Triamterene
"Purchase discount triamterene on-line, hypertension medications."
By: Paul Reynolds, PharmD, BCPS
- Critical Care Pharmacy Specialist, University of Colorado Hospital
- Clinical Assistant Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
http://www.ucdenver.edu/academics/colleges/pharmacy/Departments/ClinicalPharmacy/DOCPFaculty/Q-Z/Pages/Paul-Reynolds,-PharmD.aspx
Prevalence and occupational as ment of sacroiliac joint-mediated low Pa 1976) 1994; 19:1307-1309 blood pressure chart poster triamterene 75 mg on-line. Eriksen W blood pressure kit cvs order triamterene mastercard, Natvig B blood pressure medication parkinson's purchase triamterene 75 mg fast delivery, Knardahl S arterial nephrosclerosis purchase discount triamterene, Bruus 3rd, Kurihara C, Morlando B, Dragov of complaints of the arm, neck, and/or gaard D. Kong: A telephone survey on prevalence, Risk factors for neck pain in office work 1554. Work re sociation of neck pain with symptoms of lated risk factors for musculoskeletal pain. Occup Environ Med 1999; iliac radiofrequency denervation for the bil Med 1999; 31:17-22. Niemi S, Levoska S, Kemilä J, Rekola K, on Neck Pain and Its Associated Disor Altered perception of distorted roinflammationand neuroimmune ac neck pain in the general population: visual feedback occurs soon after whip tivation in persistent pain. Pain 2001; Results of the Bone and Joint Decade lash injury: An experimental study of 90:1-6. Eskes C, Juillerat-Jeanneret L, Leuba clinical course and prognostic factors of in 253 cases. Primary care release, microglial activation, and neu consultation, hospital admission, sick cal intervertebral disc. Spine spontaneously produce matrix metal of chronic spinal pain syndromes: From (Phila Pa 1976) 2008; 33:S83-S92. Bone and Joint Decade 2000 2010 Task biochemical understanding of human Brain Res 2003; 984:54-62. Neurotoxicology 1998; the Bone and Joint Decade 2000–2010 matrix metalloproteinases. Furusawa N, Baba H, Miyoshi N, on how proinflammatory cytokines 2008; 33:S93-S100. Cervical degenerative dis of musculoskeletal pain: Randomized root ganglion in response to different orders: Etiology, presentation, and im controlled trial. Yamazaki T, Yanaka K, Sato H, Uemura Long-term results of doubledoor lami radiculopathy. Chiba K, Ogawa Y, Ishii K, Takaishi H, vical radiculopathy: A population-based 2003; 52:122-126. Axial symptoms after cervical lamino quantitative magnetic resonance imag nance images. J Neurosurg Spine 2007; plasty with C3 laminectomy compared ing methods in the assessment of spinal 6:17-22. Physi ing paraspinal muscles on postopera ological and behavioral evidence for fo tive axial pain in the selective cervical 1615. Spine (Phila Pa 1976) 2008; Cervical spondylotic myelopathy: Sur tamate infusion in rats. Clinical and radiological correlates of ization of the medial branches of the cal Management of Acute Cervical Radicu severity and surgery-related outcome in cervical dorsal rami during cervical lar Pain: An Evidence-Based Approach. A Medical Management of Acute Cervical operative and postoperative magnetic noticeable complication. Spine (Phila Pa Radicular Pain: An Evidence-Based Ap resonance image evaluations of the spi 1976) 1996; 21:1969-1973. Herniated cervical intervertebral discs plasty for cervical spondylotic myelopa with radiculopathy: An outcome study thy. Saita K, Hishino Y, Kikkawa I, Ishii T, Lee of conservatively or surgically treated 1620. Diagnosis and gical treatment for cervical myelopathy nonoperative management of cervical in patients more than 75 years of age. Spine (Phila Pa 1976) agement of Acute Cervical Radicular Pain: cervical compression myelopathy: Pre 2001; 26:479-487. Inadvertent injec magnetic-resonance scans of the cervi morphologic changes in the interverte tion of a cervical radicular artery using cal spine in asymptomatic subjects: A bral foramen of the cervical spine: A ca an atraumatic