, preventable, and now widely accepted as the causative agent with oncogenic potential in the development of cervical cancer. Screening via Papanicolaou testing is critical, and interpretation of test results with knowledge of patient risk factors is imperative. Many evidence-based guidelines for screening, interpretation, and management have been developed and are widely available for use.