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 (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.

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.

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.

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.

Nongenital human papillomavirus disease.

Human papillomavirus (HPV) is the most common viral cause of cancer, and is responsible for 5% of cancers worldwide. Following demonstration of the causative link between HPV and cervical cancer, HPV has been shown to be associated with several anogenital malignancies and with oral pharyngeal cancers. HPV-related anal and oral pharyngeal disease is rising in incidence and includes anal warts and neoplasia, recurrent respiratory papillomatosis, and oral pharyngeal neoplasia. This article presents an overview of the epidemiology, clinical manifestations, diagnosis, and treatment of nongenital HPV-related disease.

Decreasing extremes in patient waiting time.

INTRODUCTION: We present a conceptual framework for approaching reducing excessive patient wait time in an outpatient setting. We hypothesized that statistical process control techniques can be used to identify extremes in waiting time; root cause analysis can be used to identify specific delay causes; and minimizing the contribution of the root causes will lead to an improvement in system performance. SUBJECT AND METHOD: We conducted a prospective study of waiting times in a private outpatient clinic providing high-risk obstetrical care. The baseline period consisted of 55 clinic sessions, and the intervention period consisted of 101 clinic sessions. RESULTS: Mean waiting time was prolonged during 9 (16.4%) baseline clinic sessions. The root cause analysis determined that appointment schedule, physician tardiness, and patient complexity contributed to clinic delays. After making changes to minimize root causes, there was a significant reduction in prolonged waiting times (16.4% vs 4.9%, Yates chi(2) = 4.37, P = .037); a significant decrease in mean waiting time (32.7 +/- 23.6 minutes vs 29.3 +/- 21.2 minutes, t = 3.42, P < .001); and a significant improvement in the waiting time distribution (Kruskal-Wallis test of homogeneity, P = .003). CONCLUSIONS: Our methodology was successful in identifying and reducing factors associated with prolonged wait times. However, although system operation was improved, as defined by a decrease in the occurrence of excessive clinic delays, effecting a large and sustained decrease in patient waiting times was challenging.

The natural history of cervical cryosurgical healing. The minimal effect of debridement of the cervical eschar [see comment].

BACKGROUND: Cryosurgery is a favored treatment method for cervical intraepithelial neoplasia (CIN) among family physicians, in part because it is inexpensive and requires the least technical training and skill. Although cervical cryosurgery has been used for more than 30 years, the natural history of the postprocedure process has never been described. The primary purpose of our study was to describe the natural history of the healing process after cervical cryosurgery. A secondary purpose was to determine the effect of mechanical debridement of the cervical eschar on the symptoms of healing. METHODS: We conducted a prospective multicentered trial in which women who had a histologic ally documented CIN lesion underwent cervical cryosurgery. Forty-six women were randomized to undergo eschar debridement at 48 hours after cryosurgey, and 38 women received standard care. All women were followed up and given preweighed sanitary pads for hydrorrhea (watery discharge) collection and a diary to record the severity and number of days of odor, pain, cramping, and hydrorrhea that were experienced. RESULTS: The average total amount of hydrorrhea or discharge was 288 g, which required using an average of 41 sanitary pads during a period of 12.4 days. The duration of odor was 8.9 days, and the pain and cramping experienced after cryosurgery lasted 4.7 days. Women who were obese had greater hydrorrhea and pad usage than nonobese women. Debridement of the cervical eschar did not significantly change the signs and symptoms of healing after cryosurgery. CONCLUSIONS: There are significant symptoms patients experience after cryosurgery that are not ameliorated by debridement. The expectations of the cryosurgical healing process should be disclosed to women before the procedure.

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.

Placebo-controlled trial of indole-3-carbinol in the treatment of CIN.

OBJECTIVE: Most precancerous lesions of the cervix are treated with surgery or ablative therapy. Chemoprevention, using natural and synthetic compounds, may intervene in the early precancerous stages of carcinogenesis and prevent the development of invasive disease. Our trial used indole-3-carbinol (I-3-C) administered orally to treat women with CIN as a therapeutic for cervical CIN. METHODS: Thirty patients with biopsy proven CIN II-III were randomized to receive placebo or 200, or 400 mg/day I-3-C administered orally for 12 weeks. If persistent CIN was diagnosed by cervical biopsy at the end of the trial, loop electrocautery excision procedure of the transformation zone was performed. HPV status was assessed in all patients. RESULTS: None (0 of 10) of the patients in the placebo group had complete regression of CIN. In contrast 4 of 8 patients in the 200 mg/day arm and 4 of 9 patients in the 400 mg/day arm had complete regression based on their 12-week biopsy. This protective effect of I-3-C is shown by a relative risk (RR) of 0.50 ((95% CI, 0. 25 to 0.99) P = 0.023) for the 200 mg/day group and a RR of 0.55 ((95% CI, 0.31 to 0.99) P = 0.032) for the 400 mg/day group. HPV was detected in 7 of 10 placebo patients, in 7 of 8 in the 200 mg/day group, and in 8 of 9 in the 400 mg/day group. CONCLUSIONS: There was a statistically significant regression of CIN in patients treated with I-3-C orally compared with placebo. The 2/16 alpha-hydroxyestrone ratio changed in a dose-dependent fashion.

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.

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.

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.