pencil-point needle. Correlation of magnetic reso Risk of intravascular injection in trans dromes and Definition of Pain Terms. Cervical disc stimulation and its predictive value for cervical fu lopathy syndrome after cervical transfo (provocation discography). Arch Orthop Trauma Surg 1994; raminal epidural steroid injection pre Guidelines for Spinal Diagnostic and Treat 113:199-203. The role of cervical discography cography in the management of cervi tions of cervical transforaminal epidural in interventional pain management. Fatal exserohilum menin view of the diagnostic accuracy of pro discogenic syndrome. Results of opera gitis and central nervous system vascu vocative tests of the neck for diagnosing tive intervention in patients with posi litis after cervical epidural methylpred cervical radiculopathy. Spine (Phila Pa 1976) S; Bone and Joint Decade 2000-2010 Clinimetric evaluation of active range of 2009; 34:E751-E755. Task Force on Neck Pain and its Associ motion measures in patients with non 1654. Cervical epidural depth: and its associated disorders: Results of Eur Spine J 2008; 17:905-921. Task Force on neck pain and its associat A systematic, critical review of manual S260 Complications of cervical trigger points: Evidence and clinical sig disc syndrome. Interven ings of pure foraminal-type cervical disc between magnetic resonance imaging tions in chronic pain management. J Spinal Disord Tech resonance imaging of post discogram tors for the development of Late Whip 2008; 21:430-435. J Spinal Dis dural empyema complicating cervical P, Nordin M, Hurwitz E, van der Velde ord 1989; 2:234-237. J Spinal Disord 1990; pain in whiplash-associated disorders (Phila Pa 1976) 1994; 19:21-25. Commentary: Bone and Joint Decade 2000-2010 Task tic inaccuracy of the pain response in Does needle injection cause disc degen Force on Neck Pain and Its Associated cervical discography. The value of effects of discography radiocontrast so Roentgenol Radium Ther Nucl Med 1961; diskography in disk-related pain syn lution on human annulus cell in vitro: 86:975-982. On the nature of neck pain, discography and cervical Musculoskelet Radiol 2011; 15:172-180. The prevalence of tion exposure and protective measures 2000-2010 Task Force on Neck Pain and cervical zygapophyseal joint pain. Cervical medial branch mal instantaneous axes of rotation in cations of cervical discography. Ono A, Tonosaki Y, Numasawa T, Wada logical findings in postmortem speci Spine (Phila Pa 1976) 1988; 13:1352-1354. ProDisc-C and anterior Force on Neck Pain and Its Associated tion of orphenadrine/paracetamol tab cervical discectomy and fusion as sur Disorders. Treatment of neck pain: Non lets (‘Norgesic’) on myalgia: A double gical treatment for single-level cervical invasive interventions: Results of the blind comparison with placebo in gen symptomatic degenerative disc disease: Bone and Joint Decade 2000-2010 Task eral practice. Curr Med Res Opin 1983; Five-year results of a Food and Drug Ad Force on Neck Pain and Its Associated 8:531-535. Stabilization of the tematic review within the framework of Spine J 2009; 9:859 871. Robinson anterior cervical cervical radiculopathy: A randomized can Pain Society Low Back Pain Guide discectomy and arthrodesis for cervical clinical trial. Group cognitive be ety [published correction appears in Ann throdesis adjacent-cervical segment de havioural treatment for low-back pain in Intern Med 2008; 148:247-248]. Spine lization for fractures and/or dislocation shoulder pain in women industrial (Phila Pa 1976) 1998; 23:2137-2142. Five-year re ing with isometric shoulder strength port and review of the literature. Subdural Results of cervical arthroplasty com of chronic neck pain in women: A ran hematoma after cervical epidural ste pared with anterior discectomy and domized controlled trial. N Engl J Med of fluoroscopically guided interlaminar tive management of herniated cervical 1994; 330:1047-1050.
To Dean Jairath and the School of Nursing for providing additional scholarships funds to heart attack film purchase cheap triamterene support my educational endeavors at the Catholic University of America hypertension disorder 75 mg triamterene sale. To TriService Nursing Research Program for providing grant funding to pulse pressure queen cheap generic triamterene uk support my dissertation efforts blood pressure chart bhf purchase 75mg triamterene mastercard. To my classmates, Diona, Irene, Santy, Maryann, Elaine, Rose, Natapat, Atiporn, Sandra, Teri, Agnes, for sharing their experiences and critiques. To Kathy Szymczak, Bill and Mary Throop, and Luella Windisch who willing traveled across the country to care for Masiey. To my husband and daughter, who spent many hours in the mall while I continued to write. The greatest incidence and mortality related to cervical cancer is found in developing counties with less access to cervical cancer screening (Nene et al. With screening and treatment of abnormal or precancerous cervical cells, cervical cancer is a disease which can be prevented (Germar, 2004). However, in military women cervical cancer is the second most common cancer (Yamane, 2006). Military service members receive their healthcare in an open access system without cost. Yet, nearly one in five military 1 2 women are non-adherent to annual cervical cancer screening (Thomson & Nielsen, 2006). Service members are unique in terms of job requirements, personal risk, commitments, and social support systems. Within the military, women are a minority population within a male dominated, hierarchal culture. Even though access is available within the military healthcare system and regulations prescribe annual screening, the incidence of cervical cancer in military women suggests an urgent need to understand and address gender specific health promoting activities. Within this unique and complex population, researchers must consider other factors, such as attitudes and subjective norms, which can influence a military women‟s adherence to health promoting behavior such as cervical cancer screening. As a disease which can be prevented, cervical cancer should be just a rare in the military population as it is in the U. Cancer is the overgrowth of abnormal cells which invade other adjacent cells and tissues. Specific cancers are named for the cells in which the abnormal cells originate within the body, such as breast, prostate, or cervical tissues. These abnormal collections of cells fail to perform their primary function and when invading other tissues, interrupt other cell and tissue functions as well. When cancer cells travel to other places in the body and invade distant tissues, this is referred to as metastasis. Cancer and cells that are identified as having a high likelihood to develop into cancer are often treated by direct removal by surgery, interruption of cell replication by 3 chemotherapy, or destruction by radiation or cryotherapy. Consequently, screening for early abnormal cells is a mainstay of cancer prevention and treatment, and is a major component of health promotion activities (Douglas & Fenton, 2008). Detection of cancer originating from the cervix was first developed by George Papanicolaou in 1928 and published 13 years later (Papanicolaou & Traut, 1941). Since the introduction and promotion of cervical cancer screening by the Papanicolaou test (Pap), the incidence of cervical cancer has been reduced significantly (Teitelman, Stringer, Averbuch, & Witoski, 2009). By the early the 1950‟s, routine Pap test screening for American women became common practice (Skloot, 2009). However, cervical cancer screening is less common in ethnic minority populations, populations with lower socioeconomic conditions and educational achievements, and decreased access to healthcare (Hawes & Kiviat, 2008). In the past 20 years, vaccines have been developed and administered to prevent specific cancers. Health promotion activities to prevent cervical cancer include both screening for abnormal cervical cells and vaccination. When a woman delays or fails to vaccinate against cervical cancer, she reduces her likelihood to prevent such cancer from developing later in life. Additionally, when a woman delays seeking cervical cancer screening, she reduces her likelihood that cervical cancer will be detected at an early stage. Contemporary research indicates that women in most minority populations are particularly vulnerable to cervical cancer and represent a significant target group in need of healthcare screening and vaccination (Rogers & Cantu, 2009). Cervical Cancer Cervical Anatomy the cervix is the lower third of the uterus and connects the uterus to the vagina. The central opening of the cervix (the cervical os) allows the passage of sperm into the uterus and menstrual flow out of the uterus. During childbirth, the cervix dilates to 5 approximately 10 centimeters to allow passage of the fetus from the uterus into the vagina. Towards the outermost edge, where the cervix is attached to the vagina, cells of the cervix are comprised of non-keratinizing stratified squamous epithelia cells. Towards the center of the cervix, where the cervix opens into the uterus, the cells are comprised of simple columnar epithelium. The point at which stratified squamous cells meet the simple columnar cells is referred to as the transformation zone (Figure 1). During puberty, the transformation zone is located at the outermost parts of the cervix. Visible to the naked eye during a speculum examination, the squamous cells are pink and located towards the exterior of the cervix, while the columnar cells are darker red and located towards the interior of the cervical os. As a consequence of hormonal and concomitant pH changes that accompany menarche, as women age, the squamous cells located on the exterior portion of the cervix move towards the center of the cervical os. Therefore, the interior columnar cells are paved over by the squamous cells from the exterior portion of the cervix and the transformation zone slowly retreats towards the cervical os. After several decades, the transformation zone is often no longer visible and located deep within the cervical os (Jhingran et al. Simple columnar cells Cervical os Transformation Zone Stratified squamous cells Note: this figure was created by the researcher to elucidate key cervical anatomic and pathologic concepts in regards to the development of cervical cancer. However, in the past 20 years, some specific cancers have been found to be related to infectious diseases, for example hepatitis B and liver cancer. Screening for Cervical Cancer Screening for cervical cancer is determined by the typical age for abnormal cells to manifest in a person, the time required for abnormal cells to invade and disrupt other tissues, the estimated benefit to a person‟s life, and the cost of the test. For example, while every woman could have a screening mammogram every year from birth, a majority of breast cancers do not manifest until a woman is over 40 years of age. Likewise, a 8 screening mammogram is not recommended in most 90 year old woman with advanced heart disease who could not withstand surgery or chemotherapy, since treating breast cancer would not greatly enhance quality of life. Screening for cervical cancer is conducted via a test named after the scientist who developed a technique to observe abnormal cervical cells in guinea pigs, George Papanicolaou. Papanicolaou‟s test, often referred to as the “Pap smear”, was established as a routine screening exam for cervical cancer in women by the 1950s (Gardner, 2006). The procedure has changed very little since that time in terms of collecting cervical cells and observing those cells under a microscope. During the screening exam, the cervical cells at junction of the squamous and columnar epithelium, or transformation zone, are scraped from the cervix via a spatula and brush, and then smeared on a glass plate or placed within a bottle of preservative solution and sent to a laboratory. Via microscopic examination a pathologist assesses for individual cervical cell abnormalities. Cervical Cancer Staging When cancer cells are identified, the cells are grouped into stages. Those cancerous cells to various areas of the cervix and surrounding tissues are staged in increasing numbers, with stage 4 indicating that the cervical cancer cells have spread to other distant tissues and organs within the body. Metastatic cervical cancer typically will invade local tissues in the 9 pelvis, adjacent lymph nodes, liver, lung, and bone (Garcia, 2009). Less than 20% of cervical cancers arise from glandular cervical tissues, also known as adenocarcinomas (Balasubramanian, Palefsky, & Koutsky, 2008). The vast majority of cervical cancers, greater than 80%, originate from the cervical squamous cells (Thigpen, 2003). Cervical cancer symptoms include bleeding after intercourse and unusual vaginal discharge. However, most cervical cancers are identified via cervical cancer screening conducted with the Pap smear (Shinn, 2004). Squamous cervical cells which are abnormal during the Pap smear are often referred to as precancerous, as these abnormal cells have the potential to continue to change over several months or years and evolve into cervical cancer.
Buy 75 mg triamterene otc. Taking a blood pressure.
Chiropractors focus consumer organizations and patients to blood pressure chart athlete cheap triamterene 75 mg line foster a shared on disorders of the musculoskeletal system and the nervous system heart attack high bride in a brothel triamterene 75 mg without prescription, and the understanding of professionalism and how they can effects of these disorders on general health and function blood pressure medication can you stop generic triamterene 75mg visa. For more information or to blood pressure chart metric buy triamterene with a mastercard see other lists of Things Provider and Patients Should Question, visit American College of Cardiology Five Things Physicians and Patients Should Question Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present. Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients. Performing stress cardiac imaging or advanced non-invasive imaging in patients without symptoms on a serial or scheduled pattern. This practice may, in fact, lead to unnecessary invasive procedures and excess radiation exposure without any proven impact on patients’ outcomes. An exception to this rule would be for patients more than fve years after a bypass operation. Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk 3 non-cardiac surgery. Non-invasive testing is not useful for patients undergoing low-risk non-cardiac surgery. These types of tests do not change the patient’s clinical management or outcomes and will result in increased costs. Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms. An echocardiogram is not recommended yearly unless there is a change in clinical status. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the American College of Chest Physicians. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of 4 Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the American College of Chest Physicians. We achieve this by collaborating with comprised of physicians, surgeons, nurses, physicians and physician leaders, medical trainees, physician assistants, pharmacists and practice health care delivery systems, payers, policymakers, managers, and bestows credentials upon cardiovascular consumer organizations and patients to foster a shared specialists who meet its stringent qualifcations. The College understanding of professionalism and how they can is a leader in the formulation of health policy, standards and adopt the tenets of professionalism in practice. In patients with no prior history of cancer, solid nodules that have not grown over a 2-year period have an extremely low risk of malignancy (although longer follow-up is suggested for ground-glass nodules). Meanwhile, extended or intensive surveillance exposes patients to increased radiation and prolonged uncertainty. Moreover, the use of these agents may cause harm in certain situations and incurs substantial cost and resource utilization. For patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, don’t renew the prescription without assessing the patient for ongoing hypoxemia. At the time that supplemental oxygen is initially prescribed, a plan should be established to re-assess the patient no later than 90 days after discharge. Medicare and evidence-based criteria should be followed to determine whether the patient meets criteria for supplemental oxygen. Thus, screening should be reserved for patients at high risk of lung cancer and should not be ofered to individuals at low risk of lung cancer. Released October 27, 2013 How this List Was Created this document was prepared as a joint initiative of the American College of Chest Physicians and the American Thoracic Society. A taskforce with members from both societies was selected, including individuals from diverse backgrounds and clinical areas of expertise. The taskforce debated the impact of each based on fve criteria (Evidence, Prevalence, Cost, Relevance, Innovation), and agreed to narrow the list to 10 items to explore in greater depth. Following an in-depth evidence review and consultation with external content experts for each item, the taskforce together reviewed and debated the compiled information for all 10 items. Subsequently, taskforce members independently scored each item on a scale of 1–5, rating each item on its overall impact as well as on each of the fve criteria. The 5 items with the best mean overall scores were retained in the “penultimate” list. The taskforce then reviewed and edited the wording of items on the penultimate list, and submitted it to both societies’ executive committees. The executive committees sought feedback from additional experts in the feld, debated the items, and provided written comments to the taskforce. The taskforce deliberated and incorporated these suggestions where appropriate to create the fnal list, resolving any conficts through discussion. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Diagnosis, assessment, and treatment of non-pulmonary arterial hypertension pulmonary hypertension. Report of a National Heart, Lung, and Blood Institute and Centers for Medicare and Medicaid Services Workshop. Long-term oxygen treatment in chronic obstructive pulmonary disease: recommendations for future research. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Efectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: A randomized controlled trial. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Estimating overdiagnosis in low-dose computed tomography screening for lung cancer: a cohort study. Screening for lung cancer with low-dose computed tomography: a systematic review to update the U. Founded in 1905 to combat tuberculosis, the States and more than 100 countries worldwide. Avoid placing indwelling urinary catheters in the emergency department for either urine output monitoring in stable patients who can void, or for patient or staf convenience. Indwelling urinary catheters are placed in patients in the emergency department to assist when patients cannot urinate, to monitor urine output or for 2 patient comfort. Emergency physicians and nurses should discuss the need for a urinary catheter with a patient and/or their caregivers, as sometimes such catheters can be avoided. Emergency physicians can reduce the use of indwelling urinary catheters by following the Centers for Disease Control and Prevention’s evidence-based guidelines for the use of urinary catheters. Indications for a catheter may include: output monitoring for critically ill patients, relief of urinary obstruction, at the time of surgery and end-of-life care. Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to beneft. Hospice care is palliative care for those patients in the fnal few months of life. Emergency physicians should engage patients who present to the emergency department with chronic or terminal illnesses, and their families, in conversations about palliative care and hospice services. Early referral from the emergency department to hospice and palliative care services can beneft select patients resulting in both improved quality and quantity of life. Avoid wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up. Culture of the drainage is not needed as the result will not routinely change treatment. Many children who come to the emergency department with dehydration require fuid replacement. Giving a medication for nausea may allow patients with nausea and vomiting to accept fuid replenishment orally. Syncope (passing out or fainting) or near syncope (lightheadedness or almost passing out) is a common reason for visiting an emergency department and most episodes are not serious. However, diagnostic tests for syncope 6 should not be routinely ordered, and the decision to order any tests should be guided by information obtained from the patient’s history or physical examination. Advances in medical technology have increased the ability to diagnose even small blood clots in the lung. Studies have demonstrated that certain fndings in a patient’s medical history put them at very low risk for having a blood clot in the lung.
Opportunistic screening Opportunistic screening is screening done independently of an organized or population based programme heart attack 42 year old cheap 75mg triamterene visa, on women who are visiting health services for other reasons blood pressure medication refills purchase triamterene online. Opportunistic screening tends to blood pressure chart heart foundation discount triamterene 75mg without a prescription reach younger women at lower risk blood pressure entry chart order genuine triamterene on-line, who are attending antenatal, child health and family planning services. It is generally accepted that organized screening is more cost-effective than opportunistic screening, making better use of available resources and ensuring that the greatest number of women will benefit. However, both organized and opportunistic screening can fail because of poor quality-control, low coverage of the population at risk, overscreening of low-risk populations, and high loss to follow-up. Benefits and risks of screening the benefits and risks of screening should be discussed with women as part of general health education and before obtaining informed consent. Following the recommendations in this Guide will, in general, help to minimize these undesirable outcomes. All existing data on recommended ages and frequency of screening are derived from experience in cytology programmes. Screening younger women will detect many lesions that will never develop into cancer, will lead to considerable overtreatment, and is not cost-effective. If resources are limited, screening every 5–10 years – or even just once between the ages of 35 and 45 years – will significantly reduce deaths from cervical cancer. Screening of pregnant women Not screening for cervical cancer during pregnancy is sometimes seen as a missed opportunity. Women in the target age group who attend antenatal services should be advised to return for screening 12 weeks after giving birth. Screening should be encouraged and performed on clients of family planning services within the target age group. They should be screened for cervical cancer only if there is no visible acute infection. Other opportunities for cervical cancer screening Women at the end of their reproductive years are at greatest risk of cervical cancer, particularly if they have never been screened. All women in the target age group who visit a facility for any reason should receive information and be encouraged to come for screening (see also Chapter 3). General medical services at primary, secondary and tertiary levels can provide cervical cancer screening for such women, using on-site, trained providers. If this is not possible, women should be given health education and referred to a convenient screening clinic. The most extensive and long-term experience in cervical cancer screening is with cytology, which has been used in numerous countries since the 1950s. Because of the problems of implementing quality cytology-based screening, alternative methods, such as visual inspection, have been developed. These methods have shown promise in controlled research settings but have not yet been widely implemented. While decisions about priorities are usually made at national level, providers should understand the reasons for the decisions, so that they are motivated to implement them and can explain them to their patients (see Chapter 1). If well planned and integrated into other sexual and reproductive health activities, screening for cervical cancer has the potential to both strengthen the health care system and improve the health of women, particularly women over childbearing age, whose health is often relatively neglected. In many cultures, the notion of consent may be a collective decision-making process involving others, such as partner, family, and village leaders. In addition, when results are not available immediately (as they are with 7 Note: informed consent is not equivalent to informed choice. Consent refers to the explicit permission given by a person for a procedure or test, once she (or he) has received sufficient information to make a rational personal (informed) choice. Chapter 4: Screening for Cervical Cancer 91 visual screening methods), informed consent should include explicit permission to be contacted at home or at work. The history can provide useful information for guiding decisions about management or additional examinations or tests that might benefit the patient. Providers should explain what is being done at each step during the examination; if an abnormality is noted, the provider Pelvic exam should inform the woman without alarming her. When the provider is a man, the woman may request that a female companion or clinic attendant is in the room. Women with abnormal findings can be treated or referred for further investigation, as appropriate. The entire transformation Pap smear zone should be sampled since this is where almost all high-grade lesions develop. The sample is then smeared onto a glass slide and immediately fixed with a solution to preserve the cells. The slide is AnnexAnnexAnnex 2222 sent to a cytology laboratory where it is stained and examined using a microscope to determine whether the cells are normal (Figure 4. The results of the Pap smear are then reported to the clinic where the Chapter 4: Screening for Cervical Cancer 93 specimen was taken. The Pap test takes less than 5 minutes to perform, is not painful, 4 and can be done in an outpatient examination room. Interpretation of smears Smears are read in a laboratory by trained cytotechnicians, under the supervision of a pathologist, who has final responsibility for the reported results. To maintain proficiency and avoid fatigue, cytotechnicians should spend a maximum of 5 hours a day at the microscope and should review a minimum of 3000 slides per year. Quality assurance is crucial and should be established in all cytology laboratories. Further information can be found in the references listed under “Additional resources” at the end of this chapter. The specimen can be collected by a health care provider or by the woman herself, inserting a swab deep into the vagina. In either case, the specimen containers are transported to a laboratory where they are processed. It is mainly used in combination with cytology to improve the sensitivity of the screening or as a triage tool to assess which women with borderline Pap results need to be referred for colposcopy. If the patient does not meet the above indications and no alternative screening method is available in the particular clinical setting, she should be referred for a Pap smear. Ideally, all women should receive the results of their test, whether negative or positive. Follow-up should be in line with national protocols or based on the Flowchart screening recommendations found in Annex 4. The information system should include every woman’s clinical record, appointments scheduled, and those kept or missed. If women need to return later for their results, a system must be in place to ensure that those with abnormal results are notified and that women who are hard to Annex 7777 locate are traced. New York, Cervical Health Implementation Project, South Africa, University of Cape Town, University of the Witwatersrand, EngenderHealth, 2004. It should be made clear to the woman that there will be no punitive action if she refuses the procedure. You may adapt these to individual situations to help explain procedures in terms the patient and her family understand. Ensure privacy and explain that confidentiality is always respected in your facility. You can do this by asking her to repeat points that may be difficult or important, or by using other words to reiterate the most important issues, such as: “Did you understand that you should not have intercourse for 4 weeks after this procedure? Keep a written record, either on a consent form or in the medical record (according to your facility’s guidelines), that. Ask the woman to empty her bladder (urinate) and have her undress from the waist down. Using a gloved hand to gently touch the woman, look for redness, lumps, swelling, unusual discharge, sores, tears and scars around the genitals and in between the skin folds of the vulva. Vaginal discharge and redness of the vaginal walls, which are common signs of vaginitis. If she has a painful lump, and her period is late, she may have an ectopic pregnancy; in this case, she needs medical help right away. If you found something that needs urgent treatment or that cannot 8888 be handled at your centre. Sexually transmitted and other reproductive tract infections: a guide to essential practice. However, if the woman is in the target age group and it is likely that she will not return after giving birth, proceed with the smear